Every finding on record at West Hills Health and Rehabilitation Center

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. Staff followed enhanced barrier precautions (EBP - infection control guidelines requiring staff to wear gown and gloves during high contact-care for residents with wounds, indwelling medical devices or those carrying resistant germs) for two of two sampled residents (Resident 10 and Resident 3): a. When Certified Nursing Assistant 4 (CNA 4) and Certified Nursing Assistant 5 (CNA 5) did not wear a gown before performing incontinence care for Resident 10. b. When Certified Nursing Assistant (CNA) 9 did not wear a gown when handling Resident 3's indwelling catheter tubing and drainage bag for Resident 3. 2. The facility's Water Management Program ([WMP] - a written, step-by-step plan for buildings to ensure their water system was safe, clean, and efficient) was implemented and maintained as written when daily water monitoring and monthly eye wash sanitation and cleaning were not conducted. These failures placed the residents, staff and visitors at risk for exposure to and transmission of infectious organisms and unsafe water conditions.Findings: 1.a. During a review of Resident 10's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility initially admitted Resident 10 on 10/17/2023 with diagnoses that included obstructive and reflex uropathy (a condition in which the flow of urine is blocked and urine flows backward from your bladder into your kidneys), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 10's Minimum Data Set (MDS- a resident assessment tool) dated 7/20/2026, the MDS indicated that Resident 10 had the ability to make self-understood and to understand others. The MDS also indicated Resident 10's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was moderately impaired. The MDS indicated Resident 10 required substantial assistance (helper does more than half the effort) from staff for toileting hygiene (ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). The MDS also indicated that Resident 10 had an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine). During a review of Resident 10's records titled, Order Summary Report, dated 7/31/2026, the order summary report indicated the following physician order: -Resident is on enhanced barrier precautions for suprapubic catheter, initiated on 7/02/2026. -Suprapubic catheter care, every day shift, initiated on 8/26/2025. During a review of Resident 10's care plan (a document that summarizes a resident's needs, goals, and care/treatment) report titled, enhanced barrier precaution related to moderate risk of infection, suprapubic catheter, initiated on 7/20/2026, the care plan aimed to lower the risk of active infection. The care plan also included interventions such as practicing hand hygiene during direct contact, providing incontinent care as needed, and applying enhanced barrier precautions using gloves, gowns, and masks. During an observation on 8/10/2026 at 9:33 a.m. with Certified Nursing Assistant 4 (CNA 4) and Certified Nursing Assistant 5 (CNA 5), inside Resident 10's room, CNA 4 and CNA 5 were observed providing incontinence care to Resident 10 without a gown. During an interview on 8/10/2026 at 9:51 a.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated that enhanced barrier precautions are used for residents with urinary or intravenous (IV-directly into the blood stream) catheters as an additional measure during activities of daily living (ADLs – toileting hygiene, shower/bathing), to prevent cross-contamination and infection. LVN 3 noted that Resident 10 was on enhanced barrier precautions. LVN 3 also stated that staff are expected to wear appropriate personal protective equipment (PPE- clothing or equipment that people wear to reduce the risk of injury and illness from exposure to hazards in the workplace). Furthermore, LVN 3 stated that residents may develop infections, potentially leading to sepsis, if enhanced barrier precautions are not followed. During an interview on 8/10/2026 at 10:02 a.m. with CNA 4, CNA 4 stated that he was giving CNA 5 an orientation during incontinence care for Resident 10. According to CNA 4, residents on enhanced barrier precautions require staff to wear a gown and gloves before entering their room. CNA 4 also stated that proper PPE, such as a gown, was not worn when they provided incontinence care to Resident 10, although it should have been used for safety and infection control. b. During a review of Resident 3's Face Sheet , the Face Sheet indicated the facility originally admitted Resident 3 to the facility on 10/23/2025 and re-admitted on [DATE] with diagnosis that included urinary tract infection (UTI – an infection in the bladder/urinary tract), chronic kidney disease (kidneys are damaged and cannot filter blood as well), and diabetes mellitus (DM – a disorder characterized in blood sugar control and poor wound healing). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 makes self-understood and able to understand others. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) with shower/bathe self, dressing, toileting hygiene and set-up or clean-up assistance (helper sets up cleans up; resident completes activity) with oral hygiene and eating. The MDS indicated Resident 3 had an indwelling catheter. During a review of the History and Physical (H&P) report completed on 6/15/2026, the H&P indicated Resident 3 has the capacity to understand and make decisions. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated Resident is on enhanced barrier precaution due to resident with right elbow wound and foley catheter, date ordered 8/10/2026. During an observation on 8/11/2026 at 2:10 p.m., observed Resident 3's indwelling catheter drainage bag anchored to the left side of the bed frame above Resident 3's bladder with the urine visible inside. The drainage bag was observed to be attached to a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible), with the drainage bag placed outside of the dignity bag. During a concurrent observation and interview on 8/11/2026 at 2:12 p.m. with Certified Nursing Assistant (CNA) 9, observed CNA 9 not wearing a gown when CNA 9 applied the dignity bag to the drainage bag and proceeded to touch the catheter tubing. CNA 9 stated he did not need to wear a gown during catheter care. CNA 9 stated that wearing a gown is only necessary when providing direct contact care to Resident 3, such as cleaning the resident in bed or when bathing. During an interview on 8/11/2026 at 2:20 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 3 is on EBP because of having an indwelling catheter. LVN 4 stated that gloves and gowns are required during urinary catheter care. LVN 4 stated it is important to follow EBP to prevent spread of infection. During an interview on 8/13/2026 at 4:15 p.m. with the Director of Nursing (DON), the DON stated it is important that EBP is followed to prevent the spread of unwanted microorganisms. The DON stated that not following EBP placed Resident 3 and the other residents at risk of infection from cross contamination (the transfer of harmful bacteria or other microorganisms). 2. During a concurrent interview and record review on 8/13/2026 at 9:21 a.m. with Maintenance Supervisor (MS), the facility's WMP, undated and daily room water temperature logs from August 2025 to August 2026 were reviewed. The MS stated that he is responsible for the implementation and regulation of water monitoring, as well as the maintenance of eye wash stations. The MS stated that, according to the facility's WMP section Control Points (locations in the water systems where a control measure can be applied)—Areas to be Monitored and Tested, all water fittings, including sink faucets and shower heads, are subject to daily monitoring and biofilm (slime) removal. Eye wash stations must be sanitized and tested monthly to ensure proper operation. The facility's WMP further specifies that each time a control point is assessed, both the date and time should be recorded on a log sheet, along with details regarding preventive measures. The MS indicated that he measures the water temperature in resident rooms daily. However, the MS stated that that water temperature checks in residents' rooms were not performed consistently on weekends. The daily room temperature indicated the following: -On 8/8/2026 and 8/9/2026, water temperature monitoring was not conducted. -On 6/27/2026 and 6/28/2026, water temperature monitoring was not conducted. -On 6/20/2026 and 6/21/2026, water temperature monitoring was not conducted. -On 6/13/2026 and 6/14/2026, water temperature monitoring was not conducted. -On 6/6/2026 and 6/6/2026, water temperature monitoring was not conducted. -On 5/30/2026 and 5/31/2026, water temperature monitoring was not conducted. -On 5/23/2026 and 5/24/2026, water temperature monitoring was not conducted. -On 5/16/2026 and 5/17/2026, water temperature monitoring was not conducted. -On 5/9/2026 and 5/10/2026, water temperature monitoring was not conducted. -On 5/1/2026 to 5/4/2026, water temperature monitoring was not conducted. -On 4/24/2026 to 4/29/2026, water temperature monitoring was not conducted. -On 4/18/2026 and 4/19/2026, water temperature monitoring was not conducted. -On 4/11/2026 and 4/12/2026, water temperature monitoring was not conducted. -On 4/4/2026 and 4/5/2026, water temperature monitoring was not conducted. -On 3/28/2026 and 3/29/2026, water temperature monitoring was not conducted. -On 3/21/2026 and 3/22/2026, water temperature monitoring was not conducted. -On 3/14/2026 and 3/15/2026, water temperature monitoring was not conducted. -On 3/7/2026 and 3/8/2026, water temperature monitoring was not conducted. -On 3/1/2026, water temperature monitoring was not conducted. -On 2/28/2026, water temperature monitoring was not conducted. -On 2/21/2026 and 2/22/2026, water temperature monitoring was not conducted. -On 2/14/2026 and 2/15/2026, water temperature monitoring was not conducted. -On 2/7/2026 and 2/8/2026, water temperature monitoring was not conducted. -On 1/24/2026 and 1/25/2026, water temperature monitoring was not conducted. -On 1/17/2026 and 1/18/2026, water temperature monitoring was not conducted. -On 1/10/2026 and 1/11/2026, water temperature monitoring was not conducted. -On 1/3/2026 and 1/4/2026, water temperature monitoring was not conducted. -On 12/27/2025 and 12/28/2025, water temperature monitoring was not conducted. -On 12/20/2025 and 12/21/2025, water temperature monitoring was not conducted. -On 12/13/2025 and 12/14/2025, water temperature monitoring was not conducted. -On 12/6/2025 and 12/7/2025, water temperature monitoring was not conducted. -On 11/29/2025 and 11/30/2025, water temperature monitoring was not conducted. -On 11/22/2025 and 11/23/2025, water temperature monitoring was not conducted. -On 11/15/2025 and 11/16/2025, water temperature monitoring was not conducted. -On 11/8/2025 and 11/9/2025, water temperature monitoring was not conducted. -On 11/1/2025 and 11/2/2025, water temperature monitoring was not conducted. -On 10/25/2025 and 10/26/2025, water temperature monitoring was not conducted. -On 10/18/2025 and 10/19/2025, water temperature monitoring was not conducted. -On 10/11/2025 and 10/12/2025, water temperature monitoring was not conducted. -On 10/4/2025 and 10/5/2025, water temperature monitoring was not conducted. -On 9/27/2025 and 9/28/2025, water temperature monitoring was not conducted. -On 9/20/2025 and 9/21/2025, water temperature monitoring was not conducted. -On 9/13/2025 and 9/24/2025, water temperature monitoring was not conducted. -On 9/6/2025 and 9/7/2025, water temperature monitoring was not conducted. -On 8/30/2025 and 8/31/2025, water temperature monitoring was not conducted. -On 8/23/2025 and 8/24/2025, water temperature monitoring was not conducted. -On 8/16/2025 and 8/17/2025, water temperature monitoring was not conducted. -On 8/9/2025 and 8/10/2025, water temperature monitoring was not conducted. -On 8/2/2025 and 8/3/2025, water temperature monitoring was not conducted. During a follow-up interview on 8/13/2026 at 9:21 a.m. with the MS, the MS stated that monitoring water temperature was intended to ensure proper regulation for residents and should be performed daily. The MS also noted there was no documented evidence that eye wash stations were being sanitized and tested monthly as indicated by the facility's WMP. According to the MS, residents, staff, and visitors have access to the facility's water and are therefore at risk for illnesses from waterborne pathogens (bacteria, viruses, or parasites found in contaminated water). The MS further added that if the water is not monitored, corrosion can build up and lead to the growth of waterborne pathogenic bacteria. During an interview on 8/13/2026 at 10:29 a.m. with Infection Preventionist Nurse (IPN), the IPN stated that enhanced barrier precautions are implemented when residents are identified as being at risk for infection, such as those with wounds, dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) catheters, indwelling catheters, gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tubes, ostomies (surgically created opening in the abdomen), or surgical wounds. The IPN stated that these enhanced barrier precautions serve to prevent infections, multidrug-resistant organisms (MDRO - bacteria that are resistant to more than one antibiotic and can cause serious infections), and their transmission to other residents. Additionally, the IPN stated that staff are required to adhere to guidelines regarding the use of appropriate PPE during close contact with residents, including perineal care. The IPN further stated that failure to utilize PPE, such as gowns, may increase the risk of infection for residents and necessitate antibiotic treatment, which could contribute to antibiotic resistance. During a follow-up interview on 8/13/2026 at 10:29 a.m. with the IPN, the IPN stated that the MS was responsible for monitoring the water. The IPN added that failure to routinely monitor the water, may allow the growth and spread of waterborne pathogens such as legionella (a type of bacteria found in water that can cause a severe, pneumonia-like lung infection), which could place residents, staff and visitors at risk for waterborne infections when exposed or ingested to a contaminated water. During an interview on 8/13/2026 at 12:50 p.m. with Director of Nursing (DON), the DON indicated that enhanced barrier precaution is used to prevent cross-contamination and ensure the safety of both residents and staff. The DON added that this approach is particularly important when dealing with infections, as it helps stop the spread and protects individuals from developing new infections. The DON further stated that if EBP is not implemented, residents face a higher risk of infection as many residents are on enhanced barrier precautions, especially those who are immunocompromised or have multiple comorbidities, making them more susceptible to infection. During a review of facility's Policy and Procedures (P&P) titled, Enhanced Barrier Precautions, last reviewed on 1/7/2026, the P&P indicated that Enhanced barrier precautions are used to prevent and control infection by minimizing the spread of multi-drug resistant organisms (MDROs—bacteria resistant to several common antibiotics) among residents. Enhanced barrier precautions involve selectively using gowns and gloves during care activities that require significant physical contact, such as dressing, bathing or showering, transferring, providing hygiene, changing lines or briefs, assisting with toileting, caring for devices (central line, urinary catheter, feeding tube, etc.), and wound care. EBPs are recommended for residents who have wounds and/or indwelling medical devices, regardless of MDRO colonization. During a review of the facility's P&P titled, Infection Control last reviewed on 1/7/2026, the P&P indicated, This facility has established and will maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The following effective infection control program components will be utilized: Prevention: implementation of measures to prevent transmission of infectious agents and to reduce the risks for device and procedure-related infections. During a review of facility's P&P titled, Legionella Water Management Program, last reviewed on 1/7/2026, the P&P indicated that the facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. The P&P indicated the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria including showerheads and hoses. The P&P also identified situations that can lead to legionella growth such as water main breaks, changes in municipal water quality, presence of biofilm, scale or sediments, water temperature fluctuations, water stagnation and inadequate disinfection.

Based on observation, interview, and record review, the facility failed to honor the resident's right to a dignified existence for three of 28 sampled residents (Resident 60, Resident 97, and Resident 3 by: 1. Failing to provide a meal to Resident 60 at the same time as other residents at the table in the dining room. 2. Failing to ensure Resident 97's privacy and dignity were maintained when the resident was observed lying in bed wearing only an adult brief and was visible from the hallway. 3. Failing to ensure Resident 3's indwelling catheter (a tube inserted into the bladder to continuously drain urine into a drainage bag) drainage bag was covered with a dignity bag (a cover to conceal a urinary catheter drainage bag). These failures violated residents' rights to privacy and to be treated with respect and dignity. Findings: 1. During a review of Resident 60's Face Sheet (FS), the FS indicated that the facility originally admitted the resident on 1/8/2022 and readmitted on [DATE] with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), anxiety disorder (an abnormal condition characterized by persistent and excessive worries that interfere with daily activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 60's History and Physical (H&P), dated 7/1/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 60's Minimum Data Set (MDS – a resident assessment tool), dated 6/5/2026, the MDS indicated that the resident sometimes makes self understood and sometimes has the ability to understand others. The MDS indicated that the resident required setup or clean-up assistance (helper sets up cleans up; resident completes activity) with eating and is dependent (helper does all of the effort) on staff with chair/bed-to-chair transfers. During a review of Resident 60's Order Summary Report, dated 4/1/2026, the Order Summary Report indicated a diet order of controlled carbohydrate (CCHO) diet, soft and bite-sized texture, thin consistency. During a review of Resident 60's Care Plan (CP) on alteration in nutrition status, revised 3/10/2026, the CP indicated a goal of minimizing any unplanned weight changes. The CP's interventions included setting up the meal tray, assisting and giving verbal cues if needed and assisting the resident into a chair and to the dining room at mealtimes. During an observation on 8/10/2026 at 12:28 p.m., inside Activity Room 1, observed Resident 60 seated at a table with four other residents. During an observation on 8/10/2026 at 12:32 p.m., inside Activity room [ROOM NUMBER], the meal cart arrived, and staff delivered meal trays to the other but did not provide a meal tray to Resident 60. During an observation on 8/10/2026 at 12:39 p.m., inside Activity room [ROOM NUMBER], observed the four other residents eat their meals, however, Resident 60 still had not received a meal tray. During an interview on 8/10/2026 at 12:43 p.m., inside Activity room [ROOM NUMBER], Certified Nursing Assistant (CNA) 1 confirmed that Resident 60 had not been served a meal tray. During a concurrent observation and interview on 8/10/2026 at 12:50 p.m., observed CNA 2 take Resident 60 out of Activity room [ROOM NUMBER] and bring the resident to her room. CNA 2 stated that Resident 60's meal tray had not been delivered yet. CNA 2 stated that Resident 60 eats in her room and she sets up Resident 60's bed before she (CNA 2) bringing Resident 60's meal tray. During an interview on 8/10/2026 at 2:24 p.m., CNA 2 stated she brought Resident 60's meal tray at approximately 1:30 p.m. and removed the tray approximately 30 minutes ago. During a concurrent interview and record review on 8/13/2026 at 12:14 p.m. with the Director of Nursing (DON), the facility's policy and procedures (P&P) titled, Resident Rights, last approved 1/7/2026, was reviewed. The P&P indicated that Employees shall treat all residents with kindness, respect, and dignity. The DON stated that the P&P was not followed because Resident 60 was not provided with a dignified dining experience. The DON stated that Resident 60 should not have to watch the other residents eat and should have been brought back to her room earlier since her meal tray was not yet ready. The DON further stated that the resident could feel forgotten. During a review of the facility's P&P titled, Resident Rights, last approved 1/7/2026, the P&P indicated that Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . During a review of the facility's P&P titled, Assistant with Meals, last approved 1/7/2026, the P&P indicated that Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation Dining Room Residents: 1. All residents will be encouraged to eat in the dining room. 2. Facility staff will serve resident trays and will help residents who require assistance with eating. 2. During a record review of Resident 97's Face Sheet, the Face Sheet indicated the facility admitted the resident on 7/30/2026, with diagnoses including difficulty in walking, not elsewhere classified (trouble walking normally but the specific cause has not been identified); dementia in other diseases classified elsewhere, unspecified (person has problems with memory, thinking, judgement or behavior that is caused by another medical disease); unspecified fall, subsequent encounter (had a fall and is receiving followed up care). During a review of Resident 97 's H&P, dated 7/31/2026, the H&P indicated the resident was alert but not oriented. During a review of Resident 97's MDS, dated [DATE], the MDS indicated the resident makes self-understood and understands others and had severe cognitive impairment (serious trouble thinking, remembering, or understanding things). The MDS indicated that Resident 97 required assistance with activities with daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) ranging from maximum assistance to dependent assistance from staff. During an observation on 8/10/2026, at 10: 28 a.m. from the hallway, observed Resident 97 lying in bed wearing only an adult brief. The resident's privacy curtain was open, and the resident was visible to other residents, staff, and visitors passing by. Staff members who passed by did not close the privacy curtain or cover the resident. During a concurrent observation and interview on 8/10/2026, at 10:33 a.m., with CNA 10, CNA 10 drew the privacy curtain and pulled the resident's gown down to cover the resident. CNA 10 stated that he did not know why the resident took off his gown. During an interview on 8/10/2026, at 2:20 p.m., with CNA 10, CNA 10 stated Resident 97's privacy and dignity were not maintained because the resident was not covered and the privacy curtain was open, allowing the resident to be visible from the hallway wearing only an adult brief. CNA 10 stated Resident 97 could have felt embarrassed or humiliated and could have felt a loss of control over their body and privacy. During an interview for Resident 97 on 8/12/2026, at 9:13 a.m., with Registered Nurse (RN)1, RN 1 stated Resident 97's dignity was compromised because the resident was exposed. RN 1 stated that any staff member passing by should have covered the resident to maintain the resident's privacy and dignity. RN 1 stated the facility's policy on Dignity, was not followed. During an interview for Resident 97 on 8/13/2026, at 3:25 p.m., with the DON, the DON stated that Resident 97 being visible from the hallway wearing only an adult brief was a dignity issue and could have caused embarrassment to the resident. The DON stated that any staff member that was passing by should have covered the resident. During a review of the facility's P&P titled, Dignity, last reviewed on 1/7/2026, the P&P indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem. Policy interpretation and Implementation 1. Residents are treated with dignity and respect at all times. 3. During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 3 to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included urinary tract infection (UTI – an infection in the bladder/urinary tract), chronic kidney disease (kidneys are damaged and cannot filter blood as well), and diabetes mellitus (DM – a disorder characterized in blood sugar control and poor wound healing). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 makes self-understood and able to understand others. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) with shower/bathe self, dressing, toileting hygiene and required set-up or clean-up assistance with oral hygiene and eating. The MDS indicated Resident 3 had an indwelling catheter. During a review of the H&P report completed on 6/15/2026, the H&P indicated Resident 3 has the capacity to understand and make decisions. During an observation on 8/11/2026 at 2:10 p.m., observed Resident 3's indwelling catheter drainage bag anchored to the left side of the bed frame above Resident 3's bladder with the urine visible inside. The drainage bag was observed to be attached to a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible), with the drainage bag placed outside of the dignity bag. During a concurrent observation and interview on 8/11/2026 at 2:12 p.m. with CNA 9, CNA 9 stated that the dignity bag should be covering the catheter drainage bag. During an interview on 8/11/2026 at 2:20 p.m. with Licensed Vocation Nurse (LVN) 4, LVN 4 stated that the dignity bag should be covering Resident 3's catheter drainage bag to protect Resident 3's privacy and dignity, for the urine drainage not to be seen by others. During an interview on 8/13/2026 at 4:15 p.m. with the Director of Nursing, the DON stated it is important to have dignity bag over Resident 3's drainage bag. The DON stated that Resident 3's self-esteem may be affected negatively if the drainage bag and its contents are visible to others. During a review of the facility's P&P titled,Dignity last reviewed 1/7/2026, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Residents are treated with dignity and respect at all times. During a review of the facility's P&P titled, Resident Rights last reviewed 1/7/2026, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:.a dignified existence; .be treated with respect, kindness, and dignity.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by: 1. Failing to ensure a bag of buttermilk biscuit mix was sealed. 2. Failing to ensure a bag of brown crumbs was labeled with its name. 3. Failed to ensure a bin did not have residue of brown and white crumbs in it. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 126 out of 126 medically compromised residents who received food from the kitchen. Findings: During a concurrent observation and interview on 8/10/2026 at 8:00 a.m. inside the dry storage room with the Dietary Supervisor (DS), observed an open bag of buttermilk biscuit mix that was not sealed and a bag of brown crumbs that was not labeled with its name. The DS stated that the kitchen staff are supposed to seal the bag when open and label items in the kitchen once they are opened or transferred to another container. The DS stated that if the bag of buttermilk biscuit mix is left open it could get contaminated and cause residents stomach issues or can attract bugs. The DS stated that if the bag did not indicate the item's name, then the staff would not be able to know what it is and can be mistaken for something else and residents can get sick. The DS discarded the open bag and the bag that was not labeled. Observed a bin with a sealed unopen bag of breadcrumbs and in the bin, there was residue that had brown and white crumbs in it. The DS stated that the bin should not have any crumbs in it because it can attract fruit flies, cockroaches and rats. During an interview on 8/13/2026 at 3:25 p.m., with Director of Nursing (DON), the DON stated that if an item does not have a name label it can potentially be anything and could be not edible. The DON stated it is important to label food items to ensure staff could identify and properly use them, and for resident safety. The DON stated that the food bags that are not properly closed after use or presence of residue of food crumbs can attract bugs or insects. During a review of the facility's Policy and Procedure (P&P) titled, Dating and Labeling, last reviewed on 1/7/2026, the P&P indicated to ensure food safety and prevent contamination within the facility, all food items should be properly covered, dated, and labeled in dry storage and refrigerator/freezer areas.

Based on observation, interview, and record review, the facility failed to follow the menu and did not meet the nutritional needs of two of four residents (Resident 117 and Resident 139) on pureed texture diets (diet with pudding like consistency foods used for individuals with difficulty chewing or swallowing) and six (6) of 86 residents on regular texture diets when: 1. Pureed French dip roast beef sandwich pureed bread was not flattened and pureed meat was not placed on top for Residents 117 and 139. 2. There were not enough French rolls available for lunch meal on 8/10/2026 and substituted six hot dog buns for the remaining residents six residents. The hot dog buns were not included on the planned menu. These failures had the potential to result in residents not receiving the meal as planned and could affect residents' nutritional needs and meal satisfaction. Findings: 1. a.During a review of Resident 117's Face Sheet (FS), the FS indicated that the facility originally admitted the resident on 7/10/2023 and readmitted on [DATE] with diagnoses including senile degeneration of the brain (the loss of brain cells and cognitive decline, such as memory loss), vascular dementia (a progressive state of decline in mental abilities caused by restricted blood flow or strokes that damage brain tissue), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and glaucoma (a group of diseases that damage the eye's optic nerve and can result in vision loss and even blindness). During a review of Resident 117's History and Physical (H&P), dated 7/142026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 117's physician order, dated 4/21/2026, the physician order indicated an order for regular diet, puree texture, thin consistency, may have ice cream. b. During a review of Resident 139's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 10/27/2021 and readmitted on [DATE] with diagnoses including Parkinsonism (a set of movement symptoms such as slow movements, rigidity, tremors, and balance problems), hyperlipidemia (a condition where you have too many fats in your blood), and hypothyroidism (a condition where the thyroid gland does not make enough thyroid hormones, leading to symptoms like fatigue, weight gain, and feeling cold). During a review of Resident 139's H&P, dated 5/17/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 139's physician order, dated 7/17/2024, the physician order indicated an order for no added salt diet, puree texture, honey/moderately thick consistency. During a concurrent observation and interview on 8/10/2026 at 12:25 p.m. with Certified Nursing Assistant (CNA) 6, inside Dining Room B, CNA 6 stated Resident 117 is on pureed diet. Observed resident's puree appeared to be watery on the plate. Observed three pureed foods on the plate touching other food items. During a concurrent observation and interview on 8/10/2026 at 12:36 p.m. with CNA 1, inside Activity room [ROOM NUMBER], CNA 1 stated Resident 139's pureed food on the plate is runny but is acceptable to serve. CNA 1 stated the pureed food is smooth and without no lumps and are okay to serve. During a concurrent interview and record review on 8/12/2026 at 2:02 p.m. with the Registered Dietitian (RD), the puree recipe titled, French Dip: Roast Beef Roll with Au Jus, undated was reviewed. The RD stated the recipe indicated to Flatten sandwich and top with puree meat & #16 pureed bread. The RD stated the recipe indicated this because on the regular sandwich the meat goes on top of the bread that was why they did it. The RD stated they should follow the recipe to follow the consistency. The RD stated this was not followed. During a review of the facility's menu spreadsheet (a sheet containing kind and amount of food each diet would receive) titled Cooks spreadsheet, dated 8/10/2026, the spreadsheet indicated residents on pureed diet (PD 4) diet would include the following foods in the tray: PD 4 French Dip: Roast Beef Roll with Au Jus 1/2 cup (c-a household measurement) PD 4 Roll 1/3 c PD 4 Corn Coleslaw 1/3 c PD 4 Sweet Potato During a review of the facility's production recipe titled, French Dip: Roast Beef Roll with Au Jus undated, the recipe indicated IDDSI#4/Pureed: Puree roast beef, #12. Puree bread, #16 (large #12). Flatten pureed bread and top with puree meat & #16 pureed bread. Puree following the pureed recipes in the Food Safety/Misc. section of Book #1. Utilize the critical tests and IDDSI audit to confirm texture meets level #4 specifications. During a review of the facility's policy and procedure (P&P) titled, Food Preparation, last approved on 1/7/2026, the P&P indicated that Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value. All meals must comply with the physician-ordered diet, approved menu, and portion control standards to ensure consistency, adequate nutrition, and regulatory compliance. PROCEDURE . 6. Modified Diets and Texture Compliance: All modified diets and thickened liquids will be prepared and served in accordance with the IDDSI (International Dysphagia Diet Standardization Initiative) Framework. Dietary staff will follow the standardized IDDSI levels as ordered, including: . Level 4 - Pureed During a review of the facility's P&P titled, Menu, last reviewed and approved on 1/7/2026, the P&P indicated that 5. The menus will be prepared as written using standardized recipes. The Dietary Services Supervisor and cooks are trained and responsible for the preparation and service of therapeutic diets prescribed During a review of the facilities P&P titled, IDDSI LEVEL #4: REGULAR PUREED DIET, last approved 1/7/2026, the P&P indicated that The pureed diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the prepared pureed food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep 2. During an observation on 8/10/2026 at 11:37 a.m. on the steamtable preparation area with [NAME] 1, observed [NAME] 1 use hot dog buns for the lunch meal trays of the last six residents. The Dietary Supervisor (DS) and the Registered Dietitian (RD) observed that hot dog buns were used instead of French rolls. During an interview on 8/12/2026 at 11:14 a.m., with [NAME] 1, [NAME] 1 stated that for lunch on 8/10/2026 there was no back up plan, and the best next option was to use hot dog buns instead of sandwich bread. [NAME] 1 stated that the hot dog bun was not on the recipe or menu. [NAME] 1 stated [NAME] 1 did not know what happened with the French rolls because a case was ordered and 90 French rolls come in the case and there were 86 residents on regular diet and there was supposed to be extra French rolls. During an interview on 8/12/2026 at 12:00 p.m., with the Dietary Supervisor (DS), the DS stated that if the kitchen runs out of supplies the [NAME] and the DS decide what to use. The DS stated that on previous menu it was either French rolls or hot dog buns, but the new menu only indicated French roll. During an interview on 8/12/2026 at 2:50 p.m., with the RD, the RD stated that the DS or the [NAME] decides what to use if they run out of a food item. The RD stated they should not have been short of French rolls and should have had the right number of rolls. The RD stated they need to follow the menu and recipe but can always make changes if needed to. The RD stated the menu was not followed on Monday for the last six residents, who were served hot dog buns instead of French rolls. The RD stated that it the kitchen staff had known at the beginning of the trayline that there were not enough French rolls, then the menu could have been changed but they did not discover the shortage until the end of the trayline service. The RD stated the residents may not have liked the hotdog buns or may have refused to eat them. During an interview on 8/12/2026 at 3:24 p.m., with RD, the RD stated that the residents could potentially not receive the adequate calories or protein because the hot dog buns were slightly smaller in size. During a review of the facility's Policy and Procedure (P&P) titled, Menu, last reviewed on 1/7/2026, the P&P indicated, twenty-eight day cycle menus are prepared by the dietitian and modifications of individual resident menus are made as necessary to comply with physician orders and/or resident preferences. Not less than three meals are served daily, with alternative selections daily. The standard menu will ensure nutritional adequacy of all diets, offer a variety of food in adequate amounts at each meal, and a standardized food production. Procedure: 3. Menus should be planned, written, and posted at least one week in advance. A copy of the following week's menu shall be posted in the kitchen and outside at least one week prior to the period covered. If any meal served varies from the planned menu, the change and the reason for the change shall be noted on the written menu.

Based on interview and record review, the facility failed to ensure the facility had sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three of 28 sampled residents (Resident 85, 146, and 3) by failing to ensure: 1. The facility provided documented evidence to indicate that the Licensed Nurses had been assessed and demonstrated competency in the use of CPAP/BiPAP machine for Resident 85. 2 The facility provided documented evidence to indicate that Registered Nurse (RN) 2 had been assessed and demonstrated competency for Intravenous Medication Administration to Resident 146. 3. CNA 9 demonstrated competency for when enhanced barrier precaution (EBP - infection control guidelines requiring staff to wear gown and gloves during high contact-care for residents with wounds, indwelling medical devices or those carrying resistant germs) is required, the proper placement of indwelling catheter drainage bag and the purpose of catheter bag cover/dignity cover for Resident 3. These failures had the potential for provision of substandard nursing care leading to harm on residents. Findings: 1. During a review of Resident 85's Face Sheet (FS), the Face Sheet indicated that the facility originally admitted the resident on 3/26/2025 and readmitted on [DATE] with diagnoses including insomnia (trouble falling asleep or staying asleep), obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep when the throat muscles relax and cause the airway to collapse and block airflow), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 85's History and Physical (H&P), dated 11/6/2025, the H&P indicated the resident has the capacity to understand and make decision During a review of Resident 85's Minimum Data Set (MDS-a resident assessment tool), dated 7/1/2026, the MDS indicated the resident with intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required partial/moderate assistance (helper does less than half the effort) with upper body dressing and personal hygiene and substantial/moderate assistance (helper does more than half the effort) with lower body dressing and ambulation. During a review of Resident 85's physician order, dated 11/13/2025, the physician order indicated an order AutoPeep (intrinsic positive end-expiratory pressure-when old air gets trapped inside the lungs) every hours of sleep for diagnosis of obstructive sleep apnea (OSA) four (4)-20 centimeters (cm-a unit of measurement) water and supplies. During a review of Resident 85's Care Plan (CP) focused on Sleep apnea, revised 6/23/2026, the CP indicated a goal that the resident will not have episodes of respiratory distress. The CP indicated an intervention to use CPAP machine as ordered and as needed, and Auto PEEP every hour of sleep for diagnosis of obstructive sleep apnea 4-20 cm water and supplies. During a concurrent observation and interview on 8/10/2026 at 9:11 a.m. with the Infection Preventionist Nurse (IPN), inside Resident 85's room, the IPN stated Resident 85 has a CPAP machine that the resident uses at night. The IPN stated the night shift staff removes the CPAP mask from the resident and cleans it. The IPN stated there is water inside the CPAP machine's canister. The IPN stated it should be dry. During a concurrent interview and record review on 8/12/2026 at 7:46 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 85's physician orders, medication administration record for the month of 8/2026, nursing progress notes, and CPAP User Guide (undated) were reviewed. LVN 2 stated Resident 85's CPAP was recently discontinued because Resident 85 was not using it. LVN 2 stated when the CPAP is put on and removed it should be documented. LVN 2 stated if Resident 85 refuses to wear it should be documented on the MAR or in the progress notes so staff can determine how often it is used and whether it is effective in managing the resident's apnea. LVN 2 stated there is no care plan and no physician order for cleaning and maintaining of the CPAP machine. LVN 2 stated she would need to consult the Director of Nursing regarding the proper use, cleaning, and maintenance of the CPAP machine because she was unfamiliar with the resident's personal CPAP machine. LVN 2 stated when the care instructions are not followed as indicated in the manufacturer's guidelines the resident is at risk for respiratory infection. LVN 2 stated she did not receive training for the use of this specific CPAP machine and would not know how to care for and use this machine. During a concurrent interview and record review on 8/13/2026 at 8:11 a.m. with the Assistant Director of Nursing (ADON), the facility's policy and procedure titled, CPAP/BiPAP Support, last approved 1/7/2026 was reviewed. The ADON stated Resident 85 brought the CPAP machine from home, and it is the resident's personal property. The ADON stated they notified the physician on 8/12/2026 to obtain an order, however the resident stated she did not want to use it. The ADON reviewed the P&P titled General Guidelines for Cleaning, which indicated: 1. These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device. Document the following in the resident's medical record. 2. Time CPAP was started and duration of the therapy. 5. How the resident tolerated the procedure. Reporting 1. Notify the physician if the resident refuses the procedure. The ADON stated the P&P was not followed. The ADON stated when the P&P is not followed it could potentially compromise the health and safety of the resident. During a follow-up interview on 8/13/2026 at 2:47 p.m. with the ADON, ADON stated the ADON stated that the competency skills checklist assessment is completed to ensure that nursing staff are competent in the skills listed. The ADON stated that if nursing staff are not competent in skills such as setting up a CPAP machine, they may not know how to properly care for residents who use the machine. During an interview on 8/13/2026 at 3:25 p.m. with the DON, the DON stated that she would discuss with the Quality Assurance Committee which competency checklist would be used to assess licensed nurses. The DON stated the competency assessments would be completed to ensure resident safety. During a review of the facility's P&P titled, CPAP/BiPAP Support, last approved 1/7/2026, the P&P indicated that General Guidelines Cleaning 1. These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device. Document the following in the resident's medical record. 2. Time CPAP was started and duration of the therapy. 5. How the resident tolerated the procedure. Reporting 1. Notify the physician if the resident refuses the procedure. 2. During a record review of Resident 146's Face Sheet, the Face Sheet, indicated the facility originally admitted the resident on 8/3/2026 and readmitted on [DATE], with diagnoses including sepsis due to methicillin susceptible staphylococcus aureus (a serious infection in the bloodstream caused by a type of bacteria called MSSA, which can cause low blood pressure, problems with organs, and potentially life-threatening illness), cutaneous abscess of abdominal wall (an infected lump or collection of pus in the skin/tissue of the stomach area), and local infection of the skin and subcutaneous tissue, unspecified (the skin and tissue underneath it are infected, but the specific type of infection is not specified). During a review of Resident 146's History and Physical (H&P), dated 8/4/2026, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 146's Minimum Data Set (MDS- a resident assessment tool), dated 8/8/2026, the MDS indicated the resident makes self-understood and understands others and had intact cognitive function (normal thinking). The MDS indicated that Resident 146 required assistance ranging from set up assistance (helper sets up or cleans up; resident completes the activity) to moderate assistance (helper does less than half the effort) with mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a concurrent interview and record review on 8/12/2026, at 3:28 p.m., with the DSD, reviewed Registered Nurse (RN) 2's employee file which contained an Intravenous Medication Safety Skills Competency dated 4/22/2026. The DSD stated that he had not conducted the IV Medication Skills competency assessment for RN 2. The DSD stated that the assessment should have been completed and signed by the DON or ADON because the evaluator was required to be an RN. During an interview on 8/13/2026, at 9:56 a.m., with ADON, ADON stated registered nurses must complete IV medications skills competency and return demonstration before independently starting IV or administering IV medications. The ADON and the DON were responsible for conducting competency assessment during orientation. The ADON stated that RN 2's IV medication skills competency assessment had been missed. The ADON further stated that a licensed nurse who has not demonstrated competency could place residents at risk for infection. During an interview on 8/13/2026, at 3:25 p.m., with the DON, the DON stated that IV competency assessment must be completed during orientation to verify that the licensed nurse has necessary skills to start IVs and administer IV medications before working independently on the floor. The DON further stated that without a completed competency assessment, the licensed nurse might perform tasks incorrectly. The DON stated is it important that licensed nurses are competent to ensure safety of the residents. 3. During a review of Resident 3's Face Sheet , the Face Sheet indicated the facility originally admitted Resident 3 to the facility on 10/23/2025 and re-admitted on [DATE] with diagnosis that included urinary tract infection (UTI – an infection in the bladder/urinary tract), chronic kidney disease (kidneys are damaged and cannot filter blood as well), and diabetes mellitus (DM – a disorder characterized in blood sugar control and poor wound healing). During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 makes self-understood and able to understand others. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) with shower/bathe self, dressing, toileting hygiene and set-up or clean-up assistance (helper sets up cleans up; resident completes activity) with oral hygiene and eating. The MDS indicated Resident 3 had an indwelling catheter. During a review of the History and Physical (H&P) report completed on 6/15/2026, the H&P indicated Resident 3 has the capacity to understand and make decisions. During a review of Resident 6's Order Summary Report, the Order Summary Report indicated Resident is on enhanced barrier precaution due to resident with right elbow wound and foley catheter, date ordered 8/10/2026. During an observation on 8/11/2026 at 2:10 p.m., observed Resident 3's indwelling catheter drainage bag anchored to the left side of the bed frame above Resident 3's bladder with the urine visible inside. The drainage bag was observed to be attached to a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible), with the drainage bag placed outside of the dignity bag. During a concurrent observation and interview on 8/11/2026 at 2:12 p.m. with Certified Nursing Assistant (CNA) 9, observed CNA 9 not wearing a gown when CNA 9 applied the dignity bag to the drainage bag and proceeded to touch the catheter tubing. CNA 9 stated he did not need to wear a gown during catheter care. CNA 9 stated that wearing a gown is only necessary when providing direct contact care to Resident 3, such as cleaning the resident in bed or when bathing. CNA 9 stated the catheter drainage bag may be anchored anywhere along the bed rail and did not specifically require it to be above the bladder. When CNA 9 was asked what the blue cloth was attached to the drainage bag, CNA 9 stated that it was a cover for the drainage bag. CNA 9 stated the cover was to prevent infection in case Resident 3's urine is contaminated and urine leaks from the drainage bag. During an interview on 8/11/2026 at 2:20 p.m. with LVN 4 in Resident 3's room, LVN 4 stated Resident 3's drainage bag was inappropriately placed and should always be below the bladder. LVN 4 stated placing the drainage bag above the bladder can result in urine flowing back into Resident 3 and cause a UTI. LVN 4 stated Resident 3 is on EBP because of having an indwelling catheter and a gown should be worn during catheter care. LVN 4 stated it is important to follow EBP to prevent spread of infection. LVN 4 stated that indwelling catheter drainage bag should have a dignity bag for Resident 3's privacy, for the urine drainage not be seen by others. During an interview on 8/12/2026 at 2:54 p.m. with the DSD, the DSD stated that on 8/11/2026, CNA 9 did not demonstrate competency in infection control and catheter care based on CNA 9's responses and actions when observed and interviewed. The DSD stated that staff competency is important for resident safety and quality of care. The DSD stated that CNA 9's lack of competency placed Resident 3 and others at risk for infection. During an interview on 8/13/2026 at 4:15 p.m. with the DON, the DON stated that staff need to be competent to be able to give proper care to the residents. The DON stated that Resident 3 was placed at risk for a potential negative outcome when cared for by CNA 9 who did not demonstrate competency. During a review of CNA 9's Certified Nursing Assistant Competency Check List, dated 1/29/2026, CNA 9 completed skills competency for personal protective equipment/gown, gloves, mask.catheter care.promoting privacy. During a review of the facility's Job description Job title Certified Nursing Assistant (CNA), dated 2/6/2023, the document indicated The Certified Nursing Assistant assists in providing a clean, safe, dignified, happy, and healthy environment for residents performing duties as described below. Makes actual resident rounds, providing care, monitoring and observing at least times per shift.F/C (foley catheter – indwelling catheter) care and positioning as indicated/ordered.Ensuring provision of privacy and dignity.assures placement of equipment.performs infection control practices during resident care procedures. During a review of the facility's P&P titled, Staffing, Sufficient and Competent Nursing, last approved on 1/7/2026, the P&P indicated that the facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation. Competent Staff 1. 'Competency' is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. 2. All nursing must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas: a. Resident rights;. g. Basic nursing skills;. j. Medication management. l. Infection control. m. Identification of changes in condition.

Based on observation, interview, and record review, the facility failed to ensure each resident received necessary respiratory care and services consistent with professional standards of practice for two of two sampled residents (Resident 85 and 18) reviewed for respiratory care by failing to: 1. a. Ensure Resident 85's continuous positive airway pressure (CPAP- a non-invasive device used to help people breathe more easily, typically while sleeping or in a hospital setting) machine was kept clean, dry, and maintained according to manufacturer specifications. b. Ensure Resident 85's use of the CPAP machine was monitored and documented when it was applied and removed. 2. Store the nebulizer mask in a bag and kept the tubing off the floor for Resident 18. These failures increased the resident's risk of infection and respiratory complications.Findings: 1. During a review of Resident 85's Face Sheet (FS), the Face Sheet indicated that the facility originally admitted the resident on 3/26/2025 and readmitted on [DATE] with diagnoses including insomnia (trouble falling asleep or staying asleep), obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep when the throat muscles relax and cause the airway to collapse and block airflow), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 85's History and Physical (H&P), dated 11/6/2025, the H&P indicated the resident has the capacity to understand and make decisionDuring a review of Resident 85's Minimum Data Set (MDS-a resident assessment tool), dated 7/1/2026, the MDS indicated the resident with intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required partial/moderate assistance (helper does less than half the effort) with upper body dressing and personal hygiene and substantial/moderate assistance (helper does more than half the effort) with lower body dressing and ambulation. During a review of Resident 85's physician order, dated 11/13/2025, the physician order indicated an order AutoPeep (intrinsic positive end-expiratory pressure-when old air gets trapped inside the lungs) every hours of sleep for diagnosis of obstructive sleep apnea (OSA) four (4)-20 centimeters (cm-a unit of measurement) water and supplies. During a review of Resident 85's Care Plan (CP) focused on Sleep apnea, revised 6/23/2026, the CP indicated a goal that the resident will not have episodes of respiratory distress. The CP indicated an intervention to use CPAP machine as ordered and as needed, and Auto PEEP every hour of sleep for diagnosis of obstructive sleep apnea 4-20 cm water and supplies. During a concurrent observation and interview on 8/10/2026 at 9:11 a.m. with the Infection Preventionist Nurse (IPN), inside Resident 85's room, the IPN stated Resident 85 has a CPAP machine that the resident uses at night. The IPN stated the night shift staff removes the CPAP mask from the resident and cleans it. The IPN stated there is water inside the CPAP machine's canister. The IPN stated it should be dry. During an interview on 8/10/2026 at 10:37 a.m. with Resident 85, Resident 85 stated she has not used the CPAP machine in a long time. Resident 85 stated it has been months since she last used the CPAP machine. Resident 85 stated she is supposed to wear the CPAP machine at night, but she does not like wearing it. Resident 85 stated facility staff has never cleaned the CPAP machine. During an interview on 8/12/2026 at 7:53 a.m. with LVN 2, LVN 2 stated the purpose of the care plan is to follow the interventions and follow and resolve it. LVN 2 stated they do not know her resident condition and do not wear it. LVN 2 stated if resident could experience respiratory distress. During a concurrent interview and record review on 8/12/2026 at 7:46 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 85's physician orders, medication administration record for the month of 8/2026, nursing progress notes, and CPAP User Guide (undated) were reviewed. LVN 2 stated Resident 85's CPAP was recently discontinued because Resident 85 was not using it. LVN 2 stated when the CPAP is put on and removed it should be documented. LVN 2 stated if Resident 85 refuses to wear it should be documented on the MAR or in the progress notes so staff can determine how often it is used and whether it is effective in managing the resident's apnea. LVN 2 stated there is no care plan and no physician order for cleaning and maintaining of the CPAP machine. LVN 2 stated when the care instructions are not followed as indicated in the manufacturer's guidelines the resident is at risk for respiratory infection. LVN 2 stated she did not receive training for the use of this specific CPAP machine and would not know how to care for and use this machine. LVN 2 stated Resdeint 85 uses her own CPAP machine. During a concurrent interview and record review on 8/13/2026 at 8:11 a.m. with the Assistant Director of Nursing (ADON), the facility's policy and procedure titled, CPAP/BiPAP Support, last approved 1/7/2026 was reviewed. The ADON stated Resident 85 brought the CPAP machine from home, and it is the resident's personal property. The ADON stated they notified the physician on 8/12/2026 to obtain an order, however the resident stated she did not want to use it. The ADON reviewed the P&P titled General Guidelines for Cleaning, which indicated: 1. These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device. Document the following in the resident's medical record. 2. Time CPAP was started and duration of the therapy. 5. How the resident tolerated the procedure. Reporting 1. Notify the physician if the resident refuses the procedure. The ADON stated the P&P was not followed. The ADON stated when the P&P is not followed it could potentially compromise the health and safety of the resident. During a review of the facility's P&P titled, CPAP/BiPAP Support, last approved 1/7/2026, the P&P indicated that General Guidelines Cleaning 1. These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device. Document the following in the resident's medical record. 2. Time CPAP was started and duration of the therapy. 5. How the resident tolerated the procedure. Reporting 1. Notify the physician if the resident refuses the procedure. 2. During a review of Resident 18's Face Sheet, the Face Sheet indicated that the facility originally admitted the resident on 6/25/2021 and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), insomnia, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 18's H&P, dated 9/12/2025, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 18's MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognition. The MDS indicated the resident required supervision or touching assistance with upper body dressing, chair/bed-to-chair transfer, and partial/moderate assistance with lower body dressing and personal hygiene. During a review of Resident 18's physician order, dated 7/27/2026, the physician order indicated an order for ipratropium bromide (breathing treatment) inhalation solution 0.02 percent (%-per hundred) 250 micrograms (mcg-a unit of measurement) inhale orally every six hours as needed for COPDuring a concurrent observation and interview on 8/10/2026 at 9:11 a.m. with the IPN, inside Resident 18's room, the IPN stated the nebulizer mask is dangling on the side of the nebulizer machine, and the nebulizer tubing is on the floor. The IPN stated the nebulizer mask, and nebulizer tubing should be stored inside the plastic bag when not in use for infection control. During an interview on 8/13/2026 at 8:10 a.m. with the ADON, the ADON stated that the charge nurse/assigned LVN is responsible for ensuring that the nebulizer mask and tubing is stored as soon as the resident is done with the breathing treatment and it should be placed inside the bag. The ADON stated it should be stored in the bag to prevent contamination and maintain infection control. During a review of the facility's P&P titled, Administering Medications through a Small Volume (Handheld) Nebulizer, last approved 1/7/2026, the P&P indicated that The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway . Steps in the Procedure . 19. Administer therapy until medication is gone. 20. When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece and medication cup. 21. Wash and dry hands. 22. Rinse and disinfect the nebulizer equipment according to facility protocol, or: 23. Wash and dry hands. 24. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it

Based on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards for four (Resident 51, 74, 97, 112) of four residents investigated for accidents by failing to: 1.Ensure Residents Resident 74, 97 and 112 did not have furniture or equipment on top of the floor mat (a mat on the floor next to a resident's bed or chair to minimize the impact of a fall). 2. Ensure Resident 51 did not have medications or biologicals (medicines derived from living organisms, such as humans, animals, or microorganisms, rather than being created from chemicals) left at the bedside. These failures increase the risk of accidents such as falls with injuries, and accidental ingestion causing harm to residents. Findings: 1.a. During a review of Resident 74's Face Sheet, the Face Sheet indicated that the facility initially admitted Resident 74 to the facility on 8/09/2022, with diagnoses including difficulty on walking, lack of coordination and dementia (a progressive state of decline in mental abilities). During a review of Resident 74's Minimum Data Set (MDS- a resident assessment tool), dated 8/4/2026, the MDS indicated that Resident 74's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 74 required ranging from moderate assistance (helper does less than half the effort) to dependent (helper does all of the effort) physical assistance from staff for activities of daily living (ADLs – eating, toileting, hygiene, shower/bathing). During a review of Resident 74's Order Summary Report, dated 7/31/2026, the Order Summary Report indicated the following physician's order: -Support and Safety Device-Low bed with left side of bed against the wall and right-side floor mat to decrease potential injury when rolling out of bed or fall, every shift, initiated on 7/30/2026. During a review of Resident 74's Care Plan Report, titled At risk for falls, revised on 5/8/2026, the care plan indicated Resident 74 as at high risk for falls. The care plan indicated interventions to provide the resident frequent visual monitoring, floor mats, low bed if indicated, and placing the call light within easy reach. During a concurrent observation and interview on 8/10/2026 at 10:39 a.m. with Certified Nursing Assistant 7 (CNA 7), in Resident 74's room, the base of the intravenous pole stand (IV pole-tall metal stick with wheels and hooks at the top used to hold fluids) was observed on top of the floor mat. CNA 7 stated that Resident 74 was placed on a fall prevention program, and the floor mat was intended as a cushion during a fall to reduce the risk of injury. However, CNA 7 also stated that the IV pole's base should not be placed on top of the mat, as it could pose a safety hazard if the resident fell and struck it. During an interview on 8/10/2026 at 10:44 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that floor mats are provided for residents at high risk of falls. LVN 1 stated, all nursing staff are responsible for keeping the floor mats clear of any objects. LVN 1 further noted that placing the base of an IV pole on top of a floor mat defeats its purpose and increases the risk of injury. During an interview on 8/13/2026 at 12:50 p.m. with Director of Nursing (DON), the DON stated that floor mats are utilized to reduce the risk of injury should a resident experience a fall. The DON added that any unstable items or any object were not acceptable to be on top of the floor mat, as it could potentially fall onto a resident or a resident can fall over it and cause injury. The DON further stated that the presence of unsteady objects on top of the floor mat increases the risk of injury. b. During a record review of Resident 97's Face Sheet, the Face Sheet, indicated the facility admitted the resident on 7/30/2026, with diagnoses including difficulty in walking, dementia in other diseases classified elsewhere, unspecified (person has problems with memory, thinking, judgement or behavior that is caused by another medical disease); unspecified fall, subsequent encounter (had a fall and is receiving followed up care). During a review of Resident 97 's History and Physical (H&P), dated 7/31/2026, the H&P indicated the resident was alert but not oriented. During a review of Resident 97's MDS, dated [DATE], the MDS indicated the resident makes self-understood and understands others and had severe cognitive impairment (serious trouble thinking, remembering, or understanding things). The MDS indicated that Resident 97 required assistance ranging from substantial/maximal assistance (helper does more than half the effort) to total dependence (helper does all the effort) with mobility activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 97's Order Summary Report (OSR), dated 7/30/2026, the OSR indicated an order for Support & Safety Devise- Low bed with bilateral floor mat to decrease potential injury when rolling out of bed or fall every shift. During a record review of Resident 97 's Fall Risk Evaluation, dated 7/30/2026, the Fall Risk Evaluation indicated the resident was at high risk for falls. During a concurrent observation and interview on 8/10/2026, at 10:33 a.m., with Certified Nursing Assistant (CNA), inside Resident 97's room, observed a bed wheel on top of right floor mat. CNA 10 removed floor mat from underneath the bed wheel. During an interview for Resident 97 on 8/10/2026, at 2:20 p.m., with Certified Nursing Assistant (CNA) 10, CNA 10 stated that the purpose of the floor mat is for in case the resident falls the resident does not hit hard surfaces. CNA 10 stated that by having the floor mat under the wheel of the bed it defeats the purpose of having a floor mat because there is no protection in case the resident were to fall. CNA 10 stated that Resident 97 would hit the floor instead of landing on the floor mat in case the resident were to fall. During a concurrent interview and record review on 8/12/2026, at 9:13 a.m., with Registered Nurse (RN)1 reviewed Resident 97's Fall Risk Evaluation and care plan and stated the resident is at high risk for falls. RN 1 stated the floor mats are used for prevention of injury, if residents were to fall it reduces the likelihood of an injury. RN 1 stated that nothing needs to be on top of the floor mat because it defeats the purpose of the mat and if there is an object on top of the mat, there resident was at greater risk of injury, including bruising or possible fractures. During an interview on 8/13/2026, at 3:25 p.m., with Director of Nursing (DON), the DON stated that the purpose of the floor mat is if the resident rollover or falls the resident does not fall on the floor. The DON stated the floor mat was intended to provide cushioning and reduce the risk of injury and placing objects on the mat could prevent it from serving its intended purpose. c. During a review of Resident 112's Face Sheet, the Face Sheet, indicated the facility admitted the resident on 3/30/2025, with diagnoses including essential (primary) hypertension (high blood pressure with no known specific cause); history of falling and muscle weakness. During a review of Resident 112's History and Physical (H&P), dated 8/7/2026, the H&P indicated the resident was awake and alert During a review of Resident 112's MDS, dated [DATE], the MDS indicated the resident makes self-understood and understands others and had severe cognitive impairment (serious trouble thinking, remembering, or understanding things). The MDS indicated that Resident 112 's required assistance ranging from supervision (helper sets up or cleans up; resident completes the activity) to total dependence assistance with mobility and ADLs. During a review of Resident 112's Order Summary Report (OSR), dated 6/25/2026, the OSR indicated an order for Support & Safety Devise- Low bed with bilateral floor mat to decrease potential injury when rolling out of bed or fall every shift. During a record review of Resident 112 's Fall Risk Evaluation, the Fall Risk Evaluation, dated 7/1/2026, the Fall Risk Evaluation indicated the resident was at high risk for falls. During a concurrent observation and interview on 8/10/2026, at 3:38 pm, with Certified Nursing Assistant (CNA) 8, inside Resident 112's room observed an overbed table on top of the floor mat. CNA 8 stated the overbed table should not be on top of the floor mat because if the resident were to fall the resident can hit the metal part of the table and the resident can get hurt. During a concurrent interview and record review on 8/12/2026, at 9:40 a.m., with Registered Nurse (RN)1 reviewed Resident 112's Fall Risk Assessment and care plans. RN 1 stated the resident was at high risk for falls and the floor mats are used for prevention of injury, if the resident were to fall it reduces the likelihood of an injury. RN 1 stated the overbed table should not be on top of the floor mat because it defeats the purpose of the mat because the mat is for soft landing and reduces the impact of the fall. RN 1 stated that if the resident were to potentially fall the resident can hit the bottom metal part of the table causing injuries to the resident. During a concurrent interview and record review on 8/13/2026, at 3:25 p.m., with Director of Nursing (DON), the DON stated that the purpose of the floor mat is if the resident rollover or falls the resident does not fall on the floor. The DON stated the floor mat was intended to provide cushioning and reduce the risk of injury and placing objects on the mat could prevent it from serving its intended purpose. The DON stated that if bedside table is on top of floor mat the table can tip over and fall on resident. The DON stated that if resident were to fall then the resident can potentially hit the metal part of the table and result in injuries including skin tears or a bump. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, last reviewed on 1/7/2026, the P&P indicated, environmental factors that elevate the risk of falls include obstructions present in the footpath. The P&P also indicated that resident-centered approaches to managing falls and fall risk include staff members, in collaboration with the attending physician, will implement an individualized fall prevention plan aimed at mitigating the specific risk factors for each resident identified as being at risk or with a documented history of falls. 2. During a record review of Resident 51's Face Sheet, the Face Sheet, indicated the facility originally admitted the resident on 3/5/2020 and readmitted on [DATE], with diagnoses including type 2 diabetes mellitus without complications (a disorder characterized by difficulty in blood sugar control and poor wound healing); psoriasis, unspecified (a chronic skin condition that causes red, dry, scaly patches of skin; and allergy, unspecified, subsequent encounter (follow up care for an allergic reaction but the specific allergy is not identified). During a review of Resident 51's MDS, dated [DATE], the MDS indicated the resident makes self-understood and understands others and had intact cognitive function (normal thinking). The MDS indicated that Resident 51 required assistance ranging from independent (resident completes the activity by themself with no assistance from the helper) to moderate assistance (helper does less than half the effort) with mobility and ADLs. During a review of Resident 51's Self Administration of Drugs Assessment, dated 1/16/2025, the Self Administration of Drugs Assessment indicated the resident requires assistance to secure storage of medications kept in room and requires assistance to apply topical ointments and creams. During an observation on 8/10/2026, at 11:29 a.m., in Resident 51's room observed a Vicks VapoRub (a topical cough suppressant and topical analgesic ointment designed to relieve coughs due to minor throat and bronchial irritation associated with the common cold and contains a powerful blend of active ingredients including menthol, camphor, and eucalyptus oil) jar on Resident 51's bed. Resident 51 stated that she uses it to put it in her nostrils and chest. On the dresser observed a Vaseline (is a thick pure petroleum jelly skin protectant and moisturizer used to heal dry or cracked skin and protects minor cuts and burns) jar and Resident 51 stated she uses it to put it on her arms. During a concurrent observation and interview on 8/12/2026, at 7:57 a.m., with Certified Nursing Assistant (CNA)11, inside Resident 51's room, CNA 11 observed the Vicks VapoRub jar on the resident's bed and the Vaseline jar on top of the dresser. CNA 11 stated no medication should be in the room with the resident if there is no physician order for the resident to have the medications. CNA 11 stated the resident can put it in their eyes or mouth; or other residents may get them and swallow the medication. CNA 11 took both jars and took them to the nurse supervisor. During a concurrent interview and record review on 8/12/2026, at 8:18 a.m., with Registered Nurse (RN) 1, RN 1 stated that in order for the resident to have medications in the room there needs to be a self-administration assessment, to check if the resident is alert and oriented, a physician order, a box that is locked, and a care plan. RN 1 reviewed Resident 51's Self Administration of Drugs assessment dated 1/16/2025 and RN 1 stated Resident 51 requires assistance to apply topical ointments and creams. RN 1 reviewed the resident's electronic medical record and stated there was no physician order and care plan for the use of Vicks VapoRub and Vaseline, therefore it is not safe to have them at bedside because residents would not know how to take or apply the medication. RN 1 stated the resident could potentially apply them to an unintended area, such as the eyes or mouth. During an interview on 8/13/2026, at 3:25 p.m., with Director of Nursing (DON), DON stated when medications are left in a resident's room, the resident may use them incorrectly or experience adverse effects. Another resident could also access and ingest the medications. During a review of the facility's Policy and Procedure (P&P) titled, Self-Administration of Medications, last reviewed on 1/7/2026, the P&P indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the residents to do so. Policy Interpretation and Implementation 1. As part of the evaluation comprehensive assessment, the interdisciplinary team IDT assesses each resident's cognitive and physical abilities to determine whether self-administrating medications is safe and clinically appropriate for the resident. 8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. During a review of the facility-provided Vicks VapoRub Original Ointment Instruction Manual, undated, the instruction manual indicated is a topical cough suppressant and topical analgesic ointment designed to relieve coughs due to minor throat and bronchial irritation associated with the common cold, and to temporarily relieve minor aches and pains in muscles and joints. The Safety Information and Warnings indicated for external use only, avoid contact with eyes, and do not use by mouth or in nostrils. Keep out of reach of children. If swallowed, get medical help or contact a Poison Control Center right away. During a review of the facility-provided User Manual: Vaseline 100% Pure Petroleum Jelly Skin Protection, undated. The user manual indicated that it creates a protective barrier to lock in moisture and helps heal dry or cracked skin, lips, elbows, and heels. Warning and Precautions indicated for external use only. Do not use on deep puncture wounds, animal bites, or serious burns. Avoid contact with eyes. If swallowed, get medical help or contact Poison Control Center immediately.

Based on observation, interview, and record review the facility failed to ensure residents were free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for three of four sampled residents (Residents 17, Resident 74 and Resident 117) by failing to: 1. Complete a Physical Restraint Assessment Form, obtain a physician order, and obtain informed consent from the resident or resident representative prior to placing four bed side rails up and tucking a wedge pillow (special triangle-shaped pillows that raise the top half of the body while sleeping) under the fitted sheet for Resident 17. 2. Ensure the physician's order included the indication for use, a discontinuation date and the need for reevaluation of the resident's use of bilateral hand mitten restraints for Resident 74 in accordance with the facility's policy & procedure (P&P) titled, Use of Restraints, last reviewed on 1/07/2026. 3. Ensure Resident 117 was not placed in a non-self-release soft belt restraint while in the wheelchair. These failures had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from), and death of residents. Findings: 1. During a review of Resident 17's Face Sheet, the Face Sheet indicated that the facility admitted Resident 17 to the facility on 3/18/2025, with diagnoses including legal blindness, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), history of falling and dementia (a progressive state of decline in mental abilities). During a review of Resident 17's Minimum Data Set (MDS- a resident assessment tool), dated 6/23/2026, the MDS indicated that Resident 17's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 17 required ranging from moderate assistance (helper does less than half the effort) to dependent (helper does all of the effort) physical assistance from staff for activities of daily living (ADLs – eating, toileting, hygiene, shower/bathing). The MDS did not indicate Resident 17 was using physical restraints. During a review of Resident 17's History and Physical (H&P), the H&P indicated that Resident 17 does not have the capacity to understand and make decisions. During a review of Resident 17's Order Summary Report, dated 7/31/2026, the Order Summary Report indicated the following physician's order: -Support and Safety Device-Low bed with bilateral upper half side rails up and locked when in bed for ADL changes, mobility, positioning, and to decrease potential injury when rolling out of bed, every shift, initiated on 3/12/2026. During a review of Resident 17's Care Plan Report, titled Support and Safety Device, revised on 5/13/2026, the care plan indicated an intervention to attempt to use less restrictive devices on an ongoing basis. that includes a directive to continually strive to use less restrictive devices whenever possible. During a concurrent observation and interview on 8/10/2026 at 11:38 a.m. with Licensed Vocational Nurse 1 (LVN 1), in Resident 17's room, observed four bed side rails were up, and a wedge pillow was tucked under the fitted sheet in Resident 17's right side. LVN 1 stated that the wedge pillow was used as a repositioning device to prevent pressure and should be placed on top of the sheet. LVN 1 added that there must be a physician's order, assessment, informed consent and a care plan for the use of all bed siderails. During a follow up concurrent interview and record review on 8/10/2026 at 11:38 a.m. with LVN 1, Resident 17's records including the Order Summary Report, Supportive and Safety Device/Restraint Physical dated 6/23/2026, the Physical Restrain Informed Consent dated 3/13/2026, and Care Plan Report were reviewed. LVN 1 stated that according to these records, Resident 17 had a physician's order, assessment, informed consent, and care plan for using bilateral upper bed siderails, but not for four bed siderails or for a wedge pillow placed under fitted sheets. LVN 1 stated that all four bed siderails should not be used. LVN 1 stated that it is the registered nurse's responsibility to make sure there are proper physician orders, informed consent, assessments, and care plan for any restraints used. LVN 1 stated that the physician's order documents the necessity, informed consent ensures residents understand the use, and the care plan guarantees that appropriate assessments and plan of care are followed. LVN 1 further stated she would educate certified nursing assistants about proper placement of side rails and wedge pillows, as these devices restrict resident movement and require informed consent before use. During an interview on 8/13/2026 at 12:50 p.m. with Director of Nursing (DON), the DON stated that the facility does not utilize all four bedside rails, as this practice is considered a form of restraint. The DON explained that wedge pillows are devices intended for repositioning and should be placed on top of the sheet. The DON stated that placing them under fitted sheets is inconsistent with their intended purpose. The DON further stated that prior to the use of restraints, a physician's order, assessment, informed consent, and care plan must be completed. Additionally, the DON emphasized that staff members should neither employ four side rails nor position wedge pillows under fitted sheets, as these actions restrict residents' ability to remove them independently and consequently limit mobility. The DON also stated the potential risks associated with restricted movement and safety concerns if residents attempt to exit the bed. 2. During a review of Resident 74's Face Sheet, the Face Sheet indicated that the facility admitted Resident 74 to the facility on 8/09/2022, with diagnoses including difficulty in walking, lack of coordination and dementia (a progressive state of decline in mental abilities). During a review of Resident 74's MDS dated [DATE], the MDS indicated that Resident 74's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 74 required ranging from moderate assistance to dependent physical assistance from staff for ADLs. The MDS also did not indicate Resident 74 was using physical restraints. During a review of Resident 74's Order Summary Report, dated 7/31/2026, the Order Summary Report indicated the following physician's order: -Support and Safety Device-Apply hand mitten to both hands to secure central line. Hand hygiene will be provided during release of hand mitten. Monitor placement; Every shift, initiated on 7/31/2026, no discontinuation date. -Monitor both hands for skin breakdown, impaired circulation every two hours for mitten use, initiated on 7/31/2026. During a review of Resident 74's Care Plan Report, titled Use of Mittens to Secure Central Line, initiated on 7/31/2026, the care plan indicated a goal that the mittens are to be discontinued once they are no longer clinically necessary. The care plan outlined interventions including reassessment of the need for mittens following any improvement in cognition, with discontinuation as soon as clinically appropriate. During a concurrent observation and interview on 8/10/2026 at 10:39 a.m. with Certified Nursing Assistant 7 (CNA 7) in Resident 74's room, Resident 74 was observed with bilateral hand mittens. CNA 7 stated Resident 74 had bilateral hand mittens so that he does not pull out his intravenous catheter (a tube placed inside a vein to give fluids or medication directly into the blood stream). During an interview on 8/10/2026 at 10:44 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that Resident 74 was receiving intravenous antibiotics and had a physician's order for bilateral hand mittens. LVN 1 stated that skin circulation and integrity are monitored every two hours while the mittens are in use. However, LVN 1 was not aware of the required frequency for reevaluating the continued necessity of the bilateral hand mittens. During a concurrent interview and record review on 8/12/2026 at 11:38 a.m. with Assistant Director of Nursing (ADON), Resident 74's records titled order summary report and facility policy and procedure titled Use of Restraints, dated on 1/7/2026 were reviewed. The ADON explained that a physician's order for restraints can be obtained by either the registered nurse or the licensed vocational nurse. The ADON stated that physician order for the bilateral hand mittens for Resident 74 was intended to secure a central line that started on 7/31/2026, but there was no discontinuation date indicated. The ADON stated that the mittens should be used only if Resident 74 interferes with medical treatments such as pulling out the line—not simply to secure the central line. The ADON added the need for a discontinuation date of the physician order, since restraints should not be used indefinitely and must be removed once they are no longer necessary. According to the ADON, the facility's P&P regarding restraint use were not followed; the physician's order for the bilateral hand mittens lacked both a specific medical reason and a discontinuation date. The ADON indicated that there was no reevaluation of the continued use of the hand mittens. The ADONs stated that reevaluation is crucial in order to determine whether the restraint remains needed, or if it should be discontinued. The ADON further stated that using restraints impacts the resident by limiting their movement, which can compromise their rights and quality of life. During an interview on 8/13/2026 at 12:50 p.m. with the Director of Nursing (DON), the DON stated that hand mittens are classified as physical restraints and require a physician's order, informed consent, assessment, and implementation of a care plan. The DON explained that an appropriate physician's order would indicate the need for resident safety, such as preventing removal of a central line, and must also include a discontinuation date. The DON further stated that a weekly reevaluation of mitten use is necessary, and both initial assessment and regular reassessment are important to determine whether the resident still requires restraints. The DON indicated that when the restraints are no longer needed, the restraints should be discontinued. During a review of the facility's Policy and Procedure (P&P) titled, Use of Restraints, last reviewed on 1/7/2026, the P&P states that restraints shall be utilized solely for the safety and well-being of residents and only when necessary to address a medical symptom. The P&P mandates application of the least restrictive measures for the minimal duration required, with ongoing re-evaluation of restraint necessity documented accordingly. Physical Restraint is defined as any manual method or physical or mechanical device, material, or equipment attached to or placed near the resident's body that cannot be easily removed by the individual, thereby restricting freedom of movement or normal access to their body. Examples include hand mitts, soft ties or vests, lap cushions, among others. Furthermore, the P&P specifies that inappropriate use of equipment to inhibit resident mobility constitutes a restraint and is prohibited; this includes practices such as employing bedrails to prevent voluntary bed exit or tucking sheets so tightly that a bed-bound resident cannot move. Prior to the application of any restraint, informed consent must be obtained from the resident or their responsible party. Use of restraints is permitted only upon receipt of a written physician order specifying the purpose related to the resident's medical symptom, intended benefit, type of restraint, and duration of use. Care plans must outline strategies aimed at systematically reducing or eliminating the need for restraints. Documentation regarding restraint use should detail the resident's medical symptoms necessitating restraint, the specific types of physical restraints applied, effectiveness and duration of use, among other pertinent information. During a review of facility's P&P, titled Bed Safety and Bed Rails, last reviewed on 1/7/2026, the P&P indicated that bed rails cannot be used unless certain criteria are met. These criteria include trying alternative options, conducting an interdisciplinary evaluation, assessing the resident, and securing informed consent. The P&P also states that before putting bed rails in place for any reason, staff must explain both the benefits and risks to the resident or their representative and obtain their informed consent. 3. During a review of Resident 117's Face Sheet, the Face Sheet indicated that the facility originally admitted the resident on 7/10/2023 and readmitted on [DATE] with diagnoses including senile degeneration of the brain (the loss of brain cells and cognitive decline, such as memory loss), vascular dementia (a progressive state of decline in mental abilities caused by restricted blood flow or strokes that damage brain tissue), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and glaucoma (a group of diseases that damage the eye's optic nerve and can result in vision loss and even blindness). During a review of Resident 117's H&P, dated 7/142026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 117's MDS, dated [DATE], the MDS indicated the resident rarely/never makes self-understood and rarely/never has the ability to understand others. The MDS indicated the resident had severely impaired cognition with long-term and short-term memory problem. The MDS indicated that the resident had severely impaired cognitive skills for daily decision making and uses wheelchair as a mobility device. The MDS indicated the resident required substantial/maximal assistance with sit to stand, lying to sitting on side of bed, sitting to lying, and chair/bed-to-chair transfer. The MDS indicated that the resident has not used any physical restraints. During a review of Resident 117's Care Plan focused on Self-Release Seat Belt while in wheelchair for positioning, revised 8/9/2026, the care plan indicated a goal to prevent or reduce incident of injury/fall. The care plan indicated an intervention to attempt to use less restrictive devices on an ongoing basis. During a review of Resident 117's Order Summary Report, dated 8/9/2026, the Order Summary Report indicated an order for support and safety device – self-release seat belt while in wheelchair for positioning. During an observation on 8/10/2026 at 11:51 a.m., inside Dining Room B, Resident 117 was sitting in a wheelchair with a white soft belt with a buckle wrapped around her waist. The belt's securing ties were wrapped straight across the back of the wheelchair and tied in a knot. During a concurrent observation and interview on 8/11/2026 at 12:03 p.m. with CNA 3, inside the Dining Room B, CNA 3 stated she is the assigned CNA today, 8/11/2026, for Resident 117. CNA 3 stated she has taken care of Resident 117 before. CNA 3 stated that yesterday, 8/10/2026, and today, 8/11/2026, she (CNA 3) applied the soft-belt restraints to Resident 117 while the resident was up in the wheelchair. CNA 3 stated the soft-belt restraint is used for Resident 117 to prevent the resident from falling forward because she likes to wheel herself around. CNA 3 stated Resident 117 cannot physically remove the soft-belt waist restraint. When CNA 3 was asked to instruct Resident 117 to remove her soft-belt restraint, CNA 3 provided instruction in Resident 117's spoken language. CNA 3 stated Resident 117 is confused and does not understand the instruction. CNA 3 asked Resident 117 for the second time, Resident 117 pointed at the floor. CNA 3 stated Resident 117 is not following the instruction and is easily distracted. CNA 3 demonstrated and instructed Resident 117 to release the belt herself (Resident 117). CNA 3 stated Resident 117 cannot release the belt herself (Resident 117) and has to be released by her (CNA 3). CNA 3 stated she ties the belt around the wheelchair poles and across and tie them in a knot that could be released with one pull. CNA 3 stated she then checks to make sure it is not too tight around Resident 117's waist. CNA 3 stated this was how she remembered she was taught to apply the soft belt restraint when the resident is sitting in the wheelchair. CNA 3 stated when Resident 117 cannot remove the restraint by herself that it is okay because she (CNA 3) removes it for her when the resident goes back to bed. During an interview on 8/12/2026 at 3:38 p.m. with the Director of Staff Development (DSD), the DSD stated CNAs are trained in the proper application and release of restraints. The DSD stated they provide demonstration and return demonstration and how to securely fasten the ties in a crisscross pattern. During a concurrent interview and record review on 8/13/2026 at 8:36 a.m. with the ADON, Resident 117's Interdisciplinary Team (IDT) note, dated 8/10/2026, was reviewed. The ADON stated Resident 117 was assessed on 8/9/2026 and the physician and resident representative were contacted on 8/9/2026 and the resident representative provided consent for the use of the self-release seat belt. The ADON stated the difference between a non-self-release belt restraint and a self-release belt restraint is that the self-release belt comes with a buckle and that the resident can release it independently. The ADON stated that when the resident cannot follow the instructions then the team would need to reassess the appropriateness of using the restraints. The ADON stated the assigned CNA should have reported it to the charge nurse, and the charge nurse should have notified the resident's physician because it limits the resident's mobility and could potentially cause skin breakdown. During an interview on 8/14/2026 at 12:22 p.m. with LVN 1, LVN 1 stated she was the charge nurse for Resident 117 on 8/11/2026. LVN 1 stated Resident 117 has an order for a self-release belt while in wheelchair. LVN 1 stated the self-release belt has a clip from the front and the non-self-release belt does not have one and is just tied. LVN 1 stated criteria for self-release belt would show that Resident 117 can release it and provided consent before use. LVN 1 stated the CNAs applies the restraint to the resident and no one has reported to her that Resident 117 was not able to release the belt by herself. LVN stated CNA should have informed her so Resident 117 could be reassesed to determine whether the use of a self-release belt restraint remained appropriate. During a review of the facility's policy and procedures (P&P) titled, Use of Restraints, last approved on 1/7/2026, the P&P indicated Restraints shall only be used for the safety and well- being of the resident(s) and only after other alternatives have been tried unsuccessfully. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Policy Interpretation and Implementation: 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered as a restraint. 6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessments shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. 9. Restraints shall only be used the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of restraint. 14. Residents and/or surrogate/ sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use. 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptoms(s), but the underlying problems that may be causing the symptom(s). During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last approved on 1/7/2026, the P&P indicated that A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. During a review of the facility's P&P titled, Care Planning- Interdisciplinary Team, last approved on 1/7/2026, the P&P indicated that The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation : 1. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). During a review of the facility-provided Self-Releasing Padded Belts Application Instructions, dated 5/14/2021, the application instructions indicated: CAUTION This product is designed for self-release. If the patient is not able to easily self-release, it is considered a restraint and must be prescribed by a physician. CONTRAINDICATIONS:. DO NOT use on a patient who is unwilling or unable to follow instructions, and at risk of a fall or re-injury from self-release. APPLICATION INSTRUCTIONS: WHEELCHAIR CAUTION. 3. Bring the ends of the connecting straps down at a 45-degree angle between the seat and the wheelchair sides (fig.1). Criss-cross the straps behind the chair and draw them around the opposite side kick spurs (fig. 2). 4. Secure the connecting straps, out of the patient's reach, using quick-release ties. Check that the straps are secure and will not change position, loosen, or tighten if the patient pulls on them, or if the chair is adjusted. 6. The patient may release the belt by opening the quick release buckle or hook and loop fastener.

Based on observation, interview, and record review, the facility failed to ensure proper labeling of peripheral intravenous (IV-a small, flexible tube placed into a small vein and kept there for intravenous therapy such as medication fluids) saline lock (SL-a type of intermittent intravenous device for the administration of solution or medication) site, IV antibiotics, and IV tubing (plastic tube that connects the IV fluid or medication bag to the IV SL site and allows medication to flow into the vein) for one out of one sampled resident (Resident 146) by failing to: 1. Label peripheral IV site dressing with date, time and the initials of the nurse who inserted or changed the peripheral IV dressing. 2. Label the IV antibiotic with date, time, and initials of the administering nurse. 3. Label IV tubing with date, time, and initials of the nurse who hung the tubing. These failures increased the risk of inadequate monitoring and delayed identification of an IV site infection. Findings: During a record review of Resident 146's Face Sheet, the Face Sheet, indicated the facility originally admitted the resident on 8/3/2026 and readmitted on [DATE], with diagnoses including sepsis due to methicillin susceptible staphylococcus aureus (a serious infection in the bloodstream caused by a type of bacteria called MSSA, which can cause low blood pressure, problems with organs, and potentially life-threatening illness), cutaneous abscess of abdominal wall (an infected lump or collection of pus in the skin/tissue of the stomach area), and local infection of the skin and subcutaneous tissue, unspecified (the skin and tissue underneath it are infected, but the specific type of infection is not specified). During a review of Resident 146's History and Physical (H&P), dated 8/4/2026, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 146's Minimum Data Set (MDS- a resident assessment tool), dated 8/8/2026, the MDS indicated the resident makes self-understood and understands others and had intact cognitive function (normal thinking). The MDS indicated that Resident 146 required assistance ranging from set up assistance (helper sets up or cleans up; resident completes the activity) to moderate assistance (helper does less than half the effort) with mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 146's Order Summary Report (OSR), dated 8/3/2026, the Order Summary Report indicated the following orders: -IV Medication: Tubing Hang, Change every 24 hours - Peripheral IV site care every 72 hours for site care, Restart IV and subcutaneous site (Additional MD order required for insertion of IV catheter into lower extremities) and as needed for Complications May extend IV site for poor venous access if no complications are present. Change dressing with site change and PRN (as needed). During a concurrent observation and interview on 8/10/2026, at 3:45 p.m., inside Resident 146's room observed Resident 146 sitting in bed, with a PIV inserted in the right forearm and connected to an IV tubing. The IV tubing was connected to cefazolin antibiotic bag, and the infusion had been completed. The antibiotic bag did not have a label indicating the date, time, and initials of the administering nurse. During a concurrent observation and interview on 8/10/2026, at 3:55 p.m., with Registered Nurse (RN) 2, RN 2 observed right forearm IV site wrapped with flexible cohesive bandage which was connected to the IV tubing. RN 2 disconnected the IV tubing from saline lock and removed the flexible cohesive bandage around the IV site and stated the IV site does not have date, time, and initials of the licensed nurse that started the IV or changed the IV dressing. RN 2 also stated that IV tubing and antibiotic bag were not labeled with date time and initials when the antibiotic was started. RN 2 stated the IV tubing is changed every 24 hours and the IV site every seven days to reduce risk complications including infections and infiltration (fluid or medication leaks out of the vein into the surrounding tissue instead of staying in the vein). RN 2 stated if the IV site was not labeled with the start date, the nurses may not know when it was inserted or when it should be changed. During a telephone interview on 8/12/2026, at 3:09 p.m., with Registered Nurse (RN) 2, RN 2 stated it was important to label the IV antibiotic bag and tubing with date, time, and nurse's initials so staff would know when the infusion was started, when to disconnect it, and when to change the tubing. RN 2 stated that she did not check the IV site before administering the antibiotic and forgot to label the IV antibiotic bag and tubing. During a concurrent interview and record review on 8/13/2026, at 9:56 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that the IV tubing should have been disconnected from IV SL site and flushed after the infusion was completed. The ADON stated that the IV medication, IV tubing, and IV site dressing were supposed to be labeled with date, time, and initials for infection control and if they are not labeled, they should have been changed because nurses could not verify when they were started. changed. The ADON reviewed the policy and procedures (P&P) titled, General Policies for IV Therapy, Peripheral Venous Catheter Insertion, and Peripheral IV Catheter Insertion and stated these P&P were not followed. During an interview on 8/13/2026, at 3:25 p.m., with Director of Nursing (DON), the DON stated that if the medications were not properly labeled, they could be administered to the wrong resident, resulting in a medication error. If the IV medication and tubing were not labeled with the date, time, and nurse's initials, nurses could not determine how long they had been used, increasing the risk of contamination and infection. During a review of the facility's Policy and Procedure (P&P) titled, General Policies for IV Therapy, last reviewed on 1/7/2026, the P&P indicated IV tubing will be changed every 96 hours for continuous therapy, and every 24 hours for intermittent, TPN and lipids. IV tubing will be labeled with the date, time, and a nurse hanging tubing. All additive labels will be completed by the nurse administering the IV fluid/medication and are to include the nurse's initials, date and time. During a review of the facility's Policy and Procedure (P&P) titled, Peripheral Venous Catheter Insertion, last reviewed on 1/7/2026, the P&P indicated RNs and Certified LVNs according to the state law and facility policy. Procedure: Write date, time, and initials on the dressing label. During a review of the facility's Policy and Procedure (P&P) titled, Peripheral IV Catheter Insertion, last reviewed on 1/7/2026, the P&P indicated the purpose of this procedure is to provide guidelines for the safe and aseptic insertion of a peripheral intravenous catheter for the administration of intravenous fluids and/or medications. Steps in the procedure 14. Place label on one side of catheter (not over insertion site). Include the date and time of catheter insertion, initials, length and gauge of catheter on the label.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 107) enteral feeding syringe (is a medical device specifically designed to deliver liquid nutrition, hydration, and medication directly into the patient's digestive tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces] via the gastrostomy tube [G-tube, a tube inserted through the abdomen directly into the stomach to provide nutrition, fluids, or medications]) was changed daily in accordance with the physician's order. This failure had the potential to increase the risk of contamination and infection to Resident 107.Findings: During a review of Resident 107's Face Sheet, the Face Sheet indicated that the facility originally admitted the resident on 8/17/2024 and readmitted on [DATE] with diagnoses including encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dementia (a progressive state of decline in mental abilities), and dyskinesia of esophagus (a condition where the muscular tube connecting the mouth and stomach does not work right). During a review of Resident 107's History and Physical (H&P), dated 7/30/2026, the H&P indicated that the resident has fluctuating capacity to make medical decisions. During a review of Resident 107's Minimum Data Set (MDS-a resident assessment tool), dated 7/19/2026, the MDS indicated that the resident usually makes self-understood and has the ability to understand others. The MDS indicated that the resident has severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated that the resident received nutrition through feeding tube while a resident of the facility. During a review of Resident 107's physician order, dated 7/29/2026, the physician order indicated the following order: - Enteral Feed Order [Enteral] Change feeding syringe (60 cc [cubic centimeter - a unit of volume used to measure liquid]) every 11 p.m. to 7 p.m. During a review of Resident 107's Care Plan (CP) focused on GT feeding, revised 1/29/2026, the CP indicated the resident with a goal of minimizing risk of infection at GT site which included interventions to administer enteral feedings as ordered and to change tubings per policy or as orderedDuring an observation on 8/10/2026 at 9:49 a.m., inside Resident 107's room, observed a feeding syringe at bedside, dated 8/8/2026. During a concurrent observation and interview on 8/10/2026 at 9:56 a.m. with the Infection Preventionist Nurse (IPN), inside Resident 107's room. The IPN stated Resident 107 has a feeding tube, and the feeding syringe is changed daily by the 11 p.m. to 7 p.m. shift licensed nurse. The IPN stated feeding syringe plastic sleeve containing the feeding syringe was dated 8/8/2026, however, the feeding syringe itself was not dated. The IPN further stated that the syringe appeared to contain residue from crushed medication and should have been changed daily. During a concurrent interview and record review on 8/12/2026 at 7:33 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 107's physician orders and medication administration record (MAR) for the month of 8/2026 were reviewed. LVN 2 stated feeding syringe is changed daily as ordered by the physician and is done by the night shift LVN. LVN 2 stated her initial and check mark on the electronic MAR (eMAR) means that she changed the feeding syringe on 8/8/2026. LVN 2 stated she writes the date on the feeding syringe to let the next shift nurse know that the feeding syringed had been changed. LVN 2 stated she worked on 8/7/2026 11 p.m. to 7 a.m. shift and was off on 8/9/2026 and 8/10/2026. LVN 2 stated that she had until 7 a.m. to change the feeding syringe and dated it 8/8/2026 to inform the oncoming 7 a.m.-3 p.m. shift nurse that it had been changed. LVN 2 that the eMAR indicated that the feeding syringe was changed on 8/9/2026 and 8/10/2026, however the feeding syringe at the resident's bedside was dated 8/8/2026, indicating that it had not been changed. LVN 2 stated the resident could potentially develop an infection from the continued use of a feeding syringe that was not changed daily. During an interview on 8/13/2026 at 8:27 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the facility's policy is to follow the manufacturer specifications to change the feeding syringe daily by the 11 a.m. to 7 p.m. shift nurse. The ADON stated not changing the feeding syringe daily could place Resident 107 at risk for infection. During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, last approved 1/7/2026, the P&P indicated that the purpose of this P&P is To ensure the safe administration of enteral nutrition . Preparation . 2. The facility will remain current in and follow accepted best practices in enteral nutrition . General Guidelines . Preventing misconnection errors . 7. Use only enteral tubing, syringes and devices with [Enteral Syringe Company (ESC) 1] connectors During a review of the manufacturer specification titled, [ESC 1] Tip Syringe, dated 2024, the manufacturer specification indicated Features . [ESC 1] connector designed to reduce the risk of tubing misconnections . 7. Must be replaced every 24 hours

Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling catheter (a tube inserted into the bladder to drain or collect urine) was kept below the level of the bladder for one of two sampled residents (Resident 3). This deficient practice had the potential to result in the resident acquiring a urinary tract infection (UTI - an infection in the bladder/urinary tract). Findings: During a review of Resident 3's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 3 on 10/23/2025 and re-admitted the resident on 6/14/2026 with diagnosis that included urinary tract infection, chronic kidney disease (kidneys are damaged and cannot filter blood as well), and diabetes mellitus (DM - a disorder characterized in blood sugar control and poor wound healing). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 6/26/2026, the MDS indicated Resident 3 makes self-understood and able to understand others. The MDS indicated Resident 3 required substantial/maximal assistance (helper does more than half the effort) with shower/bathe self, dressing, toileting hygiene and set-up or clean-up assistance (helper sets up cleans up; resident completes activity) with oral hygiene and eating. The MDS indicated Resident 3 had an indwelling catheter. During a review of Resident 3's History and Physical (H&P) dated 6/15/2026, the H&P indicated Resident 3 has the capacity to understand and make decisions. During a concurrent observation and interview on 8/11/2026 at 2:12 p.m., with Certified Nursing Assistant 9 (CNA 9), observed Resident 3's indwelling catheter drainage bag anchored to the left side of the bed frame above Resident 3's bladder. CNA 9 stated that the catheter drainage bag may be anchored anywhere along the bed rail and did not specifically require it to be above Resident 3's bladder. During an interview on 8/11/2026 at 2:20 p.m., with Licensed Vocational Nurse 4 (LVN) 4 in Resident 3's room, LVN 4 stated Resident 3's drainage bag was inappropriately placed and should always be below the bladder. LVN 4 stated placing the drainage bag above the bladder can result in urine flowing back into Resident 3 and cause a UTI. During an interview on 8/13/2026 at 4:15 p.m., with the Director of Nursing (DON), the DON stated it was important to ensure Resident 3's catheter drainage bag always remained below the bladder to prevent Resident 3 from acquiring a UTI. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, last reviewed 1/7/2026, the P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.

Based on interview and record review, the facility failed to develop and implement a person-centered care plan for one of 28 sampled residents (Resident 85) by failing to ensure Resident 85 had a care plan addressing the proper use, cleaning, and maintenance of the continuous positive airway pressure (CPAP- machine that delivers a steady flow of air through a mask to keep a person's airway open while sleeping) machine. This failure had the potential to result in the necessary care not being provided, leading to complications.Findings: During a review of Resident 85's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 3/26/2025 and readmitted on [DATE] with diagnoses including insomnia (trouble falling asleep or staying asleep), obstructive sleep apnea (a disorder where breathing repeatedly stops and starts during sleep when the throat muscles relax and cause the airway to collapse and block airflow), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest)During a review of Resident 85's History and Physical (H&P), dated 11/6/2025, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 85's Minimum Data Set (MDS-a resident assessment tool), dated 7/1/2026, the MDS indicated the resident has intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required partial/moderate assistance with upper body dressing and personal hygiene and substantial/moderate assistance with lower body dressing and ambulation. During a review of Resident 85's physician order, dated 11/13/2025, the physician order indicated an order for AutoPeep (intrinsic positive end-expiratory pressure-when old air gets trapped inside the lungs) every hours of sleep for diagnosis of obstructive sleep apnea (OSA) four (4)-20 centimeters (cm-a unit of measurement) water and supplies. During a review of Resident 85's Care Plan (CP) focused on Sleep apnea, revised 6/23/2026, the CP indicated a goal that the resident will not have episodes of respiratory distress. The CP indicated an intervention to use CPAP machine as ordered and as needed, and Auto PEEP every hour of sleep for diagnosis of obstructive sleep apnea 4-20 cm water and supplies. During a concurrent observation and interview on 8/10/2026 at 9:11 a.m. with the Infection Preventionist Nurse (IPN), inside Resident 85's room, the IPN stated Resident 85 has a CPAP machine that the resident uses at night. The IPN stated the night shift staff removes the CPAP mask from the resident and cleans it. The IPN stated there is water inside the CPAP machine's canister. The IPN stated it should be dry. During an interview on 8/10/2026 at 10:37 a.m. with Resident 85, Resident 85 stated she has not used the CPAP machine in a long time. Resident 85 stated it has been months since she last used the CPAP machine. Resident 85 stated she is supposed to wear the CPAP machine at night, but she does not like wearing it. Resident 85 stated facility staff has never cleaned the CPAP machine. During a concurrent interview and record review on 8/12/2026 at 7:46 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 85's physician orders, medication administration record for the month of 8/2026, nursing progress notes, and CPAP User Guide (undated) were reviewed. LVN 2 stated Resident 85's CPAP was recently discontinued because Resident 85 was not using it. LVN 2 stated when the CPAP is put on and removed it should be documented. LVN 2 stated if Resident 85 refuses to wear it should be documented on the MAR or in the progress notes so staff can determine how often it is used and whether it is effective in managing the resident's apnea. LVN 2 stated there is no care plan and no physician order for cleaning and maintaining of the CPAP machine. LVN 2 stated when the care instructions are not followed as indicated in the manufacturer's guidelines the resident is at risk for respiratory infection. LVN 2 stated she did not receive training for the use of this specific CPAP machine and would not know how to care for and use this machine. During an interview on 8/13/2026 at 8:24 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the interventions for using and caring for the CPAP machine should be care planned. The ADON stated when licensed nurses do not document the resident's use of the machine in the progress notes, it could compromise the resident's health. The ADON stated the care plan is a tool to manage the resident's care and the care plan should have interventions addressing proper use and cleaning of the CPAP machine in accordance with the manufacturer's guidelines to ensure Resident 85 does not develop an infection. During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, last approved on 1/7/2026, the P&P indicated that A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. During a review of the facility's P&P titled, Care Planning- Interdisciplinary Team, last approved on 1/7/2026, the P&P indicated that The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation 1. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of a change of condition for one of 28 sampled residents (Resident 146) by failing to ensure a change in condition in Resident 146's right forearm peripheral intravenous (IV-a small, flexible tube placed into a small vein and kept there for intravenous therapy such as medication fluids) was reported to the physician.This failure had the potential to result in a delay in the recognition and treatment of IV related complications, such as infiltration (fluid or medication leaks out of the vein into the surrounding tissue instead of staying in the vein), phlebitis (inflammation or irritation of a vein, often where an IV is inserted), and infections. Findings:During a record review of Resident 146's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 8/3/2026 and readmitted on [DATE], with diagnoses including sepsis due to methicillin susceptible staphylococcus aureus (a serious infection in the bloodstream caused by a type of bacteria called MSSA, which can cause low blood pressure, problems with organs, and potentially life-threatening illness); cutaneous abscess of abdominal wall (an infected lump or collection of pus in the skin/tissue of the stomach area); local infection of the skin and subcutaneous tissue, unspecified (the skin and tissue underneath it are infected, but the specific type of infection is not specified). During a review of Resident 146's H&P, dated 8/4/2026, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 146's MDS, dated [DATE], the MDS indicated the resident makes self-understood and understands others and had intact cognition. During a review of Resident 146's Order Summary Report (OSR), dated 8/3/2026, the OSR indicated the following orders: -cefazolin sodium injection solution reconstituted two (2) grams (gm-unit of measurement (Cefazolin Sodium) Use 2 gram intravenously every eight (8) hours for post op abscess drainage. -IV Medication: Tubing Hang, change every 24 hours -peripheral site care every 72 hours for site care, Restart IV and subcutaneous site (Additional MD order required for insertion of IV catheter into lower extremities) and as needed for complications. May extend IV site for poor venous access if no complications are present. Change dressing with site change and PRN (as needed). During a concurrent observation and interview on 8/10/2026, at 3:45 p.m., inside Resident 146's room observed Resident 146 sitting in bed, with a PIV inserted in the right forearm and connected to an IV tubing. The IV tubing was connected to cefazolin antibiotic bag, and the infusion had been completed. The PIV site was observed with redness and Resident 146 stated that the site was itching. During a concurrent observation and interview on 8/10/2026, at 3:55 p.m., with Registered Nurse (RN) 2, RN 2 observed Resident 146's right forearm IV site and stated there is redness to the site and Resident 146 complained of itchiness. RN 2 disconnected the IV tubing from saline lock and removed the flexible cohesive bandage around the IV site. RN 2 stated she will flush the site with saline and will notify physician about the change in condition to Resident 146's PIV. During a concurrent interview and record review on 8/13/2026, at 8:30 a.m., with RN 1, RN 1 stated that IV site always needs to be assessed before administering IV medication and flushing the IV saline lock with normal saline to make sure it is patent. RN 1 stated that the IV tubing needs to be disconnected once the medication has been completed. RN 2 stated IV sites need to be monitored for itchiness, redness, or pain. RN 1 stated the physician needs to be notified if there is a change in the condition of the IV site and a progress note needs to be done. RN 1 reviewed Resident 146's electronic medical records including progress notes and change of condition (COC) notes. RN 1 stated there was no documentation that indicated the IV site was changed and the physician was notified of the COC of the IV site. RN 1 stated it was important to notify the physician of any changes at the IV site to ensure safety and prevent complications. During a concurrent interview and record reviewed on 8/13/2026, at 9:56 a.m., with the ADON, the ADON stated that if IV is infiltrated, MD needs to be notified when the site is infiltrated. The ADON reviewed Resident 146's medical records and was unable to find any progress notes or COC note, or physician notification note related to a COC of the IV site. The ADON reviewed the policy and stated the policy titled, Change in a Resident's Condition, was not followed. During a review of the facility's policy and procedures (P&P) titled, Change in a Resident's Condition, last approved 1/7/2026, the P&P indicated that the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a(an):. d. significant change in the resident's physical/emotional/mental condition;. 2. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form. 4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 6. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of 28 sampled residents (Resident 41). This failure had the potential to place the residents at risk for delayed assistance, potentially affecting safety and timely care. Findings: During a review of Resident 41's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 3/16/2023 and readmitted the resident on 4/7/2025, with diagnoses including unspecified dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) with psychotic disturbance (mental state where a person loses touch with reality), unspecified glaucoma (group of eye diseases involving eye pressure increases that lead to permanent vision loss and blindness), essential (primary) hypertension (high blood pressure with no known specific cause). During a review of Resident 41's History and Physical (H&P) dated 5/6/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 41's Minimum Data Set (MDS- a resident assessment tool) dated 6/11/2026, the MDS indicated the resident sometimes makes self-understood and sometimes understands others and had severe cognitive impairment (serious trouble thinking, remembering, or understanding things). The MDS indicated that Resident 41's needs were dependent to moderate assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 41's Fall Risk Evaluation (FRE) dated 6/11/2026, the FRE indicated the resident was at high risk for falls. During a review of Resident 41's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, Resident is at risk for falls/injuries, the care plan indicated an intervention to keep call light within easy reach and encourage resident to use it to get assistance. During a concurrent observation and interview on 8/10/2026 at 3:25 p.m., with Certified Nursing Assistant 8 (CNA 8), observed Resident 41's call light on the floor. CNA 8 stated the call light was supposed to be next to Resident 41. CNA 8 stated Resident 41 would not have been able to reach the call light, and the resident could have fallen trying to reach for the call light. During a concurrent interview and record review on 8/12/2026 at 9:32 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 41's care plan and FRE. RN 1 stated Resident 41 was at high risk for falls. RN 1 stated the call light should be within reach of the resident and readily accessible for the resident to be able to communicate their needs if they need help with something. RN 1 stated the resident could have potentially fallen trying to reach for the call light that was on the floor. RN 1 stated Resident 41's Care Plan and policy titled, Answering the Call Light, was not followed. During an interview on 8/13/2026 at 3:25 p.m., with the Director of Nursing (DON), the DON stated if the call light is not within reach, the resident cannot call for help and can potentially fall trying to reach for the call light. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, last reviewed on 1/7/2026, the P&P indicated the purpose of this procedure is to ensure timely responses to the resident's requests and needs.Ensure that the call light is accessible to the resident when in bed or wheelchair in room, from the toilet or shower room if necessary.

Based on observation, interview, and record review, the facility failed to follow-up on a treatment recommendation by dental provider on 4/27/2027 for surgical extraction of teeth with full mouth upper and full lower dentures for one of two sampled residents (Resident 12) investigated under nutrition care area. This failure had the potential to result in inability to chew food efficiently and further weight loss for Resident 12. Findings During a review of Resident 12's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted Resident 12 to the facility on [DATE] with diagnosis that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipidemia (high cholesterol or excess of fats), and (hypertension) high blood pressure. During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 7/23/2026, the MDS indicated Resident 12 makes self-understood and able to understand others. The MDS indicated Resident 12 required substantial/maximal assistance (helper does more than half the effort) with shower/bathe self, lower body dressing, partial/moderate assistance (helper does less than half the effort) with toileting hygiene and was independent with oral hygiene and eating. The MDS indicated Resident 12 had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months, not on a physician-prescribed weight-loss regimen. The MDS indicated Resident 12 is on therapeutic diet (e.g., low salt, diabetic, low cholesterol) mechanically altered diet - require change in texture of foods or liquid (e.g., pureed food, thickened liquid).During a review of the History and Physical (H&P) report completed on 10/19/2025, the H&P indicated Resident 12 has the capacity to make decisions. During an interview on 8/11/2026 at 2:00 p.m. with Resident 12, Resident 12 stated that she had a significant amount of weight loss in the past 6 months. Resident 12 stated that her appetite fluctuated and does not always eat well. Resident 12 stated she had difficulty chewing and did not always like the food served. Resident 12 stated she enjoyed chewing her food, noting that even when food textures are modified to eliminate the need for chewing, some dishes simply taste better when they can be chewed. Resident 12 stated had been seen by dental provider and expecting to have dentures soon. During concurrent interview and record review on 8/13/2026 at 11:43 a.m. with the Social Services Director (SSD), reviewed Resident 12's Dental Provider 1 (DP) 1 Dental Notes, dated 4/27/2026 and DP1 Physician's Medical Order Release, dated 4/27/2026. The DP1 dental notes indicated Retake PAs (periapical X-rays) UR (upper right back teeth) and UP (upper left back teeth) posterior, surgical xB #2, #6-#15, #20-#31, new F2. The DP1 Physician Medical Order Release indicated proposed treatment as Surg XB: #2, #6-#15, #20-#31. To ensure the safety and comfort of your patient, the treating dentist has asked that this form be completed. If you have any questions or wish to further discuss any aspect of the proposed treatment for this patient, please call us at the number below. Your patient's needed dental care cannot proceed until the dentist has received the Medical Order. Please complete the form and fax back to the regional office for your area listed below. The SSD stated she did not review Resident 12's treatment recommendations on 4/27/2026 with DP1 after Resident 12's dental visit. The SSD stated she was supposed to follow-up with DP1 to assist with ensuring Resident 12 gets the necessary treatment. The SSD stated that SSD has not provided the Physician's Medical Order Release dated 4/27/2026 provided to Resident 12's physician to complete. The SSD stated that the absence of follow-up by SSD resulted in Resident 12 did not receiving treatment recommendations by DP1. The SSD stated that Resident 12 this lack of treatment could potentially cause Resident 12 to lose weight, since she does not have the necessary teeth to chew properly. During an interview on 8/14/2026 at 9:11 a.m. with the Dental Provider 1 Administrator (DP1A), the DP1A stated per Resident 12's dental notes dated 4/27/2026, dental provider had recommended full mouth extraction replacement (pulling all remaining natural teeth from the upper and lower jaw and replacing them with a complete set of artificial teeth) with full upper and full lower dentures. DP1A stated that the DP has received authorization from insurance on 5/14/2026. DPA1 stated that DP1 is waiting for facility to complete the Physician's Medical Order Release to proceed with scheduling Resident 12 for the treatment procedure. During the interview on 8/14/2026 at 12:02 p.m. with the Director of Nursing (DON), the DON stated that any resident forms needing completion are sent to Social Services. If a physician's input is needed, Social Services informs the nurse who notifies the physician. The DON noted that the Physician's Medical Order Release for Resident 12 had not been completed, resulting in Resident 12 missing necessary dental treatment. The DON stated that follow-up after dental visits is especially important for Resident 12 because of recent weight loss and dental issues, which impact their ability to chew and overall nutrition. The DON stated that without the recommended treatment, Resident 12 was at increased risk for further weight loss. During a review of the facility's policy and procedure (P&P) titled, Dental Service last reviewed 1/7/2026, the P&P indicated, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. All dental services provided are recorded in the resident's medical record. During a review of the facility's policy and procedure (P&P) titled, Social Services last reviewed 1/7/2026, the P&P indicated, Our facility provides medically-related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being.The director of social services is a qualified social worker and is responsible for.maintaining records related to social services; meeting or assisting with the medically-related social services needs of residents.Medically-related social services are provided to maintain or improve each resident's ability to control everyday physical needs (e.g., appropriate adaptive equipment for eating, ambulation, etc.) and mental and psychosocial needs.The social worker/social services staff are responsible for:.making referrals and obtaining needed services from outside entities.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed consistency did not maintain its shape, was watery, and was touching other food items for one of two sampled residents (Resident 139) observed during dining observations. These failures had the potential to result in decreased food intake and increased the risk of choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of Resident 139's FS, the FS indicated the facility originally admitted the resident on 10/27/2021 and readmitted on [DATE] with diagnoses including Parkinsonism (a set of movement symptoms such as slow movements, rigidity, tremors, and balance problems), hyperlipidemia (a condition where you have too many fats in your blood), and hypothyroidism (a condition where the thyroid gland does not make enough thyroid hormones, leading to symptoms like fatigue, weight gain, and feeling cold). During a review of Resident 139's H&P, dated 5/17/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 139's physician order, dated 7/17/2024, the physician order indicated an order for no added salt diet, puree texture, honey/moderately thick consistency. During a concurrent observation and interview on 8/10/2026 at 12:25 p.m. with Certified Nursing Assistant (CNA) 6, inside Dining Room B, CNA 6 stated Resident 117 is on a pureed diet and the resident's puree food looks flat and watery on the plate. Observed three pureed foods on the plate touching other food items. During a concurrent observation and interview on 8/10/2026 at 12:36 p.m. with CNA 1, inside Activity room [ROOM NUMBER], CNA 1 stated Resident 139's pureed food on the plate is runny but is acceptable to serve. CNA 1 stated the pureed food is smooth, and no lumps are okay to serve. During a follow-up interview on 8/10/2026 at 1:46 p.m. with CNA 1, CNA 1 stated the food in Resident 139's plate was spread out because when it is runny it does that. CNA 1 stated she noticed there was some kind of liquid on the side and assumed it is from the steam when the food is served hot. CNA 1 stated the three pureed food items were touching one another on the plate. CNA 1 stated usually it would look scooped and formed. During an interview on 8/12/2026 at 12:44 p.m. with the Dietary Supervisor (DS), the DS stated that their facility uses the International Dysphagia Diet Standardizations Initiative or IDDSI for the texture. The DS stated IDDSI has been implemented in this facility with this menu season the summer season. The DS stated the IDDSI pureed diet is followed for uniform texture. The DS stated the pureed according to IDDSI has to be soft enough and not hard enough to serve. The DS stated Resident 139's pureed diet served on 8/10/2026 was not acceptable to serve because it should have been firmer. The DS further stated that if the pureed diet is too runny it could be unappetizing and increased the resident's risk of choking. During an interview on 8/12/2026 at 1:55 p.m. with the Registered Dietitian (RD), the RD stated they do a spoon test and a fork test to check for the puree diet consistency. The RD stated the characteristics of a puree is that it should slide off the spoon, when it is put on the plate, it should not be all over the plate, it should hold its shape. The RD stated if it goes through the fork then it is too thin or runny. The RD stated the pureed diet should not be weeping, and it is unappetizing when it is all over the plate. The RD stated when the staff sees that then they should not serve it and if it's already out of the kitchen it should be returned to the kitchen so the cook can adjust and serve the right puree consistency. During a review of the facility's menu spreadsheet (a sheet containing kind and amount of food each diet would receive) titled Cooks spreadsheet, dated 8/10/2026, the spreadsheet indicated residents on pureed diet (PD 4) diet would include the following foods in the tray: PD 4 French Dip: Roast Beef Roll with Au Jus 1/2 cup (c-a household measurement) PD 4 Roll 1/3 c PD 4 Corn Coleslaw 1/3 c PD 4 Sweet Potato During a review of the facility's production recipe titled, French Dip: Roast Beef Roll with Au Jus undated, the recipe indicated IDDSI#4/Pureed: Puree roast beef, #12. Puree bread, #16 (large #12). Flatten pureed bread and top with puree meat & #16 pureed bread. Puree following the pureed recipes in the Food Safety/Misc. section of Book #1. Utilize the critical tests and IDDSI audit to confirm texture meets level #4 specifications. During a review of the facility's production recipe titled, Pureed (IDDSI Level #4) Meats, undated, the recipe indicated The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep . During a review of the facility's production recipe titled, Pureed (IDDSI Level #4) Breads . undated, the recipe indicated The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep . During a review of the facility's production recipe titled, Coleslaw undated, the recipe indicated Puree following the pureed recipes in the Food Safety/Misc. section of Book #1. Utilize the critical tests and IDDSI audit to confirm texture meets level #4 specifications. During a review of the facility's production recipe titled, Sweet Potato French Fries, undated, the recipe indicated Puree following the pureed recipes in the Food Safety/Misc. section of Book #1. Utilize the critical tests and IDDSI audit to confirm texture meets level #4 specifications. During a review of the facility's policy and procedure (P&P) titled, Food Preparation, last approved on 1/7/2026, the P&P indicated that Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value. All meals must comply with the physician-ordered diet, approved menu, and portion control standards to ensure consistency, adequate nutrition, and regulatory compliance. PROCEDURE . 6. Modified Diets and Texture Compliance: All modified diets and thickened liquids will be prepared and served in accordance with the IDDSI (International Dysphagia Diet Standardization Initiative) Framework. Dietary staff will follow the standardized IDDSI levels as ordered, including: . Level 4 - Pureed During a review of the facility's P&P titled, Menu, last reviewed and approved on 1/7/2026, the P&P indicated that 5. The menus will be prepared as written using standardized recipes. The Dietary Services Supervisor and cooks are trained and responsible for the preparation and service of therapeutic diets prescribed During a review of the facilities P&P titled, IDDSI LEVEL #4: REGULAR PUREED DIET, last approved 1/7/2026, the P&P indicated that The pureed diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the prepared pureed food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep

Based on observation, interview, and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practice for one of one sampled resident (Resident 107) reviewed for tube feeding care area when the licensed nurse documented in the electronic medication administration record (eMAR-used for the documentation of medication administration and other delegated tasks) that Resident 107's enteral feeding syringe (is a medical device specifically designed to deliver liquid nutrition, hydration, and medication directly into the patient's digestive tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces] via the gastrostomy tube [G-tube, a tube inserted through the abdomen directly into the stomach to provide nutrition, fluids, or medications]) had been changed on 8/9/2026 and 8/10/2026, when it had not been changed. This failure resulted in inaccurate documentation in the resident's electronic health record (EHR-a digital record containing a residents' health information). During a review of Resident 107's Face Sheet, the Face Sheet indicated that the facility originally admitted the resident on 8/17/2024 and readmitted on [DATE] with diagnoses including encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), dementia (a progressive state of decline in mental abilities), and dyskinesia of esophagus (a condition where the muscular tube connecting the mouth and stomach does not work right). During a review of Resident 107's History and Physical (H&P), dated 7/30/2026, the H&P indicated that the resident has fluctuating capacity to make medical decisions. During a review of Resident 107's Minimum Data Set (MDS-a resident assessment tool), dated 7/19/2026, the MDS indicated that the resident usually makes self-understood and has the ability to understand others. The MDS indicated that the resident has severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated that the resident received nutrition through feeding tube while a resident of the facility. During a review of Resident 107's physician order, dated 7/29/2026, the physician order indicated the following order: - Enteral Feed Order [Enteral] Change feeding syringe (60 cc [cubic centimeter - a unit of volume used to measure liquid]) every 11 p.m. to 7 p.m. During a review of Resident 107's Care Plan (CP) focused on GT feeding, revised 1/29/2026, the CP indicated the resident with a goal of minimizing risk of infection at GT site which included interventions to administer enteral feedings as ordered and to change tubings per policy or as orderedDuring an observation on 8/10/2026 at 9:49 a.m., inside Resident 107's room, observed a feeding syringe at bedside, dated 8/8/2026. During a concurrent observation and interview on 8/10/2026 at 9:56 a.m. with the Infection Preventionist Nurse (IPN), inside Resident 107's room. The IPN stated Resident 107 has a feeding tube, and the feeding syringe is changed daily by the 11 p.m. to 7 p.m. shift licensed nurse. The IPN stated feeding syringe plastic sleeve containing the feeding syringe was dated 8/8/2026, however, the feeding syringe itself was not dated. The IPN further stated that the syringe appeared to contain residue from crushed medication and should have been changed daily. During a concurrent interview and record review on 8/12/2026 at 7:33 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 107's physician orders and medication administration record (MAR) for the month of 8/2026 were reviewed. LVN 2 stated feeding syringe is changed daily as ordered by the physician and is done by the night shift LVN. LVN 2 stated her initial and check mark on the electronic MAR (eMAR) means that she changed the feeding syringe on 8/8/2026. LVN 2 stated she writes the date on the feeding syringe to let the next shift nurse know that the feeding syringed had been changed. LVN 2 stated she worked on 8/7/2026 11 p.m. to 7 a.m. shift and was off on 8/9/2026 and 8/10/2026. LVN 2 stated that she had until 7 a.m. to change the feeding syringe and dated it 8/8/2026 to inform the oncoming 7 a.m.-3 p.m. shift nurse that it had been changed. LVN 2 that the eMAR indicated that the feeding syringe was changed on 8/9/2026 and 8/10/2026, however the feeding syringe at the resident's bedside was dated 8/8/2026, indicating that it had not been changed. LVN 2 stated the resident could potentially develop an infection from the continued use of a feeding syringe that was not changed daily. During an interview on 8/13/2026 at 8:27 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the facility's policy is to follow the manufacturer specifications to change the feeding syringe daily by the 11 a.m. to 7 p.m. shift nurse. The ADON stated not changing the feeding syringe daily could place Resident 107 at risk for infection.During a concurrent interview and record review on 8/13/2026 at 8:35 a.m. with the ADON, the feeding syringe manufacturer's specifications dated 2024, Resident 107's physician orders and MAR for the month of 8/2026 were reviewed. The ADON stated that on 8/9/2026 and 8/10/2026, the licensed nurses documented that the feeding syringe had been changed; however, the syringe was not changed. The ADON stated that when a licensed nurse signs the MAR, it indicates that the documented task was performed. The ADON stated the documentation was inaccurate and stated that documenting incorrect information could compromise the resident's health and safety.During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, last approved 1/7/2026, the P&P indicated that the purpose of this P&P is To ensure the safe administration of enteral nutrition . Preparation . 2. The facility will remain current in and follow accepted best practices in enteral nutrition . General Guidelines . Preventing misconnection errors . 7. Use only enteral tubing, syringes and devices with [Enteral Syringe Company (ESC) 1] connectors During a review of the manufacturer specification titled, [ESC 1] Tip Syringe, dated 2024, the manufacturer specification indicated Features . [ESC 1] connector designed to reduce the risk of tubing misconnections . 7. Must be replaced every 24 hours During a review of the facility's policy and procedures (P&P) titled, Charting and Documentation, last approved on 1/7/2026, the P&P indicated that All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 1. Documentation in the medical record may be electronic, manual, or a combination. 2. The following information is to be documented in the resident medical record;. b. Medications administered; c. Treatments or services performed;.

Based on observation, interview, and record review, the facility failed to meet the requirement for no more than four residents per room for two (2) out of 60 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). This failure had the potential to adversely affect the delivery of care, quality of life, safety, and violate the resident's rights for privacy. Findings During the entrance conference interview with the Director of Nursing (DON) on 8/10/2026 at 8:03 AM, the DON stated that two rooms in the facility were occupied by more than four residents in each room, but the facility had a waiver (a permit approved by Centers for Medicare & Medicaid Services for rooms that did not meet the regulation requirement) in place and would like to request a continuing waiver this year. The DON stated the multiple beds per room had no impact on care of the residents. During a review of the facility ' s Client Accommodations Analysis form, dated 8/13/2026, the form indicated the facility had 2 rooms (Resident 46 and 56) that had more than four residents with the rooms combined. During a review of the facility's request for additional room waiver dated 3/18/2026, indicated that the two rooms combined do not restrict the freedom of movement for residents in room [ROOM NUMBER] and 56. The number of residents in room [ROOM NUMBER] and 56 do not present any adverse impact on the health, safety or welfare of the residents who reside in these rooms. There is enough room to provide for the residents' care, dignity, and privacy and the room are in accordance with special needs of the resident and will not impede the ability of any resident in the rooms to attain his or her highest practicable well-being. The request indicated the following resident bedrooms were: -room [ROOM NUMBER] (3 beds) with 249.6 square (sq - unit of measure) feet (ft - unit of measure) per resident -room [ROOM NUMBER] (2 beds) with 2 residents with 249.6 sq. ft. During the survey, from 8/10/2026 to 3/14/2026, observed rooms [ROOM NUMBERS] were connected and partitioned (separated) with a curtain. The residents residing in the affected rooms (rooms [ROOM NUMBERS]) observed with adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided to the residents when nursing staff were observed providing care to the residents. There were no observed adverse effects as to the adequacy of space, nursing care, comfort, and privacy to the residents. During interview on 8/13/2026 at 3:02 p.m. with Resident 1, Resident 1 stated there was adequate space in the room and did not have any concerns. During a review of the facility's Census from the last Health Recertification Survey from exit date 7/18/2025 indicated the residents that occupied rooms [ROOM NUMBERS] were not the same residents that occupied rooms [ROOM NUMBERS] during this current Health Recertification Survey from 8/10/2026 to 8/14/2026.

Based on observation, interview, and record review, the facility failed to ensure that a resident who was assessed as clinically appropriate to self-administer medications, had a physician's order to self-administer or store medications at bedside prior to self-administering or storing medications at bedside, and demonstrated the ability to safely and securely store medications for one of seven sampled residents (Resident 2). This deficient practice had the potential for other residents to access and ingest the medications, which could result in serious health complications and had the potential to result in unsafe medication administration or omission (the act of not including something that should have been included) for Resident 2.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/15/2026 with diagnoses including cirrhosis of liver (permanent scarring that damages the liver and interferes with its functioning), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic respiratory failure (CRF - a long-term condition that happens when the lungs cannot get enough oxygen into the blood ) with hypoxia (a dangerous medical condition where your body tissues are starved of enough oxygen to function properly). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 1/20/2026, the MDS indicated Resident 2 had the ability to make her understood and understand others. The MDS further indicated that Resident 2 needed supervision or touching assistance with eating, needed moderate assistance (helper provides less than half of the effort) from staff with oral hygiene, and needed maximal assistance (helper provides more than half of the effort) from staff with bed mobility (movement) and transfer. During a review of Resident 2's Self-Administration of Medication (SAOM) dated 2/2/2026, Registered Nurse 1 (RN 1) marked to indicate that Resident 2 was fully capable of storing medications in a secure location. During a review of Resident 2's physician's orders, the physician orders indicated the following orders: May leave the medications at bedside and can self-administer medications, XyliMelts (used to relieve dry mouth) and Biotene oral gel (a thick, soothing, saliva-substitute gel that acts as a long-lasting moisturizer for dry, sticky mouths). Order Date: 2/3/2026 timed at 3:32 p.m. Biotene oral gel, give two (2) centimeters (cm - a unit of measurement) by mouth as need for dry mouth, place directly on the tongue and spread thoroughly inside the mouth. May keep medications at bedside. Resident 2 notify charge nurses before taking medication. Order Date: 2/3/2026 timed at 5:17 p.m. XyliMelts 500 mg, give one (1) tablet by mouth every two (2) hours as needed for dry mouth, place on gum line, allow to dissolve. Do not chew or swallow. May keep medications at bedside. Resident 2 to notify charge nurses before taking medications. Order Date: 2/3/2026 timed at 5:28 p.m. During a concurrent observation and interview on 2/3/2026 at 10:23 a.m., in Resident 2's room, observed Resident 2 sitting in the wheelchair next to her bed. Resident 2 stated that she needed to take medications and pointed at the bottle of XyliMelts and Biotene oral gel which were on top of the resident's bedside table. When Resident 2 was asked if she was instructed to call a nurse prior to taking the medications, Resident 2 stated that the nurses knew she was taking these medications and she takes them whenever she needed to. Resident 2 further stated she keeps the medication on top of her bedside table. During a concurrent observation and interview on 2/3/206 at 10:36 a.m., in Resident 2's room, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 observed XyliMelts and Biotene oral gel on top of Resident 2's bedside table. LVN 1 stated that he was not aware that the resident was taking both medications and storing them at bedside. LVN 2 stated he will check if there was a physician's order for the resident to self-administer or store them (medications) at bedside. Observed Resident 2 take a tablet of XyliMelts while LVN 2 was out of the room. When LVN 2 returned to the room, LVN 2 stated there were no orders for Resident 1 to self-administer or store XyliMelts and Biotene oral gel at bedside. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 2/4/2026 at 8:43 a.m., RN 1 reviewed Resident 2's SAOM dated 2/2/2026 and stated that RN 1 received a report from the staff on 2/2/2026 that Resident 2 had medications at her bedside and wanted to keep them at her bedside. RN 1 stated that she conducted the assessment and concluded that Resident 2 was alert and oriented and was able to correctly demonstrate how to take XyliMelts and Biotene oral gel and how often they were to be taken, so she completed most sections of the assessment including the section that indicated the resident was capable to self-administer safely including storing the medications in a secure location. RN 1 stated she did not obtain a physician's order for Resident 2 to self-administer or store the medications on the day she completed the SAOM assessment. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 2/4/2026 at 10:11 a.m., the ADON reviewed Resident 2's physician order for self-administration of medications for XyliMelts and Biotene oral gel and stated that RN 1 completed the SAOM assessment on 2/2/2026, however , RN 1 did not notify Resident 2's physician to obtain orders for the resident to self-administer or store the medications at bedside, on 2/2/2026. The ADON further stated that Resident 2's medications should be stored in a secure location for safety reasons. The ADON stated leaving medications on the bedside table had the potential to allow cognitively impaired residents access to the medications. During a review of the facility's policy and procedure (P&P) titled, Self-Administration of Medications, last reviewed 1/7/2026, the P&P indicated, Self-administrated medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. During a review of the facility's P&P titled, Administering Medications, last reviewed on 1/7/2026, the P&P indicated medications are administered in a safe and timely manner, and as prescribed.

Based on interview and record review the facility failed to ensure that a physician's stat (immediate) order for an X-radiation (x-ray - a type of medical imaging that uses radiation to take pictures of the inside of the body) was completed timely for one of four sampled residents (Resident 2), following Resident 2's fall, in accordance with the facility's policy and procedure (P&P), titled Stat Orders, last reviewed on 1/8/2025 which indicated that stat orders are to be completed promptly within a four to six-hour time frame.This deficient practice had the potential for delay of treatment and services to Resident 2 following the resident's fall.Findings:During a review of Resident 2's admission Record, the admission Record indicated that Resident 2 was originally admitted to the facility on [DATE] with diagnoses including diverticulosis (small pouches) of large intestine without perforation (a hole had formed through the wall of a hollow body organ) or abscess (swollen pocket of pus) without bleeding, asthma (chronic lung condition where airways become inflamed, swollen, narrow making it hard to breathe), and unspecified abnormalities of gait (walking pattern ) and mobility (movement). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 1/5/2026, the MDS indicated that Resident 2 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required moderate (helper does less than half the effort) to maximal (helper does more than half the effort) assistance on staff with toileting hygiene, shower or bathing, dressing, personal hygiene, and mobility (movement). During a review of Resident 4's admission Record, the admission Record indicated the facility initially admitted Resident 4 to the facility on [DATE] and readmitted the resident on 8/26/2025, with diagnoses including muscle weakness and cerebral palsy (a group of conditions that affect movement and posture cause by damage to the developing brain). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognition was moderately impaired. During a review of Resident 4's History and Physical (H&P) dated 8/25/2025, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 2's Change of Condition (COC-a change in resident's health that requires immediate observation, assessment and intervention)/Interact assessment form dated 1/1/2026 and timed at 7:40 p.m., the COC/Interact assessment form indicated that Resident 2's roommate (Resident 4) pressed the call light to notify staff that Resident 2 was on the floor mat. The COC indicated Resident 4 stated that Resident 2 was coming back from the bathroom and fell on his back on the floor mat. The COC indicated Registered Nurse (RN 3) Supervisor assessed Resident 2, who reported left wrist pain rated at 3/10 (pain scale rating indicating mild pain; 0=no pain, 10=worst pain imaginable). The physician and the responsible party were notified. The physician called back on 1/1/2026 at 7:45 p.m., with orders for X-ray of the left wrist and Tylenol 325 milligrams (mg-unit of mass or weight) for pain. The COC indicated the RN Supervisor (RN 3) noted and carried out the orders. During a review of Resident 2's Order Details, the Order Details indicated an order dated 1/1/2026 at 8:47 p.m., for a Stat Left Wrist X-ray. During a review of Resident 2's Radiology Results Report dated 1/2/2026, the Radiology Results Report indicated the examination was conducted on 1/2/2026 at 8:38 a.m., and the results were reported on 1/2/2026 at 8:47 a.m. The report indicated Resident 2 had an acute nondisplaced fracture (broken bone) of the distal (farther away from the center of the body) radius (long bone in the forearm). During a review of Resident 2's Discharge Summary Report dated 1/2/2026 timed at 2:51 p.m., the Discharge Summary Report indicated Resident 2 was transferred to a general acute care hospital (GACH) on 1/2/2026 at 1:53 p.m. due to status post (S/P-after the condition of) fall and acute nondisplaced fracture of left distal radius. During a telephone interview, on 1/13/2026 at 3:12 p.m., with Registered Nurse 4, (RN 4), RN 4 stated that she worked on 1/1/2026 from 11:00 p.m. to 7:00 a.m. and acknowledged that she should have followed up on the physician's stat order for an X-ray of Resident 2's left wrist. RN 4 stated that according to the facility's policy and procedures, a stat X-ray order is required to be completed within four to six hours. RN 4 further stated that her failure to follow up on the stat order placed Resident 2 at risked of not receiving appropriate care, with the potential for untreated pain or injury. During an interview, on 1/13/2026 at 4:15 p.m., with the Director of Nursing, the DON stated not following up on the on the Stat order placed Resident 2 at risk for not receiving proper care and experiencing delayed care resulting in untreated pain or injury to the resident. During a review of the facility`s laboratory services policy and procedure (P&P), titled Stat Orders last reviewed on 1/8/2025, the policy indicated it is the goal of the facility to complete STAT orders promptly within a 4-to-6-hour time frame.

Based on interview and record review, the facility failed to ensure a safe and orderly discharge was provided to two of three sampled residents (Resident 1, who had severely impaired cognition [the mental action or process of acquiring knowledge and understanding through thought, experience and the senses], lacked capacity to understand and make decisions, and required staff assistance for all Activities of Daily Living [ADL - basic tasks that individuals perform to maintain their daily lives] and Resident 2, who also required staff assistance for all ADLs) by failing to:1. Ensure that the post-discharge destination and continuing care provider were capable of meeting the needs of Resident 1 and Resident 2 prior to discharge. 2. Ensure that an effective discharge plan addressing the health and safety needs of Resident 1 and Resident 2 was provided by failing to complete all sections of the Post-Discharge Plan of Care for both residents (Resident 1 and Resident 2). 3. Ensure that the physicians for Resident 1 and Resident 2 documented information about the basis for the discharge in their medical records. 4. Implement the following facility discharge policies and procedures (P&P): - Transfer or Discharge, preparing a Resident for - indicating residents will be prepared in advance for discharge.- Discharge Summary and Plan - indicating a discharge summary and post-discharge plan will be developed and re-evaluated by the Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their resident) to assist the resident to adjust to his/her new living environment.These deficient practices resulted in Resident and Resident 2 being discharged to an unlicensed Board and Care (BC 1 - small residential homes that provide room, meals, and assistance with daily living activities for individuals needing care, but don't require 24-hour skilled nursing care) on 8/8/2025. On 8/19/2025, Resident 1 required an emergency transfer from BC 1 to General Acute Care Hospital 1 (GACH 1) and was treated for anorexia (a general loss of appetite that can be caused by illness or medications), altered level of consciousness (ALOC - when a person is not as awake, alert, or responsive to their surroundings as they should be), pulmonary congestion (abnormal buildup of fluid in the lungs) and urinary tract infection (UTI - an infection in the bladder [muscular organ that stores urine] or urinary tract [refers to the system of organs that produce, store, and excrete urine]) and possible early sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection). Resident 1 was then transferred to Skilled Nursing Facility 2 (SNF 2) on 8/26/2025.On 8/19/2025, Resident 2 required transfer from BC 1 to GACH 2 and was treated for hyperkalemia (abnormally high potassium [an essential mineral crucial for the proper functioning of the body including nerve function, muscle contractions and maintain a regular heartbeat, normal range: 3.5 to 5.2 milliequivalent per liter {mEq/l - unit of measure}] levels in the blood and can be life-threatening, especially if it develops quickly, as it can cause serious heart problems like irregular rhythms, muscle weakness, or even paralysis [inability to move]). Resident 2 was then transferred back to Skilled Nursing Facility 1 (SNF 1) on 8/21/2025.On 8/28/2025 at 3:28 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM), Quality Assurance Nurse Consultant (QANC) and the Medical Records Director (MRD) due to the facility's failure to ensure Resident 1 and Resident 2 were provided with a safe and orderly discharge when on 8/8/2025, Resident 1 and Resident 2 were discharged to an unlicensed board and care (BC 1).On 8/29/2025 at 2:15 p.m., the QANC provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings) for the facility's failure to ensure Resident 1 and Resident 2 were provided with a safe and orderly discharge when on 8/8/2025, Resident 1 and Resident 2 were discharged to an unlicensed board and care (BC 1).On 8/29/2025 at 4:44 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the accepted IJ removal plan through observations, interviews and record reviews, and determined the IJ situation regarding facility's failure to ensure Resident 1 and Resident 2 were provided with a safe and orderly discharge was no longer present. The SSA removed the IJ on 8/29/2025 at 5:19 p.m., in the presence of the ADM and QANC.The acceptable IJ Removal Plan included the following summarized actions:1. Resident 1 is no longer at the facility. Resident 1 was discharged to a lower level of care (BC 1) on 8/8/2025. During a welfare check (a service to ensure the well-being of a resident) conducted on 8/27/2025, the facility found out that Resident 1 had been admitted to GACH 1. Facility staff contacted GACH 1 and found out that Resident 1 had been discharged to SNF 2 on 8/26/2025. The facility then completed a welfare check with SNF 2 and was able to speak directly with Resident 1. Resident 1 stated that he (Resident 1) is doing well and is receiving appropriate care and services at SNF 2. 2. Resident 2 was discharged from the facility on 8/8/2025 to a lower level of care (BC 1) and was readmitted to the facility (SNF 1) on 8/21/2025 and remains in-house. On 8/22/2025, the Social Services Assistant (SSAT) conducted a Psychosocial (refers to the mental, emotional, social and spiritual needs of residents, encompassing their feelings, relationships, coping mechanisms and over-all sense of well-being) Assessment and Trauma (deeply distressing or disturbing experience that overwhelms a resident's ability to cope) Evaluation, which identified no signs of emotional distress (refers to a state of mental suffering caused by difficult or overwhelming situations, can affect a resident's mood, thoughts, and behavior, and may interfere with daily functioning) or trauma. 3. On 8/28/2025, the ADM initiated an in-service (refers to educational or training sessions) training for the attending physicians, including the Medical Director, on the regulation concerning required documentation upon discharge of the resident to lower level of care, focusing on the information about the basis for transfer or discharge. Physicians, nurse practitioners (registered nurses with advanced education and clinical training who provide direct patient care services including diagnosing and treating illness, prescribing medications), and physician assistants (licensed and highly skilled healthcare professional, often under the supervision of a physician who provide patient care services including diagnosing illness, treating diseases, ordering tests and prescribing medications) who were unable to attend the in-person in-service were contacted by the ADM and provided the in-service training by phone. 4. Effective 8/28/2025, the facility will ensure that the resident, family, or responsible party (RP) is actively included in the discharge planning process. The facility will provide the resident and/or representative with the opportunity to participate in the selection of the post-discharge placement and ensure they are given the option to visit and inspect the receiving facility prior to discharge. 5. Effective 8/28/2025, the facility will conduct a welfare check on residents discharged to a lower level of care to evaluate the appropriateness of the placement, confirm adequate staffing is in place and identify any additional services the resident may need. 6. Effective 8/28/2025, the Social Services designee will document in the progress notes the discharge planning process, including details about the lower level of care facility (board and care), its licensing status, and the name and contact information of the transportation company assigned to pick up the resident from the facility. 7. On 8/28/2025, the ADM notified all licensed nurses, social service personnel, and the Medical Director of the findings outlined in the IJ template dated 8/28/2025 and conducted in-services training on the facility's Transfer and Discharge policy. 8. Social Services designee reviewed all resident discharges from the past three (3) months (June 2025, July 2025, August 2025) to verify the placements to lower level of care, assess resident status and confirm that the receiving facilities were licensed. A total of 13 residents were identified as having been discharged to assisted living facility or other lower level of care facilities. All receiving facilities were verified to be licensed, and all residents were confirmed to be safe. No other residents were found to have been affected by the deficient practice. 9. The Medical Records designee reviewed and audited the discharge paperwork of the residents discharged from the facility over the past three (3) months (June 2025, July 2025, August 2025) to ensure completion of Post-Discharge Plan of Care and documentation by the physician regarding the basis for discharge. The audit identified three (3) residents with incomplete Post-Discharge Plan of Care and 11 residents with missing physician documentation outlining the basis for discharge. The Assistant Director of Nursing (ADON) will complete the missing information of the Post-Discharge Plan of Care and send copies to the respective residents, families, or responsible parties. The MRD/designee has notified the physicians of the regulatory requirement to document the basis for discharge in the resident's medical record. 10. Effective 8/28/2025, the ADM or Director of Nursing (DON) will conduct a monthly in-service training for all licensed nurses and social services staff on the facility's Transfer and Discharge policy. This training will occur monthly for a period of three (3) months. 11. On 8/28/2025, the ADM provided one-to-one (refers to a training session between one trainer, such as a supervisor, educator or mentor and one trainee, such as staff member) in-service training to the Social Services staff regarding the facility's Transfer and Discharge policy. The training emphasized the importance of verifying the receiving facility or provider to ensure a safe and appropriate discharge. Additionally, the ADM reinforced the need to document the discharge planning in the progress notes, including the name and contact information of the transportation company responsible for picking up the resident. 12. On 8/28/2025, the ADON and the QANC conducted an in-service training for all licensed nurses on the accurate and timely completion of the Post-Discharge Plan of Care, the discharge planning process, and the importance of documenting the physician's basis for discharge. Licensed staff who were unable to attend the in-service on 8/28/2025 will be contacted by phone and provided with the initial in-service training. Licensed staff who are on vacation, personal leave, or medical leave will receive the in-service training on their first scheduled day back to work. 13. Effective 8/28/2025, the DON or designee will participate in discharge IDT meetings to ensure that residents receive the necessary services based on their level of care needs and current clinical condition. This determination will be made through a thorough review of the rehabilitation discharge summary, Minimum Data Set (MDS- a resident assessment tool), and physician notes as part of the discharge planning process. Residents and their family members or responsible party will be invited to attend and actively participate in the discharge planning. They will also be given the opportunity to choose a placement (lower level of care) and visit the selected facility prior to discharge. The facility will also assign designated staff to conduct an on-site visit to the chosen receiving facility to ensure it is licensed, adequately staffed and safe for the resident. The Social Services designee will invite Residential Care Facility for the Elderly (RCFE - a type of non-medical facility in California for people 60 years or older who need assistance with daily activities like dressing and bathing, as well as housing, meals, and general supervision, but do not require 24-hour nursing care) operators to visit the facility and assess the resident prior to discharge, to determine whether their facility can meet the resident's care needs. The Social Services designee will also be responsible for documenting the discharge planning process in the residents' progress notes. 14. On 8/28/2025, the MRD or designee and Social Services designee will initiate a Lower Level of Care Monitoring Log. This log will be used to track and verify all discharge and transfer details, including confirmation of receiving facility or provider information and documentation of discharge instructions. 15. Effective 8/28/2025, the MRD or designee will conduct a daily review of all discharges to ensure that the Post Discharge Plan of Care is completed accurately and in a timely manner, and that the physician documented the basis for discharge. Any identified deficiencies will be reported to the DON or designee for follow-up and completion of the required documentation. 16. Effective 8/28/2025, the DON and/or designee will review all discharges and transfers, documenting findings and any corrective action taken in the monitoring log for a period of three (3) months. If any issues are identified during this period, the DON will extend the monitoring for an additional three (3) months or until 100 percent (%) compliance is achieved.17. On 8/28/2025, the facility will initiate a Quality Assurance and Performance Improvement (QAPI- data driven and proactive approach to quality improvement) focused on the discharge and transfer process to address the findings outlined in the IJ template. The facility will review the progress every month for a period of three (3) months and will adjust the measures needed to ensure the development and implementation of an effective and consistent discharge and transfer process/plan. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/1/2025 with diagnoses that included metabolic encephalopathy (brain damage or loss of brain function that is caused by an illness or condition), fractures (break in a bone) of the fifth and sixth cervical vertebra (the seven bones that make up the neck region of the spine [backbone]) and unspecified psychosis (mental disorder characterized by a disconnection from reality). During a review of Resident 1's History & Physical (H&P - a comprehensive assessment of a resident's medical condition), dated 4/3/2025, the H&P indicated that Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Psychiatric Evaluation (a comprehensive assessment of a resident's mental health status), dated 5/5/2025, the Psychiatric Evaluation indicated that Resident 1 was confused (difficulty thinking clearly, understanding, concentrating or making decisions), disoriented (a more specific type of confusion where the resident cannot correctly identify time, place, person or situation), forgetful and had no family. Resident 1's Psychiatric Evaluation further indicated that Resident 1 had episodes of mood swings, agitation (state of restlessness, irritability or emotional disturbance), screaming for no reason and was difficult to redirect. During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognition was severely impaired. The MDS further indicated that Resident 1 was dependent on staff for toileting hygiene, lower body dressing, putting on/taking off footwear and needed assistance from staff with eating, oral hygiene, upper body dressing and personal hygiene. The MDS also indicated Resident 1 had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine and remains in place for an extended period of time) and always exhibited bowel incontinence (inability to control bowel movements). During a review of Resident 1's Physician's Order, dated 8/7/2025, timed at 11:57 a.m., the Physician's Order indicated to discharge Resident 1 to BC 1 on 8/8/2025. During a review of Resident 1's Notice of Proposed Transfer and Discharge, dated 8/8/2025, the Notice of Proposed Transfer and Discharge indicated that Resident 1 was discharged to BC 1 on 8/8/2025. The Notice of Proposed Transfer and Discharge also indicated that the reason for discharge was that Resident 1's health had improved sufficiently and no longer required the services provided by the facility. During a review of Resident 1's Discharge Summary Report, dated 8/8/2025, the Discharge Summary Report indicated Resident 1 was discharged to BC 1 on 8/8/2025 at 2:20 p.m. During a review of Resident 1's H&P from GACH 1, dated 8/20/2025, the H&P from GACH 1 indicated that Resident 1 was brought to GACH 1 (from BC 1) due to not eating for two (2) days at his (Resident 1) board and care. The H&P from GACH 1 also indicated that a social worker (not indicated) was concerned for elderly negligence (known as elder neglect, a form of elder abuse where a caregiver fails to provide the necessary care, assistance or supervision that an older adult needs to maintain their health and safety). During a review of Resident 1's Neurology (branch of medicine that deals with the study, diagnosis, and treatment of disorders related to the nervous system. This includes the brain, spinal cord, nerves and muscles.) Consultation from GACH 1, dated 8/20/2025, the Neurology Consultation indicated Resident 1 was at a different facility before (SNF 1) and was transferred to the new facility (BC 1), with seemingly very little care and knowledge of Resident 1 (including Resident 1's condition). The Neurology Consultation further indicated that the Emergency Medical Services (EMS - ambulance services, pre-hospital care or paramedic services that provide urgent pre-hospital treatment and stabilization for serious illness and injuries and transport to definitive care) call was placed not by the facility (BC 1) that Resident 1 was residing in, but from a social worker who was following up on Resident 1's well-being. During a review of Resident 1's Palliative (refers to care or treatment that focuses on relieving symptoms and improving quality of life) Care Notes from GACH 1, dated 8/21/2025, timed at 1:24 p.m., the Palliative Care Notes indicated Resident 1 was admitted with anorexia and ALOC. The Palliative Care Notes indicated Resident 1 was found to have pulmonary congestion, UTI and possible early sepsis. During Resident 1's stay at GACH 1, Resident 1 received intravenous (IV - administered into a vein) fluids for hydration, IV antibiotics (medications used to treat bacterial infections, such as Ceftriaxone - an antibiotic used to treat bacterial infections) and respiratory treatments to address the pulmonary congestion. During a concurrent interview and record review on 8/26/2025 at 1:32 p.m., with the SSAT, Resident 1's Social Services Notes from 4/1/2025 to 8/8/2025 were reviewed. The SSAT stated that there were no discharge planning notes found, and no documented evidence found in Resident 1's medical record indicating who arranged Resident 1's transfer to BC 1. The SSAT stated that there should have been documentation in Resident 1's medical records reflecting coordination between the facility and BC 1. The SSAT further stated that when a resident is preparing for discharge, IDT meetings should be held with the resident and/or resident's RP to discuss discharge goals including involving them in selecting the location the resident will be discharged to, as well as ordering any durable medical equipment (DME - medical devices and supplies prescribed by a healthcare provider for long-term or repeated use in the home to assist with daily activities and manage health conditions) or arranging home health (HH - skilled care or services that are provided to a resident while at home by a licensed health care professional). The SSAT stated that these steps were not completed for Resident 1. The SSAT further stated that she (SSAT) was not aware of Resident 1's discharge to BC 1 until after Resident 1 was discharged , when she (SSAT) was asked to make a follow-up call on 8/12/2025. The SSAT stated she (SSAT) made a follow-up call to Resident 1 on 8/12/25 and spoke to a caregiver at BC 1 (unable to recall name) who stated that Resident 1 was okay and there were no concerns. The SSAT stated she (SSAT) could not locate the phone number she (SSAT) used for the follow-up call, as it was not documented in Resident 1's medical records. The SSAT stated that as part of her (SSAT) role within the social services department, she (SSAT) is responsible for discharge planning, completing referrals to potential receiving facilities, arranging transportation, ordering HH or DME, and documenting all discharge-related coordination in the medical record. The SSAT stated that in the case of Resident 1, she (SSAT) was not informed of the discharge plan and was not involved in Resident 1's discharge process at any point. The SSAT further stated that she (SSAT) does not know who coordinated Resident 1's discharge with BC 1 and who arranged Resident 1's transportation to BC 1. During a concurrent interview and record review on 8/26/2025 at 3:10 p.m., with the ADON, Resident 1's Post Discharge Plan of Care dated 8/8/2025 was reviewed. The Post Discharge Plan of Care did not indicate the following: What type of destination Resident 1 was being discharged to, The phone number of the location Resident 1 was being discharged to. The information regarding Resident 1's responsible party, Resident 1's insurance information, The name and phone number for Resident 1's continuing care physician, Resident 1's diagnosis, Resident 1's allergies, Resident 1's skin condition, Resident 1s vital signs (key measurements that indicate how well a person's body is functioning), Resident 1's diagnostic tests (includes both laboratory tests [done using blood, urine, stool or other body fluids to check for abnormalities] and imaging tests [create pictures of structures inside the body], used to diagnose medical conditions) Resident 1's intake patterns and eating habits, Resident 1's medical equipment or supplies, Resident 1's assistive devices (refer to tools, equipment used to help residents maintain or improve their mobility, independence, safety and quality of life in daily activities), Resident 1's care preferences, Resident 1's specific care needs, safety precautions, treatment instructions, Date and time of Resident 1's last meal, Resident 1's last bowel elimination, If Resident 1's inventory checklist was completed, If Resident 1 had advance directive (a legal document that allows a person to communicate their wishes about medical care in advance, in case they become unable to speak or make decisions for themselves in the future due to illness, injury or incapacity) papers, Resident 1's community health services, If Resident 1 could administer his own medications, Any additional discharge planning notes for Resident 1, The address of the state ombudsman (advocate for residents in facility). The ADON confirmed that Resident 1's Post Discharge Plan of Care was missing the information listed above. The ADON stated that Resident 1's Post Discharge Plan of Care should have been completed to ensure that the accepting facility has all the necessary information to appropriately care for Resident 1. The ADON further stated that Resident 1's Post Discharge Plan of Care must be accurate and thorough to help ensure that Resident 1's needs are met after discharge. Regarding the timing of reviewing the Post Discharge Plan of Care with residents, the ADON stated that it is usually reviewed with residents on the day of discharge. The ADON stated he (ADON) was unaware that the facility's P&P indicated that the Post-Discharge Plan of Care was to be reviewed with the resident and/or the resident's RP at least 24 hours prior to discharge. The ADON stated he (ADON) understands the importance of reviewing the Post Discharge Plan of Care at least 24 hours prior to discharge to allow the resident time to understand the discharge plan, ask questions, and address any concerns before the actual discharge occurs. During an interview on 8/27/2025 at 10:45 a.m., with Registered Nurse 1 (RN 1), RN 1 stated that he (RN 1) was the RN responsible for entering Resident 1's discharge order. RN 1 stated that on 8/7/2025 (unable to recall specific time), while sitting next to Resident 1's Medical Doctor (MD 1) at the nursing station, he (RN 1) overheard the Facility Marketer (FM) inform MD 1 that she (FM) had found placement for both Resident 1 and Resident 2. RN 1 stated he (RN 1) witnessed the FM write down the name and address of BC 1 on a piece of paper and hand it to MD 1. RN 1 further stated that he (RN 1) overheard MD 1 ask the FM whether the discharge would be safe, to which the FM stated Yes. RN 1 stated that MD 1 then wrote a discharge order for Resident 1, and RN 1 subsequently entered the order into the system. RN 1 stated that he (RN 1) texted Resident 2's Medical Doctor (MD 2) to ask whether he (MD 2) also wanted to discharge Resident 2 to BC 1. RN 1 stated that MD 2 responded with an order to proceed with the discharge of Resident 2 to BC 1, which he (RN 1) then entered into the system as well. RN 1 stated his (RN 1) role in the discharge process is to carry out the physician's orders and complete all required discharge paperwork. RN 1 stated that the licensed nurse is also responsible for reviewing the discharge paperwork with the resident and/or their RP, reviewing the prescribed medications, checking the resident's inventory, and returning all personal items. RN 1 stated that the actual discharge planning such as identifying placement, arranging transportation and coordinating post-discharge services, is the responsibility of the social services department. RN 1 stated when he (RN 1) later learned that Resident 1 and Resident 2 had been discharged to an unlicensed board and care facility, he (RN 1) became very concerned about their safety. During an interview on 8/27/2025 at 11:08 a.m., with MD 1, MD 1 stated that she (MD 1) was sitting at the nursing station when the FM approached her (MD 1) and informed her (MD 1) that a board and care placement was available for Resident 1 and Resident 2. MD 1 stated that she (MD 1) asked the FM whether the discharge would be safe, and the FM responded Yes. MD 1 further stated that the FM then wrote down the name and address of the board and care on a piece of paper and that the information given to her (MD 1) by FM was that of BC 1. MD 1 stated that RN 1 was also present at the nursing station at the time and witnessed the interaction. MD 1 stated that it is not typical for the FM to be involved in discharge planning and placement of her (MD 1) residents, as this is usually handled by the Social Services Department. MD 1 stated that she (MD 1) assumed the FM was coordinating with the SSAT and trusted that BC 1 had been properly vetted (investigated or examined thoroughly) based on the FM's assurance that BC 1 was a safe discharge option. MD 1 stated that she (MD 1) is not aware of Resident 1's current status, as another physician was assigned to the resident following discharge. During a concurrent interview and record review on 8/28/2025 at 3:25 p.m., with the MRD, Resident 1's entire medical record from 4/1/2025 to 8/8/2025 was reviewed. The MRD stated that she (MRD) reviewed Resident 1's entire medical record from 4/1/2025 to 8/8/2025 and was unable to locate any documentation from Resident 1's physician (MD 1) indicating the basis of discharge for Resident 1. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/11/2025 with diagnosis that included encephalopathy, fracture of the right humerus (upper arm bone), and atrial fibrillation (irregular heartbeat that increases the risk of stroke and heart disease). During a review of Resident 2's H&P, dated 7/13/2025, the H&P indicated Resident 2 has the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was intact. The MDS further indicated Resident 2 needed maximal assistance from staff for toileting hygiene, upper and lower body dressing, putting on/taking off footwear and moderate assistance with personal hygiene. The MDS also indicated Resident 2 occasionally exhibited urine incontinence and frequently exhibited bowel incontinence. During a review of Resident 2's Physician's Order, dated 8/7/2025, timed at 5:31 p.m., the Physician's Order indicated to discharge Resident 2 home to BC 1 tomorrow (8/8/2025), per the resident's request. During a review of Resident 2's Notice of Proposed Transfer and Discharge, dated 8/8/2025, the Notice of Proposed Transfer and Discharge indicated that Resident 2 was discharged to BC 1 on 8/8/2025. The Notice of Proposed Transfer and Discharge also indicated that the reason for discharge was that Resident 2's health had improved sufficiently, and Resident 2 no longer required the services provided by the facility. During a review of Resident 2's Discharge Summary Report, dated 8/8/2025, the Discharge Summary Report indicated Resident 2 was discharged to BC 1 on 8/8/2025 at 2:20 p.m. During a review of Resident 2's Active Discharge Planning Notes (from GACH 2), dated 8/19/2025, the Active Discharge Planning Notes indicated that Resident 2 was transferred to GACH 2 from an unlicensed board and care facility and was treated for hyperkalemia. Laboratory test results dated 8/19/2025 at 7:13 p.m. indicated an elevated potassium level of 5.8 mEq/L. The notes indicated that Resident 2 appeared weak and required transfer to a skilled nursing facility for continued care. The notes indicated that Resident 2 cannot return to the board and care facility due to its unlicensed status.During an interview on 8/26/2025 at 12:45 p.m. with Resident 2, Resident 2 stated he (Resident 2) was not involved in any discharge planning. Resident 2 stated that no one asked him (Resident 2) where he (Resident 2) wanted to go after his (Resident 2) stay at the facility and that he (Resident 2) was unaware he (Resident 2) had any choice or input in the matter. Resident 2 stated that he (Resident 2) trusted the facility to make decisions on his (Resident 2) behalf. Resident 2 further stated that he (Resident 2) does not clearly remember being discharged to BC 1 but does recall being taken to GACH 2, although he (Resident 2) does not remember the reason for the transfer. Resident 2 stated that staff (unable to recall who) at GACH 2 informed him he (Resident 2) could not return to the place he came from (BC 1) because it was unlicensed. Resident 2 stated that following his (Resident 2) stay at GACH 2, he (Resident 2) was transferred back to SNF 1.During a concurrent interview and record review on 8/26/2025 at 1:32 p.m., with the SSAT, Resident 2's Social Services Notes from 7/11/2025 to 8/8/2025 were reviewed. The SSAT stated that there were no discharge planning notes found, and no documented evidence found in Resident 2's medical record indicating who arranged Resident 2's transfer to BC 1. The SSAT stated that there should have been documentation in Resident 2's medical records reflecting coordination between the facility and BC 1. The SSAT further stated that she (SSAT) was not aware of Resident 2's discharge to BC 1 until after Resident 2 was discharged , when she (SSAT) was asked to make a follow-up call on 8/12/2025. The SSAT stated she (SSAT) made several follow-up calls to Resident 2 on 8/12/2025 and kept getting a busy signal so she (SSAT) was unable to speak to Resident 2. The SSAT stated she (SSAT) was not informed of the discharge plan and was not involved in Resident 2's discharge process at any point. The SSAT further stated that she (SSAT) ) does not know who coordinated Resident 2's discharge with BC 1 and w[TRUNCATED]

Based on observation, interview, and record review, the facility failed to protect the residents ' right to be free from abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of four sampled residents (Residents 1 and 2) when on 4/12/2025, Residents 1 and 2, while in their wheelchairs in a hallway, Resident 2 grabbed Resident 1 ' s right arm while Resident 1 grabbed Resident 2 ' s arm. The residents (Residents 1 and 2) then pushed against each other ' s hands and arms, and each resident (Residents 1 and 2) received abrasions (when the surface layers of the skin have been broken). This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical abuse while under the care of the facility. Resident 1 sustained two abrasions: one on the right forearm (part of the arm between the elbow and the wrist) and one on the right hand that needed first aid (initial assistance and care given to a resident who has been injured) and daily wound treatments. Resident 2 sustained an abrasion on the right arm that needed first aid. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated the facility originally admitted the resident on 11/23/2024 and readmitted on [DATE], with diagnoses including but not limited to, encephalopathy (damage or disease that affects the brain), heart disease, and vascular dementia (a progressive state of decline in mental abilities caused by decreased blood flow to the brain). During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool), dated 2/26/2025, the MDS indicated Resident 1 can make self-understood and understand others. The MDS indicated Resident 1 required moderate assistance with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of 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 4/12/2025, the SBAR indicated Resident 1 had a physical altercation (confrontation or fight that involves physical contact, pushing, shoving, or other forms of aggressive behavior) with Resident 2 on 4/12/2025 at 3:50 p.m. in front of the patio door and sustained right arm abrasions. The SBAR indicated Resident 1 stated that Resident 2 grabbed his wheelchair, pushed him aside to get through, and put his hand on his right arm causing his right arm to bleed. During a review of Resident 1 ' s Non-Pressure Sore Skin Problem Report (a report documenting skin injuries that are not caused by pressure, but rather other factors), dated 4/12/25, the Non-Pressure Sore Skin Problem Report indicated Resident 1 had a right arm skin abrasion (when the surface layers of the skin have been broken). During a review of Resident 1 ' s Order Summary Report (physician orders), the Order Summary Report indicated an order dated 4/12/2025 to cleanse a right arm abrasion with normal saline (a saltwater solution), pat dry, and cover with a dry dressing daily. During a review of Resident 2 ' s Admission Record, the Admission Record indicated the facility originally admitted the resident on 1/10/2019 and readmitted on [DATE], with diagnoses including but not limited to, type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and reduced mobility (the ability to move freely). During a review of Resident 2 ' s Minimum Data Set (MDS - a resident assessment tool), dated 1/31/2025, the MDS indicated Resident 2 had severely impaired cognition (the ability to think and make decisions) and was completely dependent on staff or required substantial assistance for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2 ' s Interdisciplinary Team (IDT-a group of healthcare professionals working together to provide comprehensive care to patients) notes, dated 1/31/2025, the IDT notes indicated Resident 2 had a diagnosis of psychosis (a mental disorder characterized by a disconnection from reality) manifested by uncontrollable extreme mood swings (sudden or intense changes in a person ' s emotional state) causing verbal (having to do with words) expression of anger. During a review of Resident 2 ' s SBAR, dated 4/12/2025, the SBAR indicated on 4/12/2025 at 3:50 p.m. Resident 2 stated that Resident 1 grabbed his wheelchair, pushed him aside, and scratched his right arm. At 4:30 pm, 911 (emergency number to request emergency assistance) was called per facility protocol. Resident 2 ' s responsible party (RP) and physician were notified at 6:41 pm. At 5:39 pm, the police came and was provided report by the licensed nurse (name not indicated). At 8:33 pm, Resident 2 was transferred to a general acute care hospital (GACH) emergency department for a psyche evaluation. During a review of Resident 2 ' s Non-Pressure Sore Skin Problem Report, dated 4/12/25, the Non-Pressure Sore Skin Problem Report indicated Resident 2 had a right arm skin abrasion. During a review of Resident 2 ' s Order Summary Report, the Order Summary Report indicated an order dated 4/12/2025 to cleanse the right arm with normal saline, pat dry, and cover with a dry dressing daily. During a concurrent observation and interview on 4/15/2025 at 10:03 a.m. with Resident 1 in Resident 1 ' s room, Resident 1 had one bandage on his (Resident 1) right forearm and one bandage on his (Resident 1) right hand. Resident 1 stated he (Resident 1) was injured when he (Resident 1) and another resident (Resident 2) were moving towards each other while in their (Residents 1 and 2) wheelchairs in the hallway. Resident 1 stated the other resident (Resident 2) grabbed his (Resident 1) arm when (Resident 2) was passing and said, That is what you get for going on my side. Resident 1 stated he (Resident 1) usually has pain in his (Resident 1) right arm but the scratches on his (Resident 1) arm caused additional pain. Resident 1 stated he (Resident 1) also grabbed the other resident ' s (Resident 2) arm between his (Resident 2) elbow and shoulder and injured him (Resident 2) as well. During an interview on 4/15/2025 at 4:05 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 3/12/2025 he (CNA 1) was at the nursing station when he (CNA 1) heard somebody yelling. CNA 1 stated he then turned his (CNA 1) head and saw Resident 1 grabbing Resident 2 ' s arm with his (Resident 1) hand, and Resident 2 grabbing Resident 1 ' s arm with his (Resident 2) hand at the same time. CNA 1 stated both residents (Residents 1 and 2) were putting pressure on each other and moving their hands and arms back and forth. CNA 1 stated when the residents (Residents 1 and 2) released each other, Resident 1 had two bleeding areas on his (Resident 1) arm and Resident 2 had one bleeding area on his (Resident 2) arm. CNA 1 stated he (CNA 1) was not sure which resident (Resident 1 or Resident 2) grabbed the other first. CNA 1 stated they (Residents 1 and 2) were intentionally (doing something on purpose) grabbing each other. During an observation on 4/16/2025 at 10:15 a.m. with Treatment Nurse 1 (TN 1) in Resident 1 ' s room, TN 1 removed the bandages from Resident 1 ' s right arm to perform wound care. Resident 1 had two wounds: one on the right forearm and one on the right hand. Each wound had bloody drainage. TN 1 measured the wound on the right forearm as 2.0 centimeters (cm) by 0.2 cm. TN 1 measured the wound on the right hand as 1.0 cm by 0.5 cm. During an interview on 4/16/2025 at 1:55 p.m. with the Administrator (Adm) and the Director of Nursing (DON), the Adm stated she did not think there was abuse between Residents 1 and 2. The Adm stated this was an accident between Residents 1 and 2 when they were trying to get around each other in the hallway. The DON stated she (DON) did not think abuse occurred and the residents (Residents 1 and 2) were trying to protect themselves while moving around each other. During a review of the current facility-provided policy and procedure titled, Abuse, Neglect (is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress), Exploitation (taking advantage of a resident for personal gain through the use of manipulation , intimidation, threats, or coercion) and Misappropriation (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident ' s belongings or money without the resident ' s consent) Prevention Program, revised April 2021, the policy and procedure indicated, Residents have the right to be free from abuse The policy and procedure indicated the facility will Protect residents from abuse . by anyone including . other residents.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was unable to make safe decisions due to poor judgement related to his diagnosis of dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), had polyneuropathy (is the damage to multiple nerves outside of the brain and central nervous system. This can cause inability to feel pain, heat intolerance, pain, discomfort, and mobility difficulties) used a wheelchair for mobility, and needed staff assistance with activities of daily living (ADLs, such as: transfers, locomotion, personal hygiene, eating, and dressing), received the necessary supervision and assistance to prevent injuries while in the patio in the heat. On [DATE], Resident 1 was left, for an unclear length of time, between 3:30 p.m. and 4:25 p.m., during the hottest time of the day unsupervised and unassisted in an open patio, exposed to the heat and sunlight. As a result, Resident 1 was found at 4:25 p.m., unresponsive to stimuli (not reacting or able to react in a normal way when touched, spoken to, etc.), with [CONDITION(S)] (rapid heartbeat), [CONDITION(S)] (low blood pressure [the force of the blood as it presses against the blood vessel walls]), blisters on both shoulders and left lower abdomen, and both arms and legs were red and warm to touch. Resident 1 was in cardio-respiratory distress with hyperthermia (dangerously overheated body, usually in response to prolonged hot weather) and the facility delayed calling paramedics (or emergency medical services [EMS] are health professionals certified to perform advanced life support procedures who respond to 911 calls and treat and transport people in health crisis) for 47 minutes. EMS found Resident 1 comatose (a state of deep, unarousable unconsciousness [interruption of awareness of oneself and ones surrounding]), with suspected heat stroke (the most serious heat-related illness. It occurs when the body becomes unable to control its temperature: the body's temperature rises rapidly, the sweating mechanism fails, and the body is unable to cool down), hot to the touch with flushed red sunburn skin with some blistering. EMS administered Resident 1 intravenous (IV, through the veins) fluids, cooling measures and transported the resident to General Acute Care Hospital 1 (GACH 1) Emergency Department (ED), and after arrival, at 5:42 p.m., Resident 1 was still with hyperthermia, his rectal temperature was 107.03 degrees Fahrenheit (°F - normal rectal temperature of an adult ranges between 97.9°F - 100.4°F). Resident 1 was diagnosed with acute respiratory distress (condition in which fluid collects in the tiny, elastic air sacs in the lungs, depriving organs of oxygen), and second-degree [CONDITION(S)] (which often looks wet or moist, affects the first and second layers of the skin, blisters may develop, and pain can be severe) on the left shoulder and abdomen. Resident 1 was subsequently admitted to the intensive care unit (ICU, is a specialized section of a hospital with specially trained health care staff that provide comprehensive and continuous care to persons with life-threatening injuries and illnesses). Cross Reference F600 Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was an [AGE] year-old male, with an initial admission to the facility dated [DATE], with the last re-admitted d [DATE]. Resident 1's diagnoses included polyneuropathy, unspecified dementia, diabetes (a chronic disease characterized by elevated levels of blood glucose [or blood sugar], which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves), and major depressive disorder (persistently depressed mood [or emotional state] marked by feelings of low self-worth or guilt, and long-term loss of pleasure or interest in life). Family Member 1 (FM 1) was listed as Resident 1's responsible party (for healthcare decisions). A review of Resident 1's Physician's Orders for Life-Sustaining Treatment (POLST, is a form that gives seriously-ill patients more control over their end-of-life care, including medical treatment, extraordinary measures [such as a ventilator or feeding tube] and CPR [cardio-pulmonary resuscitation]. It is signed by both the patient or patient's representative and the physician) dated [DATE], indicated DNR (do not resuscitate or no CPR) and DNI (do not intubate). Resident 1's POLST did not indicate no hospitalization or no IV fluids. A review of Resident 1's Care Plan with a revision date of [DATE], indicated Resident 1 was at risk for falls and injury related to history of falling, diagnosis of diabetes, [CONDITION(S)] (low number of red blood cells to carry adequate oxygen to the body), congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should) and chronic kidney disease (gradual loss of kidney function). The interventions included to visibly observe resident frequently and provide a safe environment. A review of Resident 1's Care Plan developed for the resident's self-care deficits related to extensive assistance with locomotion in wheelchair, with a revision date of [DATE] included in the interventions providing Resident 1 assistance as needed and a safe environment. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated [DATE], indicated the resident had severe cognitive impairment (the person has a very hard time remembering things, making decisions, concentrating, or learning. Severe levels of impairment can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently). Resident 1 required extensive assistance with one-person physical assist with bed mobility, locomotion on/off unit, eating, and personal hygiene. Resident 1 used a wheelchair as a mobility device. A review of Resident 1's SBAR (Situation - Background - Appearance - Recommendation, is a technique that provides a framework for communication between members of the health care team about a resident's condition) Change of Condition (COC) form, dated [DATE], documented by Licensed Vocational Nurse 3 (LVN 3), indicated Certified Nursing Assistant 1 (CNA 1) found Resident 1 at 4:25 p.m. in the patio with an altered level of consciousness (ALOC) unresponsive to stimuli. At 4:25 p.m., Resident 1's tympanic temperature (taken in the ear) was 98.2 °F (normal), the oxygen saturation (O2 Sat, indicates the amount of oxygen traveling through the body with the red blood cells. Normal range is between 95% and 100% for most healthy adults), the respiration rate was even and unlabored (normal) but had [CONDITION(S)] and had low blood pressure. The actual reading of the heart and respiratory rates, and the blood pressure, were not documented as taken until 4:45 p.m. LVN 3 documented that at 4:45 p.m. Resident 1's pulse (heart rate) was 138 beats per minute (bpm, the normal heart rate for an adult range between 60 -100 bpm), the respiratory rate was 20 breaths per minutes (the normal respiration rate for an adult at rest range from 12 to 16 breaths per minute), and the blood pressure was ,d+[DATE] millimeters of mercury (mmHg - normal blood pressure between ,d+[DATE] mmHg and ,d+[DATE] mmHg). LVN 3 documented Registered Nurse 2 (RN 2) was notified and a Code Blue (means there is a medical emergency occurring within the facility. Healthcare providers activate a code blue, if they feel the life of the person they are treating is in immediate danger) was called immediately at 4:30 p.m. Resident 1 was brought inside the hallway, in his wheelchair, was warm to touch and a cold towel was placed on the resident's forehead and neck. Resident 1 was given oxygen (O2) at 15 liters per minute (L/min) with the use of a non-rebreather mask (NRBM, is a medical device that helps deliver oxygen in emergency situations. It consists of a face mask connected to a reservoir bag that is filled with a high concentration of oxygen. The reservoir bag is connected to an oxygen tank. The mask covers both the nose and mouth. One-way valves prevent exhaled air from reentering the oxygen reservoir. A NRBM is used in emergency situations to prevent hypoxemia, also known as low blood oxygen). At 4:50 p.m., Resident 1's clothes were removed and was noted with blisters on both shoulders and left lower abdomen. Resident 1's upper and lower extremities (arms and legs) were red and warm to touch and ice packs were applied to head, upper and lower extremities. At 4:55 p.m., RN 2 called FM 1 to inform him of Resident 1's condition and DNR and FM 1 instructed RN 2 to transfer Resident 1 to an emergency room (ER). At 5:00 p.m., RN 2 called 911 and Resident 1's vital signs (temperature, respiratory and heart rate, blood pressure, O2 Sat, etc.) were re-checked, the blood pressure was ,d+[DATE] mmHg, the heart rate was 151 bpm, the temperature was 98.2 °F, and the O2 Sat was 98% with O2 via NRBM at 8L/min. At 5:23 p.m., EMS arrived at Resident 1's room. A review of the EMS Report titled, Prehospital Care Report Summary dated [DATE], with a dispatch (called received) time of 5:12 p.m., and an arrival at Resident 1's room at 5:20 p.m. and a departure from the facility to GACH 1 at 5:36 p.m., indicated that upon arrival, EMS found Resident 1 in bed with ALOC, a Glasgow Coma Score of 3 (GCS, is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses. A GCS of 3 is the lowest score possible indicating coma or unresponsiveness) with labored breathing (difficulty breathing), shallow respiration, abnormal lung sounds on both lungs, hot to the touch with flushed red sunburns skin with some blistering, and diaphoretic (sweating heavily). EMS administered IV fluids, initiated active cooling measures with ice packs under armpits and groin area, and documented that per nursing staff, Resident 1 was sitting outside in his wheelchair in the patio, in the heat for several hours. Nursing staff waited an hour to activate 911 system. A review of Resident 1's GACH 1's ED Physician Notes, dated [DATE], indicated the resident was received at 5:52 p.m. with heat stroke and ALOC with an onset earlier in the day. Resident 1 was left outside in the heat, in a wheelchair, for four hours when nursing staff finally found him. The resident had second degree [CONDITION(S)] on his left shoulder and abdomen. Resident 1's rectal temperature was 107.03 °F. Patient was cooled with cooling blanket, cool IV fluids, three-way Foley catheter (thin, flexible tube placed in the bladder) with bladder irrigation with cool fluids. Ice packs were also applied to the groin and axilla. At 6:21 p.m. Resident 1's temperature was 105.8 °F. At 7:03 p.m., Resident 1 vomited, FM 1 at bedside and MD explained the resident's critical condition. At 7:47 p.m., FM 1 requested intubation. Resident 1 remained obtunded (ALOC) and not protecting airway despite normal temperature. Resident 1 was intubated (oral or tracheal [windpipe] intubation, is the placement of a flexible plastic tube into the trachea to maintain an open airway) in the ED and at 8:02 p.m. was transferred to ICU. Resident 1's diagnoses included acute renal failure, acute respiratory failure, heat stroke, second degree sunburn, and severe dehydration. A review of the facility's Administrator letter, dated [DATE], notifying the State Survey Agency (SSA, the Department) of the incident of Resident 1 hyperthermia on [DATE], indicated that based on interviews with the staff and residents, the incident was unavoidable because the resident was alert and could independently wheel himself around the facility which was demonstrated in the video footage. Resident was able to go the patio on his own which was accessible with automatic motion sensor which allow the resident to go out (to the patio) and enter the facility (return inside). The smoking break at the patio was at 2 p.m. Resident 1 had adequate supervision and monitoring by staff and the last staff interaction, or visual contact with the resident was at 3:25 p.m. which was an hour before he was found unresponsive in the patio. On [DATE], at 1:52 p.m. during a review of the security video footage with the Director of Nursing (DON), Resident 1 was last seen on [DATE] at around 1:17 p.m. leaving the Sunroom (dining room), wheeling himself towards the hallway. There were no further sightings of Resident 1 in the surveillance video. On [DATE] at 5:15 p.m. during an interview, Licensed Vocational Nurse 1 (LVN 1) stated nursing staff do not normally check the patio and residents should not be out in the patio unattended. On [DATE] at 5:18 p.m. during an interview, Registered Nurse 1 (RN 1) stated residents going to the patio should always be supervised for their safety. RN 1 stated there was no schedule for nursing staff to check the patio for residents. On [DATE] at 7:02 p.m. during an interview, CNA 1 stated he worked the 3:00 p.m. to 11:00 p.m. shift on [DATE], he came late (at 3:20 p.m.) to work and was assigned to care for Resident 1. CNA 1 stated that at around 4:20 p.m. he found Resident 1 outside in the patio alone without any staff supervising him. CNA 1 stated Resident 1 was wearing a beanie (head covering), a long-sleeved shirt, long pants, and shoes. CNA 1 stated it was a very hot that day. CNA 1 stated there are no staff outside the patio on regular bases, only during smoking break. On [DATE] at 1:26 p.m. during an interview, Assistant Administrator (AA) stated Resident 1's incident of hyperthermia and sunburns was avoidable if proper supervision and assistance was provided. Staff should have been with Resident 1 while he was in the patio. On [DATE] at 10:52 a.m. during a telephone interview, the facility's Medical Director stated not knowing how the facility managed residents that went out on the patio or if there was a policy on supervision of residents on the patio. Medical Director stated Resident 1's incident of hyperthermia was avoidable. On [DATE], at 7:30 p.m. during an interview, LVN 3 stated she worked the 3 p.m. to 11 p.m. shift on [DATE] and she took Resident 1's vital signs. When asked about Resident 1's normal body temperature reading of 98.2 °F at 4:25 p.m. but warm to the touch and needing cooling measures, LVN 3 explained it was because she had placed a cold towel first on Resident 1's forehead and then, used the temperature probe (which is a forehead gun thermometer) but LVN 3 documented the resident's temperature was taken from the ear. LVN 3 stated she administered O2 at 15 L/min via NRBM but could not explain its need when she documented Resident 1 was not in a respiratory distress. LVN 3 stated RN 2 instructed her to remove Resident 1's clothes to assess the resident's skin. On [DATE], at 7:51 p.m. during an interview, RN 2 stated the delay in calling paramedics was due to Resident 1's POLST and she had to call FM 1 first. RN 2 confirmed Resident 1's POLST did not say to call the family first in an emergency and did not say no to hospitalization . RN 2 acknowledged giving paramedics the verbal report but denied saying Resident 1 was left in the heat for several hours. RN 2 stated paramedics were not called immediately because Resident 1 was DNR, was not in distress, had vital signs and was just unresponsive. On [DATE], at 3:10 p.m. during an interview, Administrator stated once the staff found Resident 1 unresponsive, they should have called 911 immediately. On [DATE], at 3:17 p.m. during an interview, DON stated since Resident 1's POLST was DNR/DNI with selective measures, she believed the licensed nurses did the right thing by calling the FM 1 to ask permission to call 911. DON could not explain the delay of 47 minutes in calling EMS from 4:25 p.m. to 5:12 p.m. (per EMS report) and of 35 minutes, from 4:25 p.m. to 5 p.m. (per nursing note). DON confirmed Resident 1's POLST did not indicate the resident was not to be transferred to hospital or not to be administered IV fluids. According to the website, Weather.com, the temperatures registered on Sunday [DATE], in the city the facility is located, ranged from 60 °F (lowest) to 88 °F (highest). A review of the facility's undated policy on Monitoring Residents, indicated the facility was to identify ways to monitor residents and resident care. Residents with special care needs and potential for neglect shall be monitored in accordance with their plan of care and at a minimum, included in the regular monitoring of Charge Nurses during endorsements of care to nurse's aides. The facility monitoring program include daily rounds, medication/nourishment/meal/ice/water pass, toileting program, activity program, incontinent care rounds, RNA (restorative nursing assistant) program, therapy program, and daily care. A review of the facility's undated policy on Quality of Care indicated the intent of the policy was to ensure that each resident receive and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, The facility will ensure the resident obtains optimal improvement. The facility will ensure the resident environment remains as free of accident hazards as possible; and each resident receives adequate supervision and assistance devices to prevent accidents. A review of the facility's undated policy on Abuse and Mistreatment of Residents, indicated the facility shall ensure comprehensive assessment and care planning for residents with needs and behaviors which might lead to conflict or neglect are initiated. Department Supervisors shall ensure adequate supervision is being given and appropriate assistance is extended to the residents in need when performing their daily monitoring and rounds. As part of the daily and routine inspection, Director of Nursing, Director of Staff Development, Nursing Supervisors, and/or Designees shall monitor performance to ensure residents are given appropriate and adequate care based on needs identified in their comprehensive assessments. Residents with special needs and potential for neglect shall be monitored in accordance with their plans of care and at a minimum, included in the regular monitoring of Charge Nurses during endorsement of care to nurse's aides.

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was unable to make safe decisions due to poor judgement related to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This can cause inability to feel pain, heat intolerance, pain, discomfort, and mobility difficulties), used a wheelchair for mobility, and needed staff assistance with activities of daily living (ADLs, such as: transfers, locomotion, personal hygiene, eating, and dressing), had the right to be free from neglect (the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) to prevent injuries while in the patio in the heat. On [DATE], Resident 1 was left, for an unclear length of time, during the hottest time of the day between 3:30 p.m. and 4:25 p.m., unsupervised and unassisted in an open patio, exposed to the heat and sunlight. As a result, Resident 1 was found at 4:25 p.m., unresponsive to stimuli (not reacting or able to react in a normal way when touched, spoken to, etc.), with [CONDITION(S)] (rapid heartbeat), [CONDITION(S)] (low blood pressure [the force of the blood as it presses against the blood vessel walls]), blisters on both shoulders and left lower abdomen, and both arms and legs were red and warm to touch. Resident 1 was in cardio-respiratory distress with hyperthermia (dangerously overheated body, usually in response to prolonged hot weather) and the facility delayed calling paramedics (or emergency medical services [EMS] are health professionals certified to perform advanced life support procedures who respond to 911 calls and treat and transport people in health crisis) for 42 minutes. EMS found Resident 1 comatose (a state of deep, unarousable unconsciousness [interruption of awareness of oneself and ones surrounding]), with suspected heat stroke (the most serious heat-related illness. It occurs when the body becomes unable to control its temperature: the body's temperature rises rapidly, the sweating mechanism fails, and the body is unable to cool down), hot to the touch with flushed red sunburn skin with some blistering. EMS administered Resident 1 intravenous (IV, through the veins) fluids, cooling measures and transported the resident to General Acute Care Hospital 1 (GACH 1) Emergency Department (ED), and after arrival, at 5:52 p.m., Resident 1 was still with hyperthermia, his rectal temperature was 107.03 degrees Fahrenheit (°F - normal rectal temperature of an adult ranges between 97.9°F - 100.4°F). Resident 1 was diagnosed with acute respiratory distress (condition in which fluid collects in the tiny, elastic air sacs in the lungs, depriving organs of oxygen), and second-degree [CONDITION(S)] (which often looks wet or moist, affects the first and second layers of the skin, blisters may develop, and pain can be severe) on the left shoulder and abdomen. Resident 1 was subsequently admitted to the intensive care unit Resident 1 was admitted to the intensive care unit (ICU, is a specialized section of a hospital with specially trained health care staff that provide comprehensive and continuous care to persons with life-threatening injuries and illnesses). Cross Reference F689 Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was an [AGE] year-old male, with an initial admission to the facility dated [DATE], with the last re-admitted d [DATE]. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Family Member 1 (FM 1) was listed as Resident 1's responsible party (for healthcare decisions). A review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It is signed by both the patient or patient's representative and the physician) dated [DATE], indicated DNR (do not resuscitate or no CPR) and DNI (do not intubate). Resident 1's POLST did not indicate no hospitalization or no IV fluids. A review of Resident 1's Care Plan with a revision date of [DATE], indicated Resident 1 was at risk for falls and injury related to history of falling, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included to visibly observe resident frequently and provide a safe environment. A review of Resident 1's Care Plan developed for the resident's self-care deficits related to extensive assistance with locomotion in wheelchair, with a revision date of [DATE] included in the interventions providing Resident 1 assistance as needed and a safe environment. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated [DATE], indicated the resident had severe cognitive impairment (the person has a very hard time remembering things, making decisions, concentrating, or learning. Severe levels of impairment can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently). Resident 1 required extensive assistance with one-person physical assist with bed mobility, locomotion on/off unit, eating, and personal hygiene. Resident 1 used a wheelchair as a mobility device. A review of Resident 1's SBAR (Situation - Background - Appearance - Recommendation, is a technique that provides a framework for communication between members of the health care team about a resident's condition) Change of Condition (COC) form, dated [DATE], documented by Licensed Vocational Nurse 3 (LVN 3), indicated Certified Nursing Assistant 1 (CNA 1) found Resident 1 at 4:25 p.m. in the patio with an altered level of consciousness (ALOC) unresponsive to stimuli. At 4:25 p.m., Resident 1's tympanic temperature (taken in the ear) was 98.2 °F (normal), the oxygen saturation (O2 Sat, indicates the amount of oxygen traveling through the body with the red blood cells. Normal range is between 95% and 100% for most healthy adults), the respiration rate was even and unlabored (normal) but had [CONDITION(S)] and had low blood pressure. The actual reading of the heart and respiratory rates, and the blood pressure, were not documented as taken until 4:45 p.m. LVN 3 documented that at 4:45 p.m. Resident 1's pulse (heart rate) was 138 beats per minute (bpm, the normal heart rate for an adult range between 60 -100 bpm), the respiratory rate was 20 breaths per minutes (the normal respiration rate for an adult at rest range from 12 to 16 breaths per minute), and the blood pressure was ,d+[DATE] millimeters of mercury (mmHg - normal blood pressure between ,d+[DATE] mmHg and ,d+[DATE] mmHg). LVN 3 documented Registered Nurse 2 (RN 2) was notified and a Code Blue (means there is a medical emergency occurring within the facility. Healthcare providers activate a code blue, if they feel the life of the person they are treating is in immediate danger) was called immediately at 4:30 p.m. Resident 1 was brought inside the hallway, in his wheelchair, was warm to touch and a cold towel was placed on the resident's forehead and neck. Resident 1 was given oxygen (O2) at 15 liters per minute (L/min) with the use of a non-rebreather mask (NRBM, is a medical device that helps deliver oxygen in emergency situations. It consists of a face mask connected to a reservoir bag that is filled with a high concentration of oxygen. The reservoir bag is connected to an oxygen tank. The mask covers both the nose and mouth. One-way valves prevent exhaled air from reentering the oxygen reservoir. A NRBM is used in emergency situations to prevent hypoxemia, also known as low blood oxygen). At 4:50 p.m., Resident 1's clothes were removed and was noted with blisters on both shoulders and left lower abdomen. Resident 1's upper and lower extremities (arms and legs) were red and warm to touch and ice packs were applied to head, upper and lower extremities. At 4:55 p.m., RN 2 called FM 1 to inform him of Resident 1's condition and DNR and FM 1 instructed RN 2 to transfer Resident 1 to an emergency room (ER). At 5:00 p.m., RN 2 called 911 and Resident 1's vital signs (temperature, respiratory and heart rate, blood pressure, O2 Sat, etc.) were re-checked, the blood pressure was ,d+[DATE] mmHg, the heart rate was 151 bpm, the temperature was 98.2 °F, and the O2 Sat was 98% with O2 via NRBM at 8L/min. At 5:23 p.m., EMS arrived at Resident 1's room. A review of the EMS Report titled, Prehospital Care Report Summary dated [DATE], with a dispatch (called received) time of 5:12 p.m., and an arrival at Resident 1's room at 5:20 p.m. and a departure from the facility to GACH 1 at 5:36 p.m., indicated that upon arrival, EMS found Resident 1 in bed with ALOC, a Glasgow Coma Score of 3 (GCS, is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses. A GCS of 3 is the lowest score possible indicating coma or unresponsiveness) with labored breathing (difficulty breathing), shallow respiration, abnormal lung sounds on both lungs, hot to the touch with flushed red sunburns skin with some blistering, and diaphoretic (sweating heavily). EMS administered IV fluids, initiated active cooling measures with ice packs under armpits and groin area, and documented that per nursing staff, Resident 1 was sitting outside in his wheelchair in the patio, in the heat for several hours. Nursing staff waited an hour to activate 911 system. A review of Resident 1's GACH 1's ED Physician Notes, dated [DATE], indicated the resident was received at 5:52 p.m. with heat stroke and ALOC with an onset earlier in the day. Resident 1 was left outside in the heat, in a wheelchair, for four hours when nursing staff finally found him. The resident had second degree [CONDITION(S)] on his left shoulder and abdomen. Resident 1's rectal temperature was 107.03 °F. Patient was cooled with cooling blanket, cool IV fluids, three-way Foley catheter (thin, flexible tube placed in the bladder) with bladder irrigation with cool fluids. Ice packs were also applied to the groin and axilla. At 6:21 p.m. Resident 1's temperature was 105.8 °F. At 7:03 p.m., Resident 1 vomited, FM 1 at bedside and MD explained the resident's critical condition. At 7:47 p.m., FM 1 requested intubation. Resident 1 remained obtunded (ALOC) and not protecting airway despite normal temperature. Resident 1 was intubated (oral or tracheal [windpipe] intubation, is the placement of a flexible plastic tube into the trachea to maintain an open airway) in the ED and at 8:02 p.m. was transferred to ICU. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Administrator letter, dated [DATE], notifying the State Survey Agency (SSA, the Department) of the incident of Resident 1 hyperthermia on [DATE], indicated that based on interviews with the staff and residents, the incident was unavoidable because the resident was alert and could independently wheel himself around the facility which was demonstrated in the video footage. Resident was able to go the patio on his own which was accessible with automatic motion sensor which allow the resident to go out (to the patio) and enter the facility (return inside). The smoking break at the patio was at 2 p.m. Resident 1 had adequate supervision and monitoring by staff and the last staff interaction, or visual contact with the resident was at 3:25 p.m. which was an hour before he was found unresponsive in the patio. On [DATE], at 1:52 p.m. during a review of the security video footage with the Director of Nursing (DON), Resident 1 was last seen on [DATE] at around 1:17 p.m. leaving the Sunroom (dining room), wheeling himself towards the hallway. There were no further sightings of Resident 1 in the surveillance video. On [DATE] at 5:15 p.m. during an interview, Licensed Vocational Nurse 1 (LVN 1) stated nursing staff do not normally check the patio and residents should not be out in the patio unattended. On [DATE] at 5:18 p.m. during an interview, Registered Nurse 1 (RN 1) stated residents going to the patio should always be supervised for their safety. RN 1 stated there was no schedule for nursing staff to check the patio for residents. On [DATE] at 7:02 p.m. during an interview, CNA 1 stated he worked the 3:00 p.m. to 11:00 p.m. shift on [DATE], he came late (at 3:20 p.m.) to work and was assigned to care for Resident 1. CNA 1 stated that at around 4:20 p.m. he found Resident 1 outside in the patio alone without any staff supervising him. CNA 1 stated Resident 1 was wearing a beanie (head covering), a long-sleeved shirt, long pants, and shoes. CNA 1 stated it was a very hot that day. CNA 1 stated there are no staff outside the patio on regular bases, only during smoking break. On [DATE] at 1:26 p.m. during an interview, Assistant Administrator (AA) stated Resident 1's incident of hyperthermia and sunburns was avoidable if proper supervision and assistance was provided. Staff should have been with Resident 1 while he was in the patio. On [DATE] at 10:52 a.m. during a telephone interview, the facility's Medical Director stated not knowing how the facility managed residents that went out on the patio or if there was a policy on supervision of residents on the patio. Medical Director stated Resident 1's incident of hyperthermia was avoidable. On [DATE], at 7:30 p.m. during an interview, LVN 3 stated she worked the 3 p.m. to 11 p.m. shift on [DATE] and she took Resident 1's vital signs. When asked about Resident 1's normal body temperature reading of 98.2 °F at 4:25 p.m. but warm to the touch and needing cooling measures, LVN 3 explained it was because she had placed a cold towel first on Resident 1's forehead and then, used the temperature probe (which is a forehead gun thermometer) but LVN 3 documented the resident's temperature was taken from the ear. LVN 3 stated she administered O2 at 15 L/min via NRBM but could not explain its need when she documented Resident 1 was not in a respiratory distress. LVN 3 stated RN 2 instructed her to remove Resident 1's clothes to assess the resident's skin. On [DATE], at 7:51 p.m. during an interview, RN 2 stated the delay in calling paramedics was due to Resident 1's POLST and she had to call FM 1 first. RN 2 confirmed Resident 1's POLST did not say to call the family first in an emergency and did not say no to hospitalization . RN 2 acknowledged giving paramedics the verbal report but denied saying Resident 1 was left in the heat for several hours. RN 2 stated paramedics were not called immediately because Resident 1 was DNR, was not in distress, had vital signs and was just unresponsive. On [DATE], at 3:10 p.m. during an interview, Administrator stated once the staff found Resident 1 unresponsive, they should have called 911 immediately. On [DATE], at 3:17 p.m. during an interview, DON stated since Resident 1's POLST was DNR/DNI with selective measures, she believed the licensed nurses did the right thing by calling the FM 1 to ask permission to call 911. DON could not explain the delay of 47 minutes in calling EMS from 4:25 p.m. to 5:12 p.m. (per EMS report) and of 35 minutes, from 4:25 p.m. to 5 p.m. (per nursing note). DON confirmed Resident 1's POLST did not indicate the resident was not to be transferred to hospital or not to be administered IV fluids. According to the website, Weather.com, the temperatures registered on Sunday [DATE], in the city the facility is located, ranged from 60 °F (lowest) to 88 °F (highest). A review of the facility's undated policy on Monitoring Residents, indicated the facility was to identify ways to monitor residents and resident care. Residents with special care needs and potential for neglect shall be monitored in accordance with their plan of care and at a minimum, included in the regular monitoring of Charge Nurses during endorsements of care to nurse's aides. The facility monitoring program include daily rounds, medication/nourishment/meal/ice/water pass, toileting program, activity program, incontinent care rounds, RNA (restorative nursing assistant) program, therapy program, and daily care. A review of the facility's undated policy on Quality of Care indicated the intent of the policy was to ensure that each resident receive and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, The facility will ensure the resident obtains optimal improvement. The facility will ensure the resident environment remains as free of accident hazards as possible; and each resident receives adequate supervision and assistance devices to prevent accidents. A review of the facility's undated policy on Abuse and Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Department Supervisors shall ensure adequate supervision is being given and appropriate assistance is extended to the residents in need when performing their daily monitoring and rounds. As part of the daily and routine inspection, Director of Nursing, Director of Staff Development, Nursing Supervisors, and/or Designees shall monitor performance to ensure residents are given appropriate and adequate care based on needs identified in their comprehensive assessments. Residents with special needs and potential for neglect shall be monitored in accordance with their plans of care and at a minimum, included in the regular monitoring of Charge Nurses during endorsement of care to nurse's aides.

Based on interview and record review, the facility failed to call paramedics (911-telephone number used to request for emergency medical assistance) for one of two sampled residents (Resident 1), who was observed in respiratory distress on [DATE] at 2 a.m. As a result, Resident 1's difficulty breathing was not immediately treated and subsequently Resident 1 expired at the facility at 4:25 a.m. when the resident went into [MEDICAL CONDITION] (cessation of function of the heart). Findings: A review of Resident 1's Admission Record (Face Sheet) indicated an admitted d [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's Care Plan on Advance Directive initiated on [DATE] and revised on [DATE], indicated a POLST (Physician order [REDACTED]. or heartbeat has stopped), acute care hospitalization , artificial feeding, intravenous fluids, and to notifying the physician of any changes to respect the resident and/or family wishes. A review of Resident 1's POLST, dated [DATE], indicated Resident 1 was to receive full treatment and was signed by the attending physician and Resident 1. A review of Resident 1's Minimum Data Set (MDS- standardized assessment and care-screening tool) dated [DATE], indicated resident was unable to make her needs known and make decisions. Resident 1 required extensive assistance with personal hygiene, transfers, and bed mobility. A review of Resident 1's nursing notes indicated on [DATE] the resident was diagnosed with [REDACTED]. A review of Resident 1's Change of Condition Assessment Form completed by Registered Nurse 1 (RN 1) dated [DATE] and timed at 4:51 a.m., indicated Certified Nursing Assistant 2 (CNA 2) at 4 a.m. found Resident 1 breathing shallow and deep and called the Charge Nurse. The resident's blood pressure was undetectable, respirations was three breath per minute (normal range ,[DATE] breaths), the pulse (heart rate) was 60 beats per minute (normal range 60 to 100 beats per minutes), and the oxygen saturation (oxygen carried by the red blood cells) was 50% (normal rate is above 95%). Oxygen at 15 liters per minute through mask was given and the oxygen saturation 66%. At 4:25 a.m., Resident 1 stopped breathing and had no pulse at 4:25 a.m. Staff started CPR, Physician 1 was called and was informed the resident was unresponsive. Physician 1 pronounced the resident dead and told RN 1 to notify the resident's family. During an interview on [DATE], at 6:50 a.m., CNA 2 stated on [DATE], at 4 a.m., Resident 1's breathing was shallow, had difficulty breathing and was gasping for air. CNA 2 left the room and notified Licensed Vocational Nurse 2 (LVN 2). On [DATE], at 6:57 am, during an interview, LVN 2 stated that on [DATE], at around 4 a.m., CNA 2 informed her Resident 1 was breathing irregular, LVN 2 got RN 1. Both (LVN 2 and RN 1) went to Resident 1's room and the resident's breaths were shallow and LVN 2 could not get the resident's blood pressure (not detected), LVN 2 applied oxygen with mask, LVN 2 proceeded to go to the nursing station to check in Resident 1's medical record if the resident was to be given CPR. Around 4:26 a.m., RN 1 left the room to call for help. LVN 2 stated after two cycles of CPR with RN 1, RN 1 left the room and LVN 2m performed two cycles of CPR alone. LVN 2 asked RN 1 to call 911 but RN 1 called the doctor instead. On [DATE] at 7 a.m., during an interview, RN 1 stated Resident 1 was alert, awake and verbally responsive during shift rounds at 11 p.m. When asked under which circumstances, she would call 911, RN 1 stated a resident experiences chest pain, hard time breathing, shortness of breath, and uncontrolled pain after surgery. During a telephone Interview on [DATE], at 10 am, MD 1 stated the licensed nurses should have called 911. On [DATE], at 12:12 p.m., during a telephone interview, Director of Nursing (DON) stated during an emergency, the licensed nurses are to assess the resident, check the advance directives or POLST and call the MD and 911 if the resident is full code. During a telephone interview on [DATE], at 7:15 a.m., RN 1 stated she should have called 911 and the facility's policy indicates to call 911 in case of an emergency. A review of the facility's policy on Change of Condition revised [DATE], indicated in case of emergency, the following actions are optional, and the first option listed was to call 911 if necessary. A review of the facility's policy on Initiating Emergency & First Aid Care, indicated nursing duties included licensed nurse is professionally responsible for initiating emergency procedures and notifying physician promptly and/or emergency medical team.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program by failing to: 1. To have a system in place to ensure the effectiveness of the facility's pest control program. 2. Ensure the Pest Control Services recommendation dated June 22, 2017 was acted upon. 3. Ensure implementation of the undated Integrated Pest Management Program (IPM, preventive measures to prevent pest infestations). These deficient practices resulted in the failure to prevent the infestation of cockroaches throughout the facility and placed 123 out of 123 residents and facility staff at risk of diseases. Cockroaches' saliva, droppings, and decomposing roaches' bodies contain proteins known to trigger allergies [REDACTED]. Cockroaches are capable of carrying disease causing organisms such as Salmonella typhimurium (is a type of bacteria that cause food poisoning), [MEDICATION NAME] fever (an infectious bacterial fever with an eruption of red spots on the chest and abdomen and severe intestinal irritation), Entamoeba histolytica (a parasite that is transmitted to humans via contaminated water and food), polio[DIAGNOSES REDACTED] virus ([MEDICAL CONDITION] that enters the mouth and spreads from person to person and can invade an infected person's brain and spinal cord, causing paralysis), Staphylococcus spp (a bacteria that cause skin infections), Streptococcus spp (a bacteria that cause diseases such as sore throat), [MEDICAL CONDITION] virus (inflammation of the liver), and coliform bacteria (a bacteria found in water causing diseases). An Immediate jeopardy was called on July 20, 2017, at 6:35 p.m., with the administrator and director of nursing (DON) present and were informed that the urgency of the immediate jeopardy was that the roaches cause allergies [REDACTED]. A plan of Action needs to be formulated immediately. The administrator presented an immediate plan of correction action to the Evaluators on July 20, 2017, at 7:55 p.m., the immediate Plan of Correction action consisted of the following: 1. Quarantine of kitchen until treatment by the new pest control provider. 2. Thorough cleaning of the kitchen, discarded open packages of dry foods and sanitizing enclosed food items such as cans. 3. Maintenance supervisor sealed openings noted in the back door and the exhaust vent. 4. In-service of all staff of environmental cleanliness, proper food storage, discarding trash properly and timely and pest control log of cockroaches sighting to provide information to the pest control company. 5. Residents rooms, offices, nurses' stations and kitchen were inspected to identify the extent of the issues. 6. Staff inspected the residents' rooms to ensure food would be properly stored in a plastic container with lids. The immediate jeopardy was removed after the above noted plan of correction was confirmed on July 21, 2017 at 5:35 p.m. in presence of Administrator, Director of Nursing and Regional Operation Director. Findings: a. On July 20, 2017 at 9:30 a.m., during an observation tour of the kitchen in the presence of Cook 1, a small live cockroach was observed crawling on the floor next to the floor drain located by the vegetable and meat sink preparation area. Cook 1 took a piece of paper towel and disposed of the cockroach. A square shaped plastic bait trap measuring 2 by 2 inches was observed attached to the tiled wall behind the juice dispenser machine, located next to the vegetable and meat preparation area. During a concurrent interview, Cook 1 stated he had seen cockroaches in different areas of the kitchen approximately two months ago. On July 20, 2017 at 10 a.m., during an interview, the Dietary Service Supervisor (DSS) stated he did not know what the square shaped plastic (bait trap found behind the juice dispenser machine) was. The DSS stated the pest control company comes once a month and checks the entire kitchen. On July 20, 2017, at 4:36 p.m., during another observation of the kitchen in the presence of Dietary Aide 1 (DA 1), two live cockroaches were observed crawling next to the floor drain under the shelf where the pots were stored. Upon interview, DA 1 stated he saw cockroaches under the shelf in between Refrigerator #1 and the stove two months ago and reported the sighting to the DSS. On July 20, 2017, at 4:50 p.m., during an interview, DA 2 stated he saw a cockroach four days ago at approximately 2 p.m., under the shelf where the pots were stored (same area where the Evaluator observed cockroaches with DA 1). DA 2 stated he informed the DSS about the sighting and stated the DSS called the pest control company. On July 21, 2017 at 7:51 a.m., during an interview, Resident 19 stated she saw the a roach in her room crawling on the floor the night before. b. On July 18, 2017 at 12:00 p.m. in the presence of a Restorative Nursing Assistant (RNA 2), there were eight cardboard boxes observed in the Activity Room on top of the shelves strapped down with earthquake safety cords. On July 20, 2017 at 8 a.m. in the presence of the Housekeeping Supervisor (HS 1), the boxes were still observed in the same place as on July 18, 2017. On July 20, 2017 at 4:45 p.m. during an observation of Resident 6's room in the presence of Registered Nurse 3 (RN 3), the floor had accumulated dust, dirt, debris, candy wrappers and an empty bag of chips. c. On July 20, 2017 at 4:50 p.m. Random Sample Resident (RSR) 32's room was observed in the presence of RN 3. The floor had accumulation of dust, dirt, debris and an empty bag of chips. The table next to bed A was observed with food including rice, green beans, spinach, and cornbread. Two hard boiled eggs were in a container with a label indicating July 16, 2017. There was also a Chinese food box and a bowl of oatmeal. On July 20, 2017 at 4:55 p.m., during an interview RSR 32 stated there was, A little something crawling, but stated she did not notify staff. The resident stated she asked staff to clean her floor but the staff did not want to clean it. During an interview with the DON on July 20, 2017 at 5:30 p.m., she stated the pest control specialist was contacted because there were cockroaches observed in the employee's break room in June 2017. e. On July 19, 2017, at 10:53 a.m., at the Station 2 nursing workstation, a live cockroach approximately 0.5 centimeters (cm), was observed running on the counter top. The roach ran horizontally across the countertop from the direction of the portable flavored water dispenser, then vertically to a lower section of the countertop, then horizontally into a stack of residents' medical records. At the time of the observation, Registered Nurse Supervisor 1 (RNS 1) was present and called the Housekeeping Supervisor (HSK 1) and the DON. The cockroach was not captured. On July 20, 2017 at 10:11 a.m., during an interview, the DON and administrator indicated the pest control company was scheduled to come the following day (July 22, 2017) for the monthly visit to service the employees' lounge and kitchen. f. On July 19, 2017, at 12:13 p.m., a cockroach was sighted in the beauty shop in use by the Evaluators as a conference room. The roach was crawling from the direction of a cabinet closet to the door and then went up the wall. The administrator, who was outside the door, was called in to witness the roach sighting. The administrator used a paper towel, took the cockroach and disposed of it. A review of the Pest Management Sanitation Report from January 12, 2017 to June 22, 2017, indicated the pest control provider came to the facility on ce per month. Each month from March 9, 2017 to June 22, 2017 the pest Management Report recommended to, Keep doors closed, watch for food storage in rooms, food must be kept in plastic containers. The report dated March 9, 2017 had been signed by the administrator. The Report dated June 22, 2017 indicated roaches had been sighted in the employees' lounge. On July 20, 2017, at 4:45 p.m., during an interview, Pest Control Tech 1 (PCT 1) stated she visits the facility monthly and if there is a problem the facility staff would call. PCT 1 stated she did, A lot of preventive measures. When asked to give examples of the preventive measures, PCT 1 stated she implements the Integrated Pest Management Program (IPM). PCT 1 explained the Program included to use the least amount of chemicals, remove boxes from the facility, and caulking (seal a gap or seam, with a waterproof filler and sealant, to seal the gaps and cracks that exist between adjoining materials) and this was the reason she does not spray but uses bait in the kitchen, dish washer, and shelves. PCT 1 stated she uses long-term baits; the last time on June 22, 2017 when roaches were spotted in the microwave of the employees' lounge. PCT 1 also stated that ten or more roaches would be a problem but she only saw two baby roaches. On July 21, 2017, the administrator provided an undated copy of IPM Program with key elements that include habitat modification that reduces or eliminates sources of food, water, shelter, and entryways for pests. Take preventive measures, as simple as, thoroughly cleaning food storage areas; caulking; daily removal of waste to dumpsters; and educating facility staff and occupants about the importance of proper waste disposal. Buildings should be designed to be as pest resistant as possible by caulking cracks and gaps in the building to block pest entry; and using door sweeps and screens. Sanitation is a must, food in resident rooms must be in a pest-proof airtight container; no corrugated cardboard boxes allowed in resident rooms, dead roaches must be vacuumed out of bedside cabinets to prevent re-infestation; all TV's, radios, phones, etc. must be checked for roaches before installed in residents' rooms. In the kitchen, corrugated cardboard boxes must be removed from storerooms (this includes non-food items too); store food in airtight containers; no personnel items are to be stored in the kitchens; floors are to be kept clean of food and grease build up including under tables and stoves, if not, any roach baiting program will not work. Kitchen walls, under steam tables, dishwashing area, behind stoves, around door frames must be caulked and sealed to prevent nesting places for roaches. Dead roaches must be swept up, as to prevent re-infestation. g. On July 21, 2017 at 7:15 a.m., during a meal preparation observation in the kitchen, in the presence of the administrator, the following was observed: 1. One foot by one (1 by 1) foot square exhaust opening above the dishwasher machine without any type of covering to prevent any pest entry and infestation into the kitchen. 2. One cockroach under the dishwasher was observed lying on its back with twitching antennae and appeared to be dying. A cockroach shell was observed on the floor beside the stove. 3. The plumbing drain pipes had cracks at least one centimeter around the pipes into the wall where the meat and vegetable would be prepared. The administrator stated the cracks and openings will be sealed. h. On July 21, 2017 at 7:55 a.m., during a tour of the kitchen with the administrator, the following was observed: 1. Missing grout/caulking on the floor and base board tiles around the area by the kitchen entrance door. 2. There were crevices on the wall along the base edges of the new electrical panel that had been recently installed. 3. Under a new sink there were floor tiles with holes that measured approximately 2 by 2 inches. Also, underneath this sink there was a hole on the wall approximately 4 by 4 inches. On July 21, 2017, at 12:20 p.m., during an interview with the administrator, in the presence of the Regional Operations Manager, when asked when he had implemented the Pest Management Sanitation Report recommendations, the administrator stated, Just now. A review of the facility's undated policy, titled Housekeeping - Pest Control, indicated that the administrator arranges for a pest control company to visit and inspect the facility at least once a month, ensuring that: immediate action is taken to rid the facility or its grounds of any environmental pest as noted in the inspection report; after exterminating or spraying for insects, as the situation warrants, the facility is once again inspected by the pest control company to ensure that all environmental pests were removed from the premises. The company representative issues an additional report to the administrator, verifying that all environmental pests were removed.