Every finding on record at Westlake Convalescent Hospital

Based on observation, interview, and record review, the facility failed to maintain proper enhanced barrier precautions (EBP - staff wear protective gown and gloves during close, hands-on care to residents). This deficient practice had the potential to cause cross contamination between vulnerable residents, therefore, leading to decline in health and possible hospitalization. During a review of Resident 2's admission Record, the admission record indicated that Resident 2 was admitted to the facility on [DATE], with a diagnosis of but not limited to Chronic respiratory failure (long term condition where the lungs cannot properly move oxygen into your blood or get rid of waste carbon dioxide). End stage renal disease (ESRD - irreversible kidney failure), and type 2 diabetes Mellitus (DM2 - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's History and Physical (H&P), the H&P indicated that Resident 2 is dependent on a ventilator (machine that aides in breathing) and requires tracheostomy (a hole surgically created in the front of the neck and into the windpipe to help a person breathe). During a review of Resident's 2's Minimum Data Set (MDS-a resident assessment tool) dated 7/18/2026, the MDS indicated that Resident 2 is severely impaired and is a dependent on the assistance of a helper with all needs. The resident does none of the effort to complete the activity. During a review of Resident 2's Order Summary Report (OSR) dated 8/25/2026, the OSR indicated that Resident 2 is on EBP due to presence of devices/openings: such as PEG- tube (flexible tube placed directly in to the stomach through the abdomen to deliver food, fluids and medications), tracheostomy tube, Hemodialysis (HD- a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) access, midline (flexible tube placed in the a larger vein in the upper arm) and wounds. The OSR indicated Resident 2 had orders to change the Tracheostomy ties every shift or as needed to prevent infection. During an observation on 8/25/2026 at 11:59am in Resident 2's room, respiratory therapist (RT) was seen at the bedside changing Resident 2's tracheostomy ties. RT was observed performing close contact care without wearing proper personal protective equipment (PPE).During an interview on 8/25/2026 at 12:00pm with RT, RT stated that everyone in the subacute unit has enhanced barrier precautions because they all have some sort of tube, either a tracheostomy or a feeding tube. RT stated PPE must be worn when entering the room since EBP is for the entire room. During an interview on 8/25/2026 at 2:00pm with the Director of Nursing (DON), the DON stated that EBP means staff must wear Personal protective equipment when they are providing close contact care to the residents. The DON stated that Trach care of any kind requires PPE to be worn in the room. The DON stated If PPE is not worn it places the residents at risk of infection, cross contamination and worsening infections, which can lead to hospitalization. All staff must wear PPE when going into an EBP room. During a review of facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions (EBP), dated 1/10/2025, the P&P indicated that PPE for EBP shall be performed during high contact care activities. The P&P indicated that EBP is indicated for resident with wounds or indwelling (something that stays inside of your body for a period of time to do a specific job) medical devices even if the resident is not infected with a Multi Drug Resistant Organism (MDRO)

Based on observation, interview, and record review the facility failed to ensure proper use of bed rails (metal or plastic bars attached to the sides of a bed) for two of four sampled residents (Resident 9 and Resident 70) by failing to: -Ensure Resident 9 did not have a full-length side rail on the left side of Resident 9's bed without an informed consent (resident or their legal helper must agree to any medical treatment, new medication, or care plan only after the staff explains the choices, benefits, and risks) for Resident 9's full-length side rail.-Ensure to take measurements to ensure Resident 9's bed/bed rails were appropriate for Resident 9's size and weight.-Ensure to use the manufacturer guidelines for Resident 9's bed/bed rails. -Ensure to obtain measurements to ensure Resident 70's bed/bed rails were appropriate for Resident 70's size and weight and/or use the manufacturer guidelines for Resident 70's bed/bed rails. Findings: a. During a record review of Resident 9's admission Record dated 8/6/2026, the admission Record indicated the facility admitted Resident 9 on 12/18/2025 with diagnoses of functional quadriplegia (complete inability to move all four limbs), nontraumatic intracerebral hemorrhage (sudden bleed inside the brain tissue caused by diseased or weakened blood vessels), contracture of muscle left and right hand (permanent or long-lasting tightening and shortening of muscles, tendons, skin, and other soft tissues). During a record review of Resident 9' s History and Physical (H &P- formal, comprehensive evaluation and written record created by a healthcare provider) dated 4/28/2026, the H&P indicated Resident 9 did not have the capacity to understand and make decisions. During a record review of Resident 9' s Minimum data Set (MDS- a resident assessment tool) dated 6/29/2026, the MDS indicated Resident 9 required full assistance from staff when provided Activities of Daily Living (ADL-bed mobility, transfer, locomotion on unit, locomotion off unit, dressing, eating, toilet use and personal hygiene). The MDS indicated Resident 9 had severe cognitive (ability to remember things, solve problems, or make decisions). During a record review of Resident 9's Order Summary Report dated 4/28/2026, the Order Summary Report indicated for bilateral (both) one fourth(1/4) bed side rails (short safety rail- covering one-quarter of bed's total length) for safety precaution per Responsible party (RP) request every shift. During a review of Resident 9' s Care Plan Report dated 4/28/2026, the Care Plan Report indicated bilateral 1/4 Bed side rails for safety precaution per responsible party's request. The Care Plan Report indicated the IDT to review quarterly for reduction, bed rails up in bed and monitor for agitation, monitor for effectiveness or continued use, range of motion (ROM, means the full movement potential of a joint), visual checks, and repositioning every two hours. During a record review of Resident 9' s Physical Restraint (any device, material, chemical, or physical method used to restrict a patient's freedom of movement, physical activity, or normal access to their body) assessment dated [DATE], the Physical Restraint Assessment indicated the Interdisciplinary Team (IDT- group of professionals from different fields who work closely together to reach a shared goal) did not recommend the use of restraints at this time and will continue to anticipate needs, do frequent visual checks to assure safety and wellbeing of the resident. The Physical Restraint Assessment indicated Resident 9 was non ambulatory (could not walk), had impaired cognition and less restrictive measures including pillows, wedges, frequent, visual checks. The Physical Restraint Assessment indicated the facility will continue to monitor & assess for any significant changes & will inform Medical Doctor (MD) approaches to prevent or minimize decreased functioning related to restraint use. During a record review of Resident 9' s Entrapment (when a patient gets caught, trapped, or tangled in the spaces in or around a hospital bed rail, mattress, or bed frame) risk evaluation for Bedrails dated 6/23/2026, the Entrapment risk evaluation for bedrails indicated the bed rails were not medically necessary and the IDT did not recommend the use of side rails. During an observation on 8/3/2026 at 9:26 Am, Resident 9 was observed with full-length side rail on left side of bed and 1/4 side rail on the right side of the bed. During a concurrent interview and record review 8/9/2026 at 10:54 AM with Registered Nurse 3 (RNS 3), Resident 9's order for bed rails was reviewed. The physician's order indicated bilateral 1/4 bed side rails for safety precaution per responsible party request every shift. During a concurrent interview and record review on 8/6/2026 at 10:57 AM with RNS 3, Resident 9's Entrapment Evaluation dated 6/23/2026 was reviewed. The Entrapment Evaluation indicated the bedrails were not medically necessary and the IDT did not recommend the use of side rails. RNS 3 stated the recommendation for Resident 9 was not to have side rails per the IDT recommendation. RNS 3 stated that she (RNS3)did not set up Resident 9's bed. RNS 3 stated that she (RNS3) considered a full-length side rail as a restraint. RNS 3 stated that she (RNS3) was not sure if all of the facility's staff were aware that a full-length side rail was considered a restraint. RNS 3 stated that if Resident 9 had a full-length side rail the facility would need to get a consent and evaluate the resident for the need to use a side rail. RNS 3 stated the facility would need to verify the dimensions of the bed to ensure the bed was appropriate for Resident 9's size and weight. RNS 3 stated she (RNS3) could not find a consent for the full-length side rail. RNS 3 stated that a potential issue for Resident 9 was entrapment and this was why proper measurements were needed. During a concurrent interview and record review 8/6/2026 at 11:25 AM with Director of Nursing (DON) Resident 9's Entrapment Evaluation dated 6/23/2026 was reviewed. The DON stated if Resident 9 had a full-length side rail, the facility would have to obtain consent for the full-length side rail. The DON stated the facility needed to check the resident's measurements to ensure the resident size and weight were appropriate for the bed being used. The DON stated the facility would also need to use the manufacturer guidelines for the bed being used. During a record review of facility's Policy and Procedure (P&P) titled Care Plans – Comprehensive dated 1/1/2025, the P&P indicated IDT is in coordination with the resident, family or representative to maintain a comprehensive care plan for each resident that identifies highest level of functioning the resident may be expected to attain. It includes care plans, MDS, and ongoing resident assessments of their condition change. b.During a review of Resident 70's admission Record, the admission Record indicated the facility admitted the resident on 5/23/2025 with a diagnosis that included chronic respiratory failure (a long-term condition where the respiratory system fails to properly move oxygen into the blood or remove carbon dioxide from the body), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of the left and right hand, dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), cerebral infarction (when a blood clot blocks or narrows an artery that supplies blood to the brain), tracheostomy (a surgical opening made through the front of the neck into the windpipe to help the resident to breathe), and dependence on a respirator (ventilator, a mechanical device to help support or replace breathing). The admission Record indicated Family Member 1 (FM 1) was Resident 70's responsible party. During a review of Resident 70's MDS dated [DATE], the MDS indicated the resident had moderate cognitive impairment (decline in the ability to think, understand, and reason). The MDS indicated Resident 70 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from facility staff for eating and oral hygiene. The MDS indicated Resident 70 required substantial/maximal assistance (helper does more than half the effort) from facility staff for upper body dressing and personal hygiene. The MDS indicated Resident 70 was dependent (helper does all the effort) on help from facility staff for toileting hygiene, showering/bathing himself, lower body dressing, and putting on/taking off footwear. The MDS indicated bed rails were used daily for Resident 70. During a review of Resident 70's Entrapment Risk Evaluation For Bedrails dated 6/3/2026 at 9:24 AM, the Entrapment Risk Evaluation For Bedrails indicated the resident was to have a low bed, bilateral full side rails, and a floor mat for safety. The Entrapment Risk Evaluation for Bedrails indicated that bedrails placed Resident 70 at a significantly higher risk for strangulation (the compression of the neck that blocks blood flow, oxygen, or air to the brain), entanglement (a state of being twisted or tied up), and asphyxiation (deprivation of oxygen that can result in unconsciousness and/or death). The Entrapment Risk Evaluation indicated the Interdisciplinary Team (IDT, a group of professionals from different medical and support fields that meet to create one shared and unified treatment plan for a patient) and Medical Doctor (MD) agreed to use full side rails and a floor mat for safety in agreement with the resident's responsible party. During a review of Resident 70's Physical Restraint assessment dated [DATE], the Physical Restraint Assessment indicated the IDT recommend the use of bilateral (both sides) full padded side rails for safety. The Physical Restraint Assessment indicated that the benefits of using bilateral full padded side rails outweighed the risks. The Physical Restraint Assessment indicated that bilateral full padded side rails were not considered a restraint since the bilateral full padded side rails did not limit the resident's freedom of movement. During a review of Resident 70's Order Summary Report, the Order Summary Report indicated the resident had a physician order dated 7/10/2026 for bilateral full padded side rails for safety precaution and per the family's request every shift. During a review of Resident 70's Informed Consent Verification dated 7/10/2026, the Informed Consent Verification indicated FM 1 provided consent for the resident to use bilateral full padded sides rails for safety precaution. During an observation on 8/03/2026 at 10:35 AM in Resident 70's room, the resident was observed lying in bed. Resident 70's bed was observed with a full bed side rail on both sides. The bed side rails were padded. A floor mat was observed to the left side of Resident 70's bed. Resident 70 could not be interviewed during the observation. During a concurrent interview and record review on 8/6/2026 at 11:13 AM with Registered Nurse Supervisor 3 (RNS 3), Resident 70's Entrapment Risk Evaluation For Bedrails dated 6/3/2026, Physical Restraint assessment dated [DATE], physician order dated 7/10/2026, and Informed Consent Verification dated 7/10/2026 were reviewed. RNS 3 stated Resident 70 had full bed side rails. RNS 3 stated there was an informed consent, a physician order, an Entrapment Risk Evaluation, and Physical Restraint Assessment for Resident 70's use of full bed side rails. RNS 3 stated there had been attempts to use other methods to prevent falls and promote safety such as a low bed, floor mats, and Restorative Nursing Assistant (RNA) exercises, however, those methods alone did not work. RNS 3 stated Resident 70 utilized full padded bed side rails for safety and per the family's request. RNS 3 stated there were no measurements or dimensions taken of Resident 70 or the resident's bed side rails. RNS 3 stated there should have been dimensions and measurements taken to ensure that the bed side rails were appropriate for the size of Resident 70. RNS 3 stated that without any measurements or dimensions there was potential for Resident 70 to become injured from the full bed side rails due to entrapment (a situation in which a resident gets caught, trapped, or entangled in the spaces around medical devices, bed rails, or physical restraint structures). RNS 3 stated full bed side rails were considered a restraint which could have potentially restricted Resident 70's movement and caused injury. During a concurrent observation and interview on 8/06/2026 at 11:25 AM, in Resident 70's room, the resident was observed lying in bed. Resident 70's bed was observed with a full bed side rail on both sides. The bed side rails were padded. Resident 70 stated that he (Resident 70) could still move around in bed. Resident 70 stated the bed side rails did not limit his (Resident 70) movement. During a concurrent interview and record review on 8/06/2026 at 11:30 AM with the Director of Nursing (DON), Resident 70's Entrapment Risk Evaluation For Bedrails dated 6/3/2026, Physical Restraint assessment dated [DATE], physician order dated 7/10/2026, and Informed Consent Verification dated 7/10/2026 were reviewed. The DON stated Resident 70 had full bed side rails. The DON stated Resident 70 had a physician order, informed consent, and IDT meeting completed for the use of full bed side rails. The DON stated there were no measurements or dimensions taken of Resident 70 or the resident's bed side rails. The DON stated measurements of Resident 70 and the bed side rails should have been taken to ensure that the bed side rails were the right size for the resident. The DON stated measurements of the Resident 70 and the bed side rails should have been taken to ensure that the resident would have enough space to move while the bed side rails were in place. The DON stated full bed side rails were a restraint. The DON stated there was potential that Resident 70's full bed side rails could have entrapped and injured the resident if measurements or dimensions of the bed side rails were not taken. During a review of the facility's Policy and Procedure (P&P) titled Proper Use of Side Rails dated revised 1/10/2025. The P&P indicated When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used).

Based on observation, interview, and record review the facility failed to ensure safe and sanitary food storage and preparation practices when: 1.One large tray of raw chicken with dates 7/29/2026-8/29/2026 exceeding storage period for raw chicken were stored in the walk-in refrigerator. One tray containing ten ham and cheese sandwiches with use by date of 8/2/2026 were stored in the walk-in refrigerator. One previously prepared rotisserie chicken (stored bought roasted chicken) stored in the refrigerator with dates 7/31/2026-8/3/2026 exceeding storage period for leftovers. 2.The Ice machine was not clean; the inner board inside the ice storage bin had pink stains. 3.The juice machine dispenser drip tray was not clean and had thick juice and residue inside the tray. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness (infections organisms or their toxins are the most common cause of food poisoning, symptoms may include cramping, nausea, vomiting, or diarrhea) for 32 of 76 residents (unidentified) who received food from the facility.Findings:1.During an observation in the kitchen on 8/3/2026 at 8 AM there was an open bag of rotisserie chicken (store bought roasted chicken) with dates of 7/31/2026-8/3/2026 stored in the walk-in refrigerator. During a concurrent observation and interview on 8/3/2026 at 8 M with Dietary Supervisor (DS), the DS stated that the roasted chicken was purchased from the store and opened. The DS stated the kitchen staff (in general) would store leftover food for three days in the refrigerator. The DS stated the rotisserie chicken was in the refrigerator for longer than three days and needed to be discarded. The DS stated the three days storage was per facility's guidelines and to reduce the risk of food borne illness. During the concurrent observation and interview on 8/3/2026 at 8 M with the DS in the walk-in refrigerator, the DS stated there was a large tray of raw chicken that was stored on the bottom shelf with dates 7/29/2206-8/29/2026. The DS stated the chicken was stored to thaw for three days in the refrigerator and the tray was in the refrigerator for six days. The DS stated it was incorrectly labeled indicating use by date of one month. The DS stated the kitchen staff (in general) received new orders for chicken, and needed to be discarded because it was old. During the concurrent observation and interview on 8/3/2026 at 8:15AM with [NAME] 1 (Cook1), Cook1 stated the chicken was removed from the freezer to thaw one week prior 8/3/2026 and was never used. Cook1 stated the kitchen staff (in general) would not use the chicken and that the kitchen staff (in general) had a new order that came in on 8/3/2026. Cook1 removed the chicken from the walk-in refrigerator to discard. During an observation on 8/3/2026 at 8:15AM in the walk-in refrigerator there were ten ham and cheese sandwiches on a tray with a use by date of 8/2/2026. The DS stated sandwiches were made daily and consumed for snacks and any leftovers were discarded. The DS stated the sandwiches were dated with a use by 8/2/2026 date and needed to be discarded. During a review of facility's policy and procedure (P&P) titled Leftover Foods (dated 2023) the P&P indicated, leftover foods will be stored and served in a safe manner. Storage of leftovers b. use refrigerated leftovers within 72 hours. During a review of facility's policy and procedures (P&P) titled Thawing of Meats (dated 2023) the p&p indicated, Thawing meat properly can be done in these four ways: In a refrigerator at 41 F or colder. Allow 2 to 3 day to defrost.[NAME] defrosting meat with pull and use by date. Once thawed, uncooked meat is to be used within 2 days. A review of the 2022 U.S. Food and Drug Administration Food Code titled Ready to Eat, Time/Temperature control for safety food, Date Marking Code#3-501.17, indicated, Ready to eat, time temperature control for safety food prepared and packaged by food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed, sold, or discarded. 2.During an observation on 8/3/2026 at 8:30AM of the facility's ice machine located in the kitchen, a clean paper towel swipe of the ice storage bin ceiling and metal board inside the bin produced small amount of pink residue. The residue was in the corners of the baffle (an ice machine baffle or ice deflector is an internal panel or partition that directs the flow of ice as it falls from the evaporator into the storage bin or dispenser. It prevents ice from jamming the machine, guides it evenly into the bin, and stops cubes from spilling out of the front panel.) During a concurrent observation and interview on 8/3/2026 at 8:30AM with the DS, the DS stated the kitchen staff (in general) would clean the ice machine once a month following the manufacturer's instructions. The DS stated there was pink reside produced on the paper towel when the corners of the metal board were swiped. The DS stated the ice machine was not clean and the residue could contaminate the ice. The DS stated the kitchen staff (in general) did not want the ice to be contaminated because it contaminate the water and juice for the residents and staff. During a review of facility's policy and procedure (P&P) titled Ice Machine Cleaning Procedures (dated 2023) the P&P indicated, The ice machine needs to be cleaned and sanitized monthly. Be sure special attention is paid to cleaning the door molding and the lid of the machine. 3.During an observation on 8/3/2026 at 8:45AM in the kitchen, the juice machine dispenser drip tray was dirty with juice and debris. During a concurrent observation and an interview on 8/3/2026 at 8:45AM with DS, and Dietary Aide 1 (DA1), the DS stated there was juice and sediment (particles) in the drip tray. The DS stated the drip needed to be emptied and washed every day. The DS stated the juice machine dispenser and drip tray needed to be washed and cleaned to prevent from attracting flies in the juice machine area and kitchen. During the same observation and interview on 8/3/2026 at 8:45AM with DA1, DA1 stated the drip tray was full of juice and needed to be cleaned after every shift. DA1 removed the juice dispenser nozzle and drip tray and took it to the dishwashing area. During a review of the 2022 U.S. Food and Drug Administration Food Code 4-602.11 tilted Equipment Food-Contact Surfaces and Utensils, the code indicated, (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned:(1) At any time when contamination may have occurred;(2) At least every 24 hours for iced tea dispensers and CONSUMER self-service UTENSILS such as tongs, scoops, or ladles;(3) Before restocking CONSUMER self-service EQUIPMENT and UTENSILS such as condiment dispensers and display containers; and(4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT:(a) At a frequency specified by the manufacturer, or(b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold.

Based on observation, interview and record review, the facility failed to maintain infection control measures (the set of everyday rules and cleaning habits used to stop germs/infections from spreading among residents, workers, and visitors) necessary to prevent the spread of infections for two of seven sampled residents (Resident 59 and Resident 73) by failing to: -Ensure staff (in general) disposed soiled/dirty disposable gowns and/or disposable gown ties were properly disposed of in trash receptacles and not left on the floor near Resident 59and Resident 73's beds, in accordance with the facility's policy and procedures (P&) titled Infection Prevention and Control revised by the facility on 1/10/2025. This failure had the potential to increase the risk of infection to Resident 59 and Resident 73, staff (in general), and visitors. Findings: a.During a review of Resident 59's admission Record, the admission Record indicated the facility admitted the resident on 4/25/2022 with diagnoses that included Diabetes Mellitus (a chronic metabolic disease characterized by high blood sugar levels resulting from defects in insulin production, insulin action, or both), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), and depression (a mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). During a review of Resident 59's Minimum Data Set (MDS - a resident assessment tool) dated 4/27/2026, the MDS indicated Resident 59 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and could not make daily decision for self-requiring total assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 59's Order Summary Report, the Order Summary Report indicated the resident 59 had a physician order dated 7/18/2026 for enhanced barrier precautions(EBP-infection control strategy for nursing home, requiring gowns and gloves to be used during high-contact care for residents with or at high risk for multidrug-resistant organisms [MDRO-predominantly bacteria, that are resistant to one or more classes of antimicrobial agents] in nursing homes) related to increased white blood cell (defend the body against infections, viruses, and bacteria) count and increased Neutrophils (an abundant type of white blood cells) count. During a review of Resident 59's Care Plan Report dated 7/19/2026, the Car Plan Report indicated the resident was placed on enhanced barrier precautions and was at risk of increased infection related to elevated white blood cell count and Neutrophil count. b.During a review of Resident 73's admission Record, the admission Record indicated the facility admitted the resident on 5/17/2023 with diagnoses that included Schizophrenia (a serious brain disorder that changes how a person thinks, feels, and acts.), psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with reality), and depression (a mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). During a review of Resident 73's MDS dated [DATE], the MDS indicated Resident 73 cognition was intact and can make daily decisions for self. No assistance is required for ADL. During a review of Resident 73's Order Summary Report, the Order Summary Report indicated the resident 73 had a physician order dated 7/4/2026 for EBP related to increased white blood cell count and increased Neutrophils count. During a review of Resident 73's Care Plan Report dated 7/19/2026, the Care Plan Report indicated Resident 73 was placed on enhanced barrier precautions related to side effects of medication therapy and was at increased risk of infection related to medication side effects. During an observation in Resident 59 and Resident 73's room (roommates) on 8/6/2026 at 10:15AM multiple isolation gown pieces were observed scattered around the garbage receptacle and near Resident 59 and Resident 73's beds. During a concurrent interview and observation in Resident 59 and Resident 73's room on 8/6/2026 at 10:45AM with Certified nursing Assistant 2 (CNA 2), CNA2 stated the blue articles looked like pieces of an isolation gown. CNA 2 stated that the pieces of the gown might have fallen off when the gown was being taken off and thrown away. CNA2 stated the gown pieces were used and dirty. CNA2 stated the chances of the residents catching an infection increased. During a concurrent interview and observation in Resident 59 and Resident 73's room on 8/6/2026 at 11:30AM with Licensed Vocational Nurse 4 (LVN 4), LVN4 stated the blue articles on the floor of the room were pieces of isolation gown, specifically the securing belt used to keep the gown in place and part of the flaps used to secure around the body. LVN 4 stated that clean isolation gowns were stored in containers right outside of every room that required the use of a gown for care. LVN 4 stated that gowns were supposed to be discarded in the trash can in the room before exiting. LVN 4 stated that the gowns on the floor in Resident 29 and Resident 73's room were not disposed of properly. LVN 4 stated that if dirty and used isolation gowns were not disposed of properly the chances of the residents in that room catching a infection was increased. During a concurrent interview and observation in Resident 59 and Resident 73's room interview on 8/6/2026 at 12:15PM, with the Infection Prevention Nurse (IPN), the IPN stated looks like a piece of the isolation gowns used before entering rooms for residents that are on isolation. The IPN stated she (IPN)believed that the blue articles on the floor were the part of the gown that tied around the body and pieces of the back of the gown. The IPN stated the ties and pieces of gown were used and should have been discarded in the trashcan. The IPN stated the residents (unidentified) had an increased chance of catching an infection. During a concurrent interview and record review on 8/6/2026 at 1PM, the Director of Nursing (DON) reviewed the facility's P&P titled Infection Prevention and Control revised on 1/10/2025. The DON stated facility staff (unidentified) did not properly dispose of soiled isolation gowns. The DON stated the residents were put at an increased risk for contracting an infection. During a review of the facility's P&P titled Infection Prevention and Control revised 1/10/2025, the P&P indicated the facility had to prevent, identify, report, investigate, and control infections and communicable diseases in the facility and maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

Based on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 8) was 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) by failing to: -Ensure staff (in general) did not position Resident 8's bed against the wall without obtaining an informed consent (the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure) from the resident's representative and obtaining an order from the attending physician. This failure had the potential to result in the restriction of Resident 8's freedom of movement, a decline in physical functioning, psychosocial (describes the way your inner mental life and your outer social world influence each other) 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 the resident.Findings: During a review of Resident 8's admission Record, the admission Record indicated the facility admitted Resident 8 on 11/207/2013 with diagnoses that included but not limited to chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs) type, and muscle weakness. During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool), dated 5/31/2026, the MDS indicated Resident 8 had severe cognitive (ability to remember things, solve problems, or make decisions) impairment skills for daily decision making. The MDS further indicated Resident 8 had delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 8 was dependent on eating, toileting hygiene, showering/bathing, putting on/taking off footwear and personal hygiene and needed maximal assistance with oral hygiene, upper and lower body dressing and personal hygiene. The MDS did not indicate restraints and alarms were used for Resident 8. During a review of Resident 8's History and Physical (H&P) dated 6/1/2026, the H&P indicated Resident 8 did not have the capacity to understand and make decisions. During a review of Resident 8's Order Summary Report dated 8/5/2026, the Order Summary Report did not indicate an order to place Resident 8's bed against the wall. During a concurrent observation and interview on 8/5/2026 at 8:17 AM with Certified Nursing Assistant4 (CNA 4) in Resident 8's room, Resident 8 was observed sleeping in the bed with her (Resident 8) left side of the bed against the wall. CNA 4 stated Resident 8 was confused and could not express her (Resident 8) needs. CNA 4 stated resident 8's bed was against the wall to prevent Resident 8 from falling. During a concurrent interview and record review on 8/5/2026 at 11:06 AM with Licensed Vocational Nurse 2 (LVN 2), Resident 8's Physician Orders as of 8/5/2026 were reviewed. The Physician Orders did not indicate that there was an order for Resident 8's bed against the wall. LVN 2 stated Resident 8's bed against the wall was a form of restraint because it prevented Resident 8 from moving. LVN 2 stated an order from the physician needed to be obtain before placing Resident 8's bed against the wall and also a consent from the resident or representative. During a concurrent interview and record review on 8/5/2026 at 11:31 AM with the Director of Nursing (DON), Resident 8's medical chart was reviewed. The medical chart did not indicate an informed consent was obtained prior to placing Resident 8's bed against the wall. The DON stated an informed consent needed to be obtained from the resident's representative and a physician order needed to be obtain. The DON stated Resident 8's bed should not have been placed against the wall because this was a form of restraint wherein it restricted Resident 8's freedom of movement. During a review of the facility's policy and procedure (P&P) titled, Use of Restraints, last revised on 1/10/2025 the P&P indicated 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. Restraints shall only be used upon 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; andc.The type of restraint, and period of time for the use of the restraint.

Based on interview and record review, the facility failed to develop and implement a resident specific comprehensive care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) for two of five sampled residents (Resident 52 and Resident 70) by failing to: - Ensure the licensed nurses (in general) assessed and revised Resident 52's care plan to reflect Resident 52's current weight for the correct low air loss mattress (LALM- mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) settings. -Ensure to develop a care plan for dementia (a progressive state of decline in mental abilities) for Resident 70. These failures had the potential to increase Resident 52's risk for developing skin breakdown and pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence); and a potential for Resident 70 to receive care that was not related to the resident's needs. Findings: a.During a review of Resident 52's admission Record, the admission Record indicated the facility originally admitted Resident 52 on 2/6/2026 and readmitted Resident 52 on 6/22/2026 with diagnoses that included chronic respiratory failure (a long-term condition where a person's lungs struggle to get enough oxygen or fail to push out carbon dioxide [an invisible, odorless gas that animals/people breath out]), dependence on ventilator status (person's body cannot breathe well enough on its own, so they need a machine to pump air into and out of their lungs), type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), cerebral infarction (a stroke happens when there is a loss of blood flow to part of the brain), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and pressure-induced deep tissue damage of sacral region (a serious bedsore on the tailbone that develops after prolonged pressure to that part of the body). During a review of Resident 52's Minimum Data Set (MDS, a resident assessment tool) dated 5/18/2026, the MDS indicated Resident 52 rarely had the ability to understand others and rarely had to ability to make himself (Resident 52) understood. Resident 52's MDS indicated Resident 52 was dependent (helper does all of the effort and resident does none of the effort) for oral hygiene (cleaning mouth/teeth), toileting hygiene (cleaning private area including wiping after going to the bathroom), shower/bathing, upper/lower body dressing, putting on socks/footwear, personal hygiene (shaving, combing hair, washing/drying hands/face), for getting in and out of a tub/shower, and for rolling left and right while in bed. During a review of Resident 52's History and Physical (H&P - the most formal and complete assessment of the resident and the problem) dated 6/22/2026, the H&P indicated Resident 52 did not have the capacity (ability) to make healthcare decisions, was unable to decide for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and is unable to make his (Resident 52) needs known. The H&P indicated a plan for Resident 52 to have a specialized mattress if indicated. The H&P indicated Resident 52 weighed 182 pounds (lbs.). During a review of Resident 52's phone order dated 6/22/2026, the phone order indicated Resident 52 had a physician order for a low air loss mattress with comfort control set between 5-6 for wound management. During a review of Resident 52's Care Plan Report dated 6/22/2026, the Care Plan Report indicated a nursing intervention (any action or care that a nurse performs to help a resident get better, feel comfortable, or stay safe) to set the LALM between 5-6 for wound management. During a review of Resident 52's Treatment Administration Record (TAR - an official nurse or caregiver to-do list and log of treatment given to a resident) for July 2026, printed on 8/6/2026, the TAR indicated LALM with comfort control set between 5-6 for wound management. During a concurrent observation and interview on 8/3/2026 at 11:41 AM, with Licensed Vocational Nurse 9 (LVN 9) and Registered Nurse Supervisor 2 (RNS 2) in Resident 52's room, Resident 52's LALM was observed to be set to 7. A setting of 7 indicated the setting would be appropriate for a resident (in general) who weighed between 300 to 350 lbs. A setting of indicated the LALM would be appropriate for a resident (in general) who weighed between 200 to 250 lbs. A piece of tape located on the top right side on the LALM control unit indicated the facility would needed to set Resident 52's LALM to 3-4. RNS 2 stated the facility's licensed vocational nurses (LVNs in general) would be responsible for ensuring Resident 52's LALM was set at the correct setting. RNS 2 Resident 52's LALM needed to be set at 3 to 4 setting. RNS 2 stated she (RNS 2) would contact Resident 52's doctor for an order to set Resident 52's LALM to a setting of 3 to 4. During an interview on 8/6/2025 at 8:34 AM with Registered Nurse Supervisor 3 (RNS 3), RNS 3 stated the consequences of setting Resident 52's LALM to a weight setting of 300 lbs., would mean Resident 52's LALM would be too hard for Resident 52 which would increase the amount of pressure on Resident 52's skin. RNS 3 stated having Resident 52's LALM set too hard would increase Resident 52's chance of getting a pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence). RNS 3 stated the facility's licensed nurses (in general) would have had to check the setting on Resident 52's mattress and would have had to change Resident 52's mattress to the correct setting. During a concurrent interview and record review on 8/6/2026 at 1:27 PM with the Director of Nursing, the facility's policy and procedure (P&P) titled, Prevention of Pressure Ulcers, dated 1/10/2025 was reviewed. The P&P indicated LALM settings were based on the person's (a resident in general) weight and in alternating pressure. The DON stated the facility would have needed to adjust Resident 52's LALM based on the facility's P&P. The DON stated the facility did not follow their P&P. During a concurrent interview and record review on 8/6/2026 at 1:27 PM with the DON, the facility's P&P titled Care Plans, Comprehensive Person-Centered Policy Statement, dated 1/10/2025, was reviewed. The P&P indicated assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The DON stated the facility would have needed to change Resident 52's care plan based on Resident's weight because the setting of 5 to 6 was still too high for Resident 52's current weight. During a review of the User Manual for [NAME] Air mattress manufactured (made) by Wellell, undated, the User Manual indicated, according to the weight and height of the patient, adjust the pressure setting to the most suitable level without bottoming out. b.During a review of Resident 70's admission Record, the admission Record indicated the facility admitted the resident on 5/23/2025 with a diagnosis that included dementia. During a review of Resident 70's MDS dated [DATE], the MDS indicated the resident had moderate cognitive impairment (decline in the ability to think, understand, and reason). The MDS indicated Resident 70 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) from facility staff for eating and oral hygiene. The MDS indicated Resident 70 required substantial/maximal assistance (helper does more than half the effort) from facility staff for upper body dressing and personal hygiene. The MDS indicated Resident 70 was dependent (helper does all the effort) on help from facility staff for toileting hygiene, showering/bathing himself, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 70 had a diagnosis of dementia. During a review of Resident 70's Care Plan Report, the Care Plan Report did not indicate the resident had a specific care plan for dementia. During a concurrent interview and record review on 8/05/2026 at 2:31 PM with Registered Nurse Supervisor 2 (RNS 2), Resident 70's Care Plan Report was reviewed. RNS 2 stated a care plan contained the plan of care for Resident 70. RNS 2 stated that a care plan was a guide on how to care for Resident 70. RNS 2 stated that a care plan was supposed to be created to address Resident 70's diagnoses, medication, change of conditions, diet, and treatment. RNS 2 stated Resident 70 did not have a care plan for dementia. RNS 2 stated Resident 70 should have had a care plan for dementia because the resident had a diagnosis of dementia. RNS 2 stated that a care plan for dementia would have included interventions to redirect and reorient Resident 70 during moments of confusion, and to ensure the resident's environment was safe. RNS 2 stated that without a care plan for dementia there was potential for Resident 70 to not receive care that was specific to the resident's needs. During a concurrent interview and record review on 8/5/2026 at 2:43 PM with the Director of Nursing, Resident 70's Care Plan Report was reviewed. The DON stated that a care plan was a guide for the nursing staff (in general) on how to care for Resident 70. The DON stated Resident 70 did not have a care plan for dementia. The DON stated that Resident 70 should have had a care plan for dementia. The DON stated that Resident 70's care plan for dementia should have included interventions to redirect and reorient the resident as needed, provide the resident with appropriate activities, and monitor the resident for safety. The DON stated that without a care plan for dementia there was potential that Resident 70 may not have received care that was appropriate to the resident's needs. During a review of the facility's Policy and Procedure (P&P) titled Care Plans – Comprehensive revised 1/10/2025, the P&P indicated Each resident's comprehensive care plan is designed to: Incorporate identified problem areas; Incorporate risk factor's associated with identified problems; Build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals; Reflect treatment goals, timetables and objectives in measurable outcomes; Identify the professional services that responsible for each element of care; Aid in preventing or reducing declines in resident's functional status and/or functional levels; Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and Reflect currently recognized standards of practice for problem areas and conditions. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered Policy Statement reviewed 1/10/2025, the P&P indicated The comprehensive, person-centered care plan will: Include measurable objectives and timeframes; Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.Include the resident's stated goals upon admission and desired outcomes; Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; Incorporate identified problem areas; Incorporate risk factors associated with identified problems; Build on the resident's strengths; Reflect the resident's expressed wishes regarding care and treatment goals; Reflect treatment goals, timetables and objectives in measurable outcomes; Identify the professional services that are responsible for each element of care; Aid in preventing or reducing decline in the resident's functional status and/or functional levels; Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and Reflect currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to minimize the risk of development and worsening of pressure ulcers/injuries (PU/PI, injuries to the skin and underlying tissue resulting from prolonged pressured on the skin) for two of six sampled residents (Resident 2 and Resident 52) reviewed for PU/PI by failing to: -Ensure Resident 2 and Resident 52's low air loss (LALM, a pressure-relieving mattress used to prevent and treat pressure ulcers) were set at the correct pressure setting in accordance with the facility's policy and procedure (P&P) based on the residents' weight This failure had the potential to increase Resident 2 and Resident 52's risk for development of skin breakdown and or development or worsening of pressure ulcers. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 7/23/2025, with the most recent admission on [DATE] with diagnoses that included but not limited to chronic respiratory failure (is a serious condition happening repeatedly over a long period that makes it difficult to breathe on your own), tracheostomy (a surgical opening made in the neck into the windpipe (trachea) to help a person breathe), dependence on ventilator ( a machine that helps a person breathe when they cannot breathe well enough on their own) status, pressure ulcer of sacral (area at the bottom of the back, just above the buttocks) region, stage 4 pressure injury (deep wounds that may impact muscle, tendons, ligaments, and bone). During a review of Resident 2's Order Summary Report dated 4/15/2026, the Order Summary Report indicated for a LALM with comfort control set between 4-5 for wound management. During a review of Resident 2's History and Physical (H&P) dated 4/16/2026, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 4/29/2026, the MDS indicated Resident 2 had severe cognitive (ability to remember things, solve problems, or make decisions) impairment skills for daily decision making. The MDS further indicated Resident 2 was dependent on oral and toileting hygiene, showering/bathing, upper and lower body dressing and putting on/taking off footwear and personal hygiene. The MDS also indicated Resident 2 had a feeding tube (a tube used to give a person food, fluids, or medications when they cannot eat or drink enough by mouth. The MDS indicated Resident 2 had an indwelling catheter (a tubing inserted through the urethra passageway between the bladder and the external part of the body, which allows urine to be excreted from the body and into the bladder to drain urine) and was incontinent of bowel (feces). The MDS also indicated Resident 2 had a stage 4 pressure ulcer that was present upon admission and was on a pressure reducing device for bed. During a review of Resident 2's Surgical Consult dated 7/30/2036, the Surgical Consult indicated Resident 2 had a stage 4 pressure ulcer to the sacrococcyx (tailbone) extending to right and left buttocks measuring 3.5 centimeters (cm., a unit of measurement) x 2.4 cm x 0.2 cm. During a review of Resident 2's Care Plan Report dated 7/10/2026 and revised 7/20/2026, the Care Plan Report indicated Resident 2 had a sacrococcyx pressure ulcer extending to left and right buttocks. The Care Plan Report indicated a goal for Resident 2's pressure ulcer to improve in size and stage and would not exhibit signs and symptoms of complications by providing pressure relieving device appropriate for size/stage such as LALM. During a review of Resident 2's weight summary dated 8/3/2026, the weight summary indicated Resident 2's weight was 161 pounds (lbs., a unit of weight). During a concurrent observation and interview on 8/5/2026 at 2:15 PM with the Treatment Nurse (TN) 1 in Resident 2's room, Resident 2 was observed with a LALM that was set at 225. TN 1 stated LALM pressure setting was set according to the weight of the resident. TN 1 stated the LALM needed to be set between 90-200 because Resident 2 weighed 161 lbs. TN 1 stated that it was important to have the LALM set according to the resident's weight to help with wound healing. During a concurrent interview and record review on 8/5/2026 at 2:31 PM with the Director of Nursing (DON), Resident 2's weight summary was reviewed. The weight record indicated on 8/3/2026 Resident 2 weighed 161 lbs. The DON stated LALM pressure setting was based according to the resident's weight to promote wound healing. The DON stated Resident 2's LALM pressure setting of 225 was too high defeating the purpose of LALM to promote wound healing. During a review of the facility provided Operation Manual for [NAME] Air LALM, undated indicated to adjust the pressure setting to the most suitable level without bottoming out according to the weight and height of the resident. During a review of the facility's P&P titled, Prevention of pressure ulcers, last revised on 1/10/2025, the P&P indicated, LALM settings based on person's weight and in alternating pressure. b.During a review of Resident 52's admission Record, the admission Record indicated the facility originally admitted Resident 52 on 2/6/2026 and readmitted Resident 52 on 6/22/2026 with diagnoses that included chronic respiratory failure (a long-term condition where a person's lungs struggle to get enough oxygen or fail to push out carbon dioxide [an invisible, odorless gas that animals/people breath out]), dependence on ventilator status (person's body cannot breathe well enough on its own, so they need a machine to pump air into and out of their lungs), type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), cerebral infarction (a stroke happens when there is a loss of blood flow to part of the brain), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and pressure-induced deep tissue damage of sacral region (a serious bedsore on the tailbone that develops after prolonged pressure to that part of the body). During a review of Resident 52's MDS dated [DATE], the MDS indicated Resident 52 rarely had the ability to understand others and rarely had to ability to make himself (Resident 52) understood. Resident 52's MDS indicated Resident 52 was dependent (helper does all of the effort and resident does none of the effort) for oral hygiene (cleaning mouth/teeth), toileting hygiene (cleaning private area including wiping after going to the bathroom), shower/bathing, upper/lower body dressing, putting on socks/footwear, personal hygiene (shaving, combing hair, washing/drying hands/face), for getting in and out of a tub/shower, and for rolling left and right while in bed. During a review of Resident 52's H&P dated 6/22/2026, the H&P indicated Resident 52 did not have the capacity (ability) to make healthcare decisions, was unable to decide for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and is unable to make his (Resident 52) needs known. The H&P indicated a plan for Resident 52 to have a specialized mattress if indicated. The H&P indicated Resident 52 weighed 182 lbs. During a review of Resident 52's phone order dated 6/22/2026, the phone order indicated Resident 52 had a physician order for a LALM to be set between 5-6 for wound management. During a review of Resident 52's Care Plan Report dated 6/22/2026, the Care Plan Report indicated an intervention (any action or care that a nurse performs to help a resident get better, feel comfortable, or stay safe) to provide a LALM with comfort control set between 5-6 for wound management. During a review of Resident 52's Treatment Administration Record (TAR - an official nurse or caregiver to-do list and log of treatment given to a resident) for July 2026, printed on 8/6/2026, the TAR indicated LALM with comfort control set between 5-6 for wound management. During a concurrent observation and interview on 8/3/2026 at 11:41 AM, with Licensed Vocational Nurse 9 (LVN 9) and Registered Nurse Supervisor 2 (RNS 2) in Resident 52's room, Resident 52's LALM was observed to be set to 7. A setting of 7 indicated the setting would be appropriate for a resident (in general) who weighed between 300 to 350 lbs. A setting of indicated the LALM would be appropriate for a resident (in general) who weighed between 200 to 250 lbs. A piece of tape located on the top right side on the LALM control unit indicated the facility needed to set Resident 52's LALM to 3-4. RNS 2 stated the facility's licensed vocational nurses (LVNs in general) were responsible for ensuring Resident 52's LALM was set to the correct setting. RNS 2 Resident 52's LALM needed to be set to 3-4. RNS 2 stated she (RNS 2) would contact Resident 52's doctor for an order to set Resident 52's LALM to a setting of 3-4. During an interview on 8/6/2025 at 8:34 AM with Registered Nurse Supervisor 3 (RNS 3), RNS 3 stated the consequences of setting Resident 52's LALM to a weight setting of 300 lbs., would mean Resident 52's LALM would be too hard for Resident 52 which would increase the amount of pressure on Resident 52's skin. RNS 3 stated having Resident 52's LALM set too hard would increase Resident 52's risk for getting a pressure ulcer. RNS 3 stated the facility's licensed nurses (in general) needed to check the setting on Resident 52's mattress and needed to change Resident 52's mattress to the correct setting. During a concurrent interview and record review on 8/6/2026 at 1:27 PM with the DON, the facility's policy and procedure (P&P) titled, Prevention of Pressure Ulcers, dated 1/10/2025 was reviewed. The P&P indicated LALM settings were based on the person's (a resident in general) weight and in alternating pressure. The DON stated the facility would have needed to adjust Resident 52's LALM based on the facility's P&P. The DON stated the facility did not follow their P&P. During a concurrent interview and record review on 8/6/2026 at 1:27 PM with the DON, the facility's P&P titled Care Plans, Comprehensive Person-Centered Policy Statement, dated 1/10/2025, was reviewed. The P&P indicated assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change. The DON stated the facility would have needed to change Resident 52's care plan based on Resident's weight because the setting of 5 to 6 was still too high for Resident 52's current weight. During a review of the User Manual for [NAME] Air mattress manufactured (made) by Wellell, undated, the User Manual indicated, according to the weight and height of the patient, adjust the pressure setting to the most suitable level without bottoming out.

Based on observation, interview and record review, the facility failed to maintain gastrostomy tube (G-tube, is a tube inserted through the abdomen that delivers nutrition directly to the stomach) care for one of five sampled residents (Resident 76) reviewed for tube feeding by failing to: -Ensure the licensed nurses (in general) capped (process of placing a cover over the opening of the tubing which delivers nutrition and/or medication into the body) Resident 76's G-tube and properly stored after use, as per the facility's P&P titled Policies and Practices - Infection Prevention and Control, dated 1/10/2025. This failure had the potential to increase Resident 76's risk for infection and G-tube complications.Findings:During a review of Resident 76's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility originally admitted Resident 12/25/2014 and readmitted Resident 76 on 5/24/2024 with diagnosis that included dysphagia following other cerebrovascular disease (difficulty swallowing caused by a previous stroke or a blood flow problem in the brain), encounter for attention to gastrostomy (a medical visit for routine checkups, cleaning, or general maintenance of a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of left and right hand, dependence on ventilator (a person's body cannot breathe well enough on its own, so they need a machine to push air into and out of their lungs to keep them alive) and dependence on supplemental oxygen (a person's lungs or heart cannot get enough oxygen into your blood on their own, requiring the use of a tank or machine to provide extra oxygen). During a review of Resident 76's Care Plan Report dated 5/24/2024titled, the Care Plan Report indicated Resident 76 had a feeding tube present and the nursing intervention (any action or care that a nurse performs to help a resident get better, feel comfortable, or stay safe) was for the licensed nursing staff to monitor Resident 76's ostomy site (a surgically created opening on a person's belly where the gastrostomy tube was placed) for signs and symptoms of infection. During a review of Resident 76's Care Plan Report dated 5/29/2024, the Care Plan Report indicated Resident 76 was on Enhanced Barrier Precaution (EBP-staff wear gowns and gloves to stop the spread of tough, drug-resistant germs or infections). The Care Plan indicated a goal was for the facility to prevent the spread of infection. The care plan indicated an intervention for staff (in general) to wear gowns and gloves when performing high contact tasks such as Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care and device care (cleaning, checking, and maintaining medical equipment, like oxygen tanks, wheelchairs, blood pressure cuffs, or feeding pumps, so it stays safe, clean, and works correctly for the resident). During a review of Resident 76's History and Physical (H&P - the most formal and complete assessment of the resident and the problem) dated 3/31/2026, the H&P indicated Resident 76 had a gastrotomy tube in situ (a feeding tube is currently placed and resting correctly inside a person's stomach through a small belly opening). The H&P indicated Resident 76 did not have the capacity (ability) to make healthcare decisions, was unable to decide for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily), and was unable to make her (Resident 76) needs known. During a review of Resident 76's Minimum Data Set (MDS, a resident assessment tool) dated 7/15/2026, the MDS indicated Resident 76 rarely had the ability to make herself (Resident 76) understood and rarely had the ability to understand others. The MDS indicated Resident 76 had no speech (had the absence of spoken words/unable to speak). The MDS indicated resident 76 had a feeding tube. The MDS indicated Resident 76 received more than 51 % (percent) or more of her total calories (a unit of measurement that tracks energy, specifically, the amount of energy food and drink give to a person's body, and how much energy a person's body uses) from a parenteral (giving medicine, fluids, or food through an injection or an IV [into a vein] instead of swallowing it through the mouth or tube feeding. During a review of Resident 76's Order Summary Report dated 8/6/2026 at 2:36 PM, the Order Summary Report indicated Resident 76 had physician enteral (using the stomach and intestines to get food or medicine) feeding orders for Jevity 1.5 (a specialized liquid medical food that provides complete nutrition packed with extra calories, protein, and fiber [a part of plant food that your body cannot digest acting like a helpful cleaner to keep your stomach and heart healthy] through a feeding tube) at 50 cc/hr (delivering 50 milliliters [a small metric unit of volume used to measure liquids], about 3.4 tablespoons or a small 1/4 cup of liquid nutrition per hour) for 18 hours to provide 900 ml/1350 calories, turn enteral pump on at 11 am and turn off at 5 am the following day or until the ordered total dose was delivered. The Order Summary Report indicated a physician order for the facility to check Resident 76's G-tube site for signs and symptoms of infection every shift. During a concurrent observation and interview on 8/3/2026 at 10:43 AM with Licensed Vocational Nurse 8 (LVN 8), in Resident 76's room, Resident 76's tube feeding was observed in the drawer with the tip of the tube feeding uncapped and exposed to air. LVN 8 stated Resident 76's tube feeding was not capped. LVN 8 stated the uncapped tube feeding could cause an infection control problem for Resident 76. LVN 8 stated he (LVN8) would change Resident 76's tube feeding set because the uncapped tube feeding could have been contaminated. During an interview on 8/6/2026 at 8:24 AM with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated Resident 76 was placed on EBP to prevent Resident 76 from possible infections. RNS 1 stated if staff (in general) had to disconnect the feeding tube from Resident 76's gastrostomy, the staff would need to cap the end of the feeding tube. RNS 1 stated and uncapped feeding tube could increase Resident 76's risk for infection because it was open and could be exposed to bacteria (germs that can cause infection). RNS 1 stated the staff (in general) would have to throw away any feeding tube that was not capped and would have to replace it with a new one. During a concurrent interview and record review on 8/6/2026 at 1:28 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Policies and Practices - Infection Prevention and Control, dated 1/10/2025 was reviewed. The P&P indicated the facility's infection prevention and control policies and practices are intended to facilitate maintaining a safe, sanitary (clean) and comfortable environment and to help prevent and manage transmission of communicable diseases (an illness that spreads from one person to another, or from an animal or bug to a person) and infections. The DON stated the staff (in general) would need to replace Resident 76's tube feeding if it was uncapped and exposed. The DON stated the facility would have needed to cap and properly store Resident 76's tube feeding if the staff (in general) disconnected Resident 76's tube feeding from Resident 76's gastrostomy.

Based on observation, interview, and record review the facility failed to ensure one of 13 sampled residents (Resident 9) reviewed for respiratory care received the necessary respiratory care and services by failing to: Ensure Resident 9's oxygen tubing (a flexible plastic hose that carries oxygen from a machine or tank straight into a resident's breathing hole) did not rest on the floor while connected to Resident 9's tracheostomy (a curved, hollow plastic or metal tube placed through a surgical opening in the front of the neck directly into the windpipe [trachea]) T-Bar ( a T-shaped plastic adapter that attaches directly to a tracheostomy tube that delivers moist, oxygen-rich air from a machine or wall tube straight into the lungs), and humidifier (a small water bottle attached to an oxygen machine to prevent the throat from drying or bleeding) on 8/3/2026 at 9:26 AM. This failure had the potential for Resident 9 to experience an increased risk for respiratory infections (illnesses that affect the parts of your body involved in breathing).Findings:During a review of Resident 9's admission Record, the admission Record indicated the facility originally admitted Resident 9 on 12/18/2025 and readmitted Resident 9 on 4/27/2026 with diagnoses that included chronic respiratory failure (a long-term condition where a person's lungs struggle to get enough oxygen or fail to push out carbon dioxide [an invisible, odorless gas that animals/people breath out]) with hypoxia (a medical condition where a person's body tissues do not get enough oxygen to work the right way), functional quadriplegia (a person cannot move their arms or legs), dependence on supplemental oxygen (a person needs extra oxygen from a machine or oxygen tank), dependence on renal dialysis s (hemodialysis - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), and nontraumatic intracranial hemorrhage (a sudden bleed inside the skull that happens on its own, not caused by an injury, crash, or blow to the head). During a review of Resident 9's History and Physical (H&P - the most formal and complete assessment of the resident and the problem) dated 4/28/2026, the H&P indicated Resident 9 did not have the capacity (ability) to make healthcare decisions, was unable to decide for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) and is unable to make his (Resident 9) needs known. During a review of Resident 9's Minimum Data Set (MDS, a resident assessment tool) dated 4/29/2026, the MDS indicated Resident 9 could not make himself (Resident 9) understood and did not have the ability to understand others. Resident 9's MDS indicated Resident 9 was dependent (helper does all of the effort and resident does none of the effort) for oral hygiene (cleaning mouth/teeth), toileting hygiene (cleaning private area including wiping after going to the bathroom), shower/bathing, upper/lower body dressing, putting on socks/footwear, personal hygiene (shaving, combing hair, washing/drying hands/face), for getting in and out of a tub/shower, and for rolling left and right while in bed. During a review of Resident 9's Order Summary Report (a master list of all medical instructions, treatments, and medications a doctor has prescribed for a resident's care while living in the facility) dated 8/6/2026, the Order Summary Report indicated Resident 9 had orders for enhanced barrier precautions (EBP - requires facility staff to use gown and gloves when in close physical contact with a resident to stop the spread of harmful germs like bacteria and viruses) due to presence of g-tube (gastrostomy - a small, flexible tube placed through a tiny opening in the belly directly into the stomach), tracheostomy, and HD (hemodialysis) access (a specially prepared spot on your body, usually on your arm, that lets blood flow out to a cleaning machine and back in). The Order Summary Report indicated a physician order for Resident 9 to receive 3 LPM (liters per minute - where a machine pushes 3 liters of concentrated oxygen into your airways every 60 seconds). During a concurrent observation and interview on 8/3/2026 at 9:26 AM with Certified Nursing Assistant 3 (CNA 3) in Resident 9's room, Resident 9's oxygen tubing was observed to be resting on the floor. CNA 3 stated Resident 9's oxygen tubing was not supposed to be on the floor due to infection control (the set of practical methods and rules used to stop the spread of harmful germs like bacteria and viruses). During a concurrent observation and interview on 8/3/2026 at 9:29 AM with Respiratory Therapist 1 (RT 1) in Resident 9's room, Resident 9's oxygen tubing was observed to be resting on the floor. The oxygen tubing was observed to be connected to Resident 1's oxygen humidifier. The oxygen tubing was observed to be connected to Resident 1's T-Bar. RT 1 was observed putting Resident 9's oxygen tubing on top of the oxygen concentrator/compressor (a plug-in medical machine that pulls in regular room air, removes the nitrogen, and blows out pure, concentrated oxygen for people who have trouble breathing). RT 1 stated he (RT1) would only change Resident 9's oxygen tubing. RT 1 was asked again what he (RT1) would need to do if the oxygen tubing was connected to Resident 9's humidifier and T-Bar, RT 1 stated that he (RT 1) would only change Resident 9's oxygen tubing. RT 1 was asked if Resident 9's oxygen tubing that was found on the floor could possibly infect Resident 9's humidifier and T-Bar because the oxygen tubing, humidifier, and T-Bar were all connected. RT 1 stated he (RT1) would need to change Resident 9's oxygen tubing, humidifier, and T-Bar for infection control. During an interview on 8/3/2026 at 9:35 AM with the facility's Infection Prevention Nurse (IPN - a nurse who has specialized training who tracks, stops, and manages the spread of germs and diseases), the IPN stated having Resident 9's oxygen tubing on the floor could cause an infection control issue and increased Resident 9's risk for infection. The IPN stated the facility would need to replace Resident 9's oxygen tubing, humidifier, and T-Bar. During an interview on 8/3/2026 at 9:41 AM with Registered Nurse Supervisor 1 (RNS 1), RNS 1 stated Resident 9's oxygen tubing would need to be kept from touching the floor. RNS 1 stated when the facility staff (in general) entered Resident 9's room, the staff (in general) would need to identify actual or potential infection control issues and would need to address them right away. RNS 1 stated staff (in general) would need to Replace 9's humidifier, oxygen tubing, and T-Bar when staff found Resident 9's oxygen tubing on the floor. RNS 1 sated Resident 9's oxygen tubing on the floor would increase Resident 9's risk for getting an infection. During a concurrent interview and record review on 8/6/2026 at 1:28 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Policies and Practices - Infection Prevention and Control, dated 1/10/2025 was reviewed. The P&P indicated the facility's infection prevention and control policies and practices were intended to help maintain a safe, sanitary (clean), and comfortable environment and to help prevent and manage the transmission (spread) of communicable diseases (an illness that spreads from one person to another, or from an animal or bug to a person) and infections. The DON stated the facility staff (in general) would have needed to replace Resident 9's oxygen tubing, humidifier, and T-Bar if Resident 9's oxygen tubing had touched the floor to prevent an infection control issue. The DON stated the facility did not follow their infection control P&P.

Based on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu were followed for one of one sampled resident (Resident 23) who was on a soft and bite-sized diet (IDDSI-Level 6-All foods prepared for are soft and chopped into bite size 1/2 inch x 1/2 inch pieces) with mildly thickened liquids (Level 2-is a drink consistency that flows off a spoon and pours quickly, but noticeably slower than thin water) on 8/3/2026 by failing to: -Ensure Resident 23 received cookies for dessert in a texture that met Resident 23's needs and in accordance with the international dysphagia Diet Initiative (IDDSI-a framework made up of levels and describes food textures and drink thickness) when the cookies were served whole and not cut and were soaked in thin nondairy milk and were not drained of excess fluids per the recipe and menu. This failure had the potential to result in meal dissatisfaction and increased choking risk for Resident 23 who received thin texture milk with the cookies instead of thickened milk.Findings:During a review of Resident 23's admission Record, the admission Record indicated the facility admitted the resident on 3/29/2026 with diagnoses that included End Stage Renal disease dependence on dialysis (last stage of kidney disease when kidneys fail and no longer work well requiring dialysis or kidney transplant-dialysis machine cleans your waste and extra fluids in the body when your kidneys cannot do it anymore), Type2 Diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels), dysphagia oropharyngeal phase (difficulty moving food and liquid from the mouth and through the throat, affects swallowing, making it hard to swallow, chew properly or protect the airway from choking). During a review of Resident 23's Order Summary Report dated 4/15/2026, the Order Summary Report indicated for Resident 23 to receive renal CCHO (controlled carbohydrate diet for people with blood sugar problems) diet soft and bite size- Level 6 texture, mildly thick -Level 2 consistency. During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool) Section K-Swallowing/Nutritional Status dated 7/8/2026, the MDS indicted Resident 23 was on a mechanically altered diet -required change in texture of food or liquids (e.g., pureed food, thickened liquids). During an observation on 8/3/2026 at 12 PM of the tray line (tray line - system of food preparation, in which trays move along an assembly line) service for lunch, Resident 23 who was on a soft and bite size and mildly thickened liquid diet texture (Level 2-is a drink consistency that flows off a spoon and pours quickly, but noticeably slower than thin water. Examples include tomato juice, pear or peach nectars, eggnog, heavy milkshakes, cream-based soups etc.) received whole cookies (not cut) and soaked in non-dairy thin liquid milk for dessert. During a concurrent interview on 8/3/2026 at 12 PM with the Dietary Supervisor (DS) and a review of the cook's spreadsheet (food portion and serving guide), the DS stated it indicated to serve two small cookies to residents who were on a soft and bite size diet. The DS stated the kitchen staff (in general) needed to soak the cookies to make the cookies soft for the soft and bite size diets. The DS stated the cookie needed to be soaked in thickened milk to prevent the risk of choking for residents (in general) with mildly thickened liquids. During an interview on 8/3/2026 at 12:30PM with the Registered Dietitian (RD), the RD stated the cookies needed to be soaked in thickened liquid to prevent choking risk. During a concurrent interview on 8/4/2026 at 10 AM with the DS and a review of the recipe for the cookies, the DS stated the cookies needed to be crumbled and soaked in milk then drained of excess milk before serving. The DS stated the kitchen staff (unidentified) served whole cookies soaked in regular thin liquid nondairy milk that was still in the bowl that could have been a risk for choking. During a review of facility's recipe titled Lemon Cookies (dated 2026), the recipe indicated, #6/Soft and Bite Size: chop into pieces =1.5 [centimeters -cm-a unit of measurement] by 1.5cm in size (1/2 inch). Soak in milk, drain excess fluid. During a review of facility policy and procedures (p & p) titled, Menu Planning (dated 2023), the p & p indicated, The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physicism's orders. Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. During a review of the IDDSI guideline website titled IDDSI, dated 1/2019, the IDSSI guideline indicated that Level 6 soft and Bite sized texture is for people who have ability to chew bite-sized pieces so that they are safe to swallow; Bite-Sized pieces no bigger than 1.5cm x 1.5cm in size and a knife is not required to cut this food.

Based on interview and record review the facility failed to accurately document that treatment was not provided to one of six sampled residents (Resident 81) when Resident 81 was hospitalized .This failure had the potential for nurses (in general) to misinterpret (to understand or explain something incorrectly) the documented information and lead to a delay in resident care and/or resident harm.Findings:During a review of Resident 81's admission Record, the admission Record indicated the facility admitted the resident on 7/16/2026 with diagnoses that included stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacral region (tailbone area), tracheostomy (a surgical opening made through the front of the neck into the windpipe to help the resident to breathe), dependence on respirator (ventilator), dysphagia (difficulty swallowing), end stage renal disease (irreversible kidney failure), dependence on renal (kidney) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have failed), hypertension (high blood pressure), cerebral infarction (when a blood clot blocks or narrows an artery that supplies blood to the brain), gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly into the stomach common for people with swallowing problems), and hyperlipidemia (high levels of cholesterol in the blood).During a review of Resident 81's Minimum Data Set (MDS, a resident assessment tool) dated 7/18/2026, the MDS indicated the resident had severely impaired cognition for daily decision making (never/rarely made decisions). The MDS indicated Resident 81 was dependent (helper does all the effort) on help from facility staff for oral hygiene, toileting hygiene, showering/bathing herself, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene.During a review of Resident 81's Treatment Administration Record (TAR) dated 7/1/2026 - 7/31/2026, the TAR indicated the following:1. Monitor the resident for pain before each treatment. The TAR indicated to document 0 for no pain, 1-4 for mild pain, 5-7 for moderate pain, or 8-10 for severe pain. The TAR indicated Licensed Vocational Nurse 10 (LVN 10) documented Resident 81 had no pain during the day shift on 7/22/2026.2. Provide the resident with rectal balloon catheter care (a flexible medical tube with an inflatable balloon at the tip, designed for insertion into the rectum, and used for bowel management to divert liquid stool and protect skin) every day shift. The TAR indicated LVN 11 documented rectal balloon catheter care was administered to Resident 81 on 7/20/2026. The TAR indicated LVN 10 documented rectal [NAME] catheter care was administered to Resident 81 on 7/22/2026.3. Provide treatment to the resident's multiple body scabs. The TAR indicated to paint Resident 81's multiple scabs with Betadine (a medication used to kill bacteria and viruses on the skin) and leave open to air every day and as needed for 30 days. The TAR indicated LVN 11 administered treatment to Resident 81's multiple scabs on 7/20/2026. The TAR indicated LVN 10 administered treatment to Resident 81's multiple scabs on 7/22/2026.4. Provide treatment to the resident's dry body skin. The TAR indicated to apply Amlactin (a moisturizing body lotion that contains lactic acid) lotion to Resident 81's dry body skin and leave open to air every day and as needed for 30 days. The TAR indicated LVN 11 administered treatment to Resident 81's dry body skin on 7/20/2026. The TAR indicated LVN 10 administered treatment to Resident 81's dry body skin on 7/22/2026.5. Provide treatment to the resident's perianal (tissues around the anus) incontinence associated skin damage (IASD, skin irritation and breakdown caused by contact with urine or stool). The TAR indicated to wash Resident 81's perianal IASD with soap, water, and pat dry. The TAR indicated to apply Nystatin (a medication used to treat infections caused by yeast) powder to Resident 81's IASD and leave open to air every day for 30 days as needed. The TAR indicated LVN 11 administered treatment to Resident 81's perianal IASD on 7/20/2026. The TAR indicated LVN 10 administered treatment to Resident 81's perianal IASD on 7/22/2026.6. Provide treatment to the resident's perianal Moisture Associated Skin Damage (MASD, moisture associated skin damage caused from prolong exposure to moisture). The TAR indicated to wash Resident 81's perianal MASD with soap, water, and pat dry. The TAR indicated to apply Nystatin powder to Resident 81's MASD and leave open to air every day for 30 days as needed. The TAR indicated LVN 11 administered treatment to Resident 81's perianal MASD on 7/20/2026. The TAR indicated LVN 10 administered treatment to Resident 81's perianal MASD on 7/22/2026.7. Provide treatment to the resident's sacrococcyx (tailbone area) pressure injury (localized damage to the skin and/or underlying tissue usually over a body prominence. The TAR indicated to irrigate Resident 81's sacrococcyx pressure injury with normal saline (a saltwater solution) and pat dry. The TAR indicated to apply medihoney (a medical-grade topical honey used to manage wounds) and calcium alginate (a soft, fibrous, water-insoluble substance used to help heal wounds) to Resident 81's sacrococcyx pressure injury and cover with a dry dressing every day for 30 days and as needed. The TAR indicated LVN 11 administered treatment to Resident 81's sacrococcyx pressure injury on 7/20/2026. The TAR indicated LVN 10 administered treatment to Resident 81's sacrococcyx pressure injury on 7/22/2026.9. Monitor the resident for pain after each treatment. The TAR indicated to document 0 for no pain, 1-4 for mild pain, 5-7 for moderate pain, or 8-10 for severe pain. The TAR indicated LVN 10 documented Resident 81 had no pain during the day shift on 7/22/2026.10. Provide treatment to the resident's right heel pressure injury. The TAR indicated to cleanse Resident 81's right heel pressure injury with normal saline and pat dry. The TAR indicated to paint Resident 81's right heel pressure injury with Betadine and cover with dry dressing every day for 30 days and as needed. The TAR indicated LVN 10 provided treatment to Resident 81's right heel on 7/22/2026.11. Provide treatment to the resident's multiple body scars. The TAR indicated to apply A and D ointment (a topical skin protectant and moisturizer) to Resident 81's multiple body scars and leave open to air every day for skin maintenance. The TAR indicated LVN 10 provided treatment to Resident 81's multiple body scars on 7/22/2026.12. Provide treatment to the resident's peg (percutaneous endoscopic gastrostomy, a medical procedure where a flexible feeding tube is placed directly into the stomach through the skin of the abdomen) stoma (a small, surgical opening created on the abdomen during a PEG procedure). The TAR indicated to cleanse Resident 81's peg stoma with normal saline and pat dry. The TAR indicated to cover Resident 81's peg stoma with a dry dressing every day shift for 30 days and as needed. The TAR indicated LVN 10 provided treatment to Resident 81's peg stoma on 7/22/2026.13. Change the resident's [NAME] Valve (a specialized three-way stopcock used with enteral feeding tubes) every month on the 28th. The TAR indicated LVN 10 changed Resident 81's [NAME] Valve on 7/22/2026.14. Provide treatment to the resident left lower extremity (left leg) edema (swelling caused by fluid trapped in the body's tissues). The TAR indicated to elevate Resident 81's left lower extremity as tolerated. The TAR indicated to monitor and record Resident 81's edema every shift. The TAR indicated LVN 11 administered treatment to Resident 81's edema on 7/20/2026. The TAR indicated LVN 10 administered treatment to Resident 81's edema on 7/22/2026.15. Provide treatment to the resident left upper extremity (left arm) edema. The TAR indicated to elevate Resident 81's left upper extremity as tolerated. The TAR indicated to monitor and record Resident 81's edema every shift. The TAR indicated LVN 11 administered treatment to Resident 81's edema on 7/20/2026. The TAR indicated LVN 10 administered treatment to Resident 81's edema on 7/22/2026.16. Provide treatment to the resident's right lower extremity (right leg) edema. The TAR indicated to elevate Resident 81's right lower extremity as tolerated. The TAR indicated to monitor and record Resident 81's edema every shift. The TAR indicated LVN 11 administered treatment to Resident 81's edema on 7/20/2026. The TAR indicated LVN 10 administered treatment to Resident 81's edema on 7/22/2026.17. Provide treatment to the resident's right upper extremity (right arm) edema. The TAR indicated to elevate Resident 81's right upper extremity as tolerated. The TAR indicated to monitor and record Resident 81's edema every shift. The TAR indicated LVN 10 administered treatment to Resident 81's edema on 7/22/2026.18. Set the resident's Low Air Loss Mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure injuries) with comfort control set between #3-#4 for wound management. The TAR indicated LVN 10 set Resident 81's LALM on 7/22/2026.19. Provide treatment to the resident's multiple left lower extremity discoloration (when an area of skin changes to a color that is not normal). The TAR indicated to monitor the resident for signs of skin breakdown every day shift for 30 days. The TAR indicated LVN 10 monitored Resident 81 for signs of skin breakdown on 7/22/2026.20. Provide treatment to the resident's multiple left upper extremity discoloration. The TAR indicated to monitor the resident for signs of skin breakdown every day shift for 30 days. The TAR indicated LVN 10 monitored Resident 81 for signs of skin breakdown on 7/22/2026.21. Provide treatment to the resident's multiple right lower extremity discoloration. The TAR indicated to monitor the resident for signs of skin breakdown every day shift for 30 days. The TAR indicated LVN 10 monitored Resident 81 for signs of skin breakdown on 7/22/2026.22. Provide treatment to the resident's multiple right upper extremity discoloration. The TAR indicated to monitor the resident for signs of skin breakdown every day shift for 30 days. The TAR indicated LVN 10 monitored Resident 81 for signs of skin breakdown on 7/22/2026.23. Provide treatment to the resident's abdomen hyperpigmentation (a condition where patches or spots of skin become darker than the surrounding area). The TAR indicated to monitor the resident for signs of skin breakdown every day shift for 30 days. The TAR indicated LVN 10 monitored Resident 81 for signs of skin breakdown on 7/22/2026.24. Check the resident's peg site for signs and symptoms of infection every shift. The TAR indicated LVN 10 documented Resident 81 had no signs and symptoms of infection on 7/22/2026.25. Provide treatment to the resident's face hyperpigmentation. The TAR indicated to monitor the resident for signs of skin breakdown every day shift for 30 days. The TAR indicated LVN 10 monitored Resident 81 for signs of skin breakdown on 7/22/2026.During a concurrent interview and record review on 8/5/2026 at 12:39 PM with LVN 10, Resident 81's TAR dated 7/1/2026 - 7/31/2026 was reviewed. LVN 10 stated he (LVN 10) was the treatment nurse on 7/22/2026. LVN 10 stated Resident 81 was in the hospital on 7/22/2026. LVN 10 stated he (LVN 10) documented that Resident 81 was monitored for pain, monitored for skin breakdown, monitored for signs and symptoms of infection, monitored for edema, provided with treatment, provided with rectal tube care, had the resident's Lopez valve changed, and that the resident's LALM was set. LVN 10 stated the documentation was a mistake. LVN 10 stated he should have documented that Resident 81 was hospitalized instead of that treatment was administered on 7/22/2026. LVN 10 stated that documentation should always be accurate. LVN 10 stated that there was potential for documentation to be misinterpreted if the documentation was not accurate.During a concurrent telephone interview and record review on 8/5/2026 at 1:57 PM with LVN 11, Resident 81's TAR dated 7/1/2026 - 7/31/2026 was reviewed. LVN 11 stated that she (LVN 11) was working on 7/20/2026. LVN 11 stated Resident 81 was in the hospital on 7/20/2026. LVN 11 stated she (LVN 11) accidentally documented that treatment was given to Resident 81 on 7/20/2026. LVN 11 stated she (LVN 11) made a mistake and should have documented that Resident was in the hospital instead. LVN 11 stated that documentation needed to be accurate and needed to reflect Resident 81's status in the facility. LVN 11 stated that there was potential for Resident 81's documentation to be misinterpreted if documentation was not performed accurately.During a concurrent interview and record review on 8/5/2026 at 2:48 PM with the Director of Nursing (DON), Resident 81's TAR dated 7/1/2026 - 7/31/2026 was reviewed. The DON stated Resident 81 was transferred to the hospital on 7/18/2026 and was readmitted to the facility on [DATE]. The DON stated that the documentation on 7/20/2026 by LVN 11 and the documentation on 7/22/2026 by LVN 10 indicated that Resident 81 was monitored and provided with treatment at the facility during the time the resident was in the hospital. The DON stated that Resident 81's TAR documentation on 7/20/2026 and 7/22/2026 was not accurate. The DON stated LVN 10 and LVN 11 should have documented that Resident 81 was hospitalized instead of documenting that treatment and monitoring were administered. The DON stated that documentation should always be accurate and reflect which care the residents (in general) were given and not given. The DON stated there was potential for Resident 81's inaccurate documentation to be misinterpreted which could potentially lead to delayed resident care.During a review of the facility's Policy and Procedure (P&P) titled Charting and Documentation revised 1/10/2025, the P&P indicated All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, service performed, etc., must be documented in the resident's clinical record.All incidents, accidents, or changes in the resident's condition must be recorded.To ensure consistency in charting and documentation of the resident's clinical record, only facility approved abbreviations and symbols may be used when recording entries in the resident's clinical records.Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: The date and time the procedure/treatment was provided; The name and title of the individual (s) who provided the care; The assessment data and/or any unusual findings obtained during the procedure/treatment; How the resident tolerated the procedure/treatment; Whether the resident refused the procedure/treatment; Notification of family, physician, or other staff, if indicated; The signature and title of the individual documenting.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment for one of four sampled resident (Resident 1) by failing to ensure Resident 1's curtain strings were untangled, and the ceiling did not have multiple brownish stains. This failure had the potential to negatively impact on Resident 1's quality of life, and possible risk of infection.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/10/2022 and was re-admitted on [DATE] with diagnoses including chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) and dependence on respirator (ventilator-a machine or device used medically to support or replace the breathing of a person, unable to breath on their own). During review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/4/2026, the MDS indicated Resident 1 had impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 1's History and Physical (H&P) dated 4/9/2026, the H&P indicated the resident did not have the capacity to understand or make decisions. During a concurrent observation and interview with the Director of Nursing (DON) and Maintenance Staff (MS) on 4/24/2026 at 1:41 PM, inside Resident 1's room, observed Resident 1's curtain strings were tangled and ceiling had multiple brownish stains. The MS stated that staff (in general) were supposed to check the room weekly for any issues. The DON stated that curtain strings were not supposed to be tangled and there should not have any stains in the ceiling to be able to provide a clean and homelike environment to Resident 1. During a review of the facility's policy and procedure (P&P), titled, Quality of Life: Homelike Environment, reviewed on 1/16/2026, the P&P indicated that residents were provided with a safe, clean, and homelike environment characterized by cleanliness and order; and privacy curtains clean and in good condition.

Based on observation, interview and record review, the facility failed to provide an environment that is free from accident hazards in preventing avoidable accidents to one of six sampled residents (Resident 1) when Resident 1 was left unattended while up in the Hoyer lift (a medical device designed to safely transfer patients with limited mobility between beds, chairs, wheelchairs and showers). This deficient practice had the potential to negatively impact on Resident 1's safety, placing Resident 1 for possible fall or accident.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) and dependence on respirator (ventilator-a machine or device used medically to support or replace the breathing of a person, unable to breath on their own). During review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/4/2026, the MDS indicated Resident 1 had impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 1's History and Physical (H&P) dated 4/9/2026, the H&P indicated the resident did not have the capacity to understand or make decisions. During a review of Resident 1's Care Plan Report, revised on 4/9/2026, the care plan indicated Resident 1 was at risk for fall as manifested by poor safety awareness. The Care Plan Report indicated to assist Resident 1 with all the transfers. During a concurrent observation and interview with Registered Nurse 1 (RN1) on 4/24/2026 at 9:06 AM, inside Resident 1's room, observed Resident 1 up in the Hoyer lift on top of the bed with no staff around. RN1 immediately called for Certified Nursing Assistant 1 (CNA1). CNA1 stated that she (CNA1) was calling another staff (unidentified) for assistance. CNA1 stated that she (CNA1) was not supposed to leave Resident 1 in the Hoyer lift unattended. RN1 stated that it was important to make sure that when a resident was up in the Hoyer lift, resident should not be left unattended due to safety concern. During an interview with the Director of Nursing (DON) on 4/24/2026 at 11:20 AM, the DON stated that staff (in general) should not leave residents (in general) unattended when using a Hoyer lift and it was best practice to make sure there was at least two staff assisting a resident when using a Hoyer lift due to safety issues. During a review of the facility's policy and procedure (P&P), titled, Safe Lifting and Movement of Residents, reviewed on 1/16/2026, the P&P indicated that facility used appropriate techniques and devices to lift and move residents in order to protect the safety and well-being of staff and residents and to promote quality of care. During a review of facility's P&P titled, Safety and Supervision of Residents, reviewed on 1/16/2026, the P&P indicated that facility strived to make the environment as free from accident hazards as possible; and resident safety, supervision and assistance to prevent accidents were facility-wide priorities.

Based on observation, interview, and record review, the facility failed to maintain a clean, safe environment by failing to maintain the:Toilet, counter top and sink in the all gender bathroom next to the nursing station in good working order, clean and sanitary, by not securing the toilet to prevent it from shifting during use, keeping the sink counter corners free from crumbling grout/caulk, as well as, the sink being free from black mold-like build up under the lip of the counter. Wall in room [ROOM NUMBER] from crumbling behind the baseboard and it falling free from the wall, prevent crumbling wall corners above the baseboards and corners, as well as, free from dust and grime build up. Sink in the bathroom for rooms [ROOM NUMBERS], from pulling away from the wall from cracked caulking and peeling paint, keeping the exposed pipes to the sink clear of rust, as well as the walls above the baseboard on corners and edges intact and free from dirt and grime build up and the baseboard from peeling away from the walls. Corners and edges of the wall and flooring next sliding glass door in room [ROOM NUMBER] free from dust and grime build up, and crumbling foam filler material on either side of the metal transition threshold ramp. These deficient practices exposed the residents to an unkempt, dirty, run down, environment and had the potential to attract pests and affect resident safety. During a concurrent observation and interview on 4/10/26 at 11:54 am with the Maintenance Assistant (MA), the bathroom next to the nurses station in the subacute unit was observed with the toilet loose from the floor with newspaper stuffed between the floor and toilet and it missing the caulk to seal it. MA states it is like that because they recently did some plumping and replaced a pipe underneath that turned out to be too long and so the toilet is not flush with the floor. States he can fix it and it should be glued/sealed around the base. During further observation in the same bathroom with MA, the sink counter was observed to be pulling away from the back splash piece and to have missing or cracked/crumbling grout or caulking material. The MA validated this and stated he can reglue it. On the same sink there was also a black build up under the lip of where the counter top met the sink bowl. The MA validated this observation and stated that is a housekeeping is a housekeeping issue. During a concurrent observation and interview on 4/10/26 at 12:04 PM with the MA, the baseboard near the patio sliding glass door of resident room [ROOM NUMBER] was observed peeling off the wall, then when the MA went to pull back the curtain the baseboard fell off exposing a completely crumbled area of wall. The MA picked up the baseboard and stated he can fix it needs to be reglued on, and further states there are no mice in there currently. During a concurrent observation and interview on 4/10/26 at 12:07 PM with the MA, the bathroom in between room [ROOM NUMBER] and 24 was observed with sink what was pulling away from wall with cracked/crumbling caulking/grout and peeled off paint. The exposed pipes to sink with rust, and the corners of the bathroom with dirt, grime build up and with the right side baseboard peeling away from the wall. The MA acknowledged and validated the observations and stated they should be fixed. During a concurrent observation and interview on 4/10/26 at 12:07 PM with the Maintenance Assistant (MA), the bathroom in between room [ROOM NUMBER] and 24 was observed with sink what was pulling away from wall with cracked/crumbling caulking/grout and peeled off paint. The exposed pipes to sink with rust, and the corners of the bathroom with dirt, grime build up and with the right side baseboard peeling away from the wall. The MA acknowledged and validated the observations and stated they should be fixed. During a concurrent observation and interview on 4/10/26 at 12:11 PM with the MA, in room [ROOM NUMBER]. The baseboard near the sliding glass door is observed peeling away from the wall along with some of the paint and the corners of the sliding glass door are observed with dirt and grime build up. The MA validated the observations and states he can fix the baseboard but the dirt is a housekeeping issue. During a record review of the facility's daily maintenance log dated from 11/16/25 through 3/29/26, the log had no mention any of the above environmental issues, which was verified by the MA. During a record review of facility's policy & procedure (P&P) titled, Quality of Life - Homelike Environment, revised 1/10/25, Residents are provided with a safe, clean, comfortable and homelike environment.The facility staff and management shall maximize , to the extent possible, the characteristics include. cleanliness and order.

Based on observation, interview, and record review, the facility failed to maintain a safe environment by failing to secure the upper end of the stairway handrail (on the right side as you go up) to the wall.This deficient practice had the potential to affect staff and residents' safety while using the stairs. During a concurrent observation and interview on 4/10/26 at 11:51 am with the Maintenance Supervisor (MS) and Maintenance Assistant (MA), the handrail for the right hand side of the stairs from the parking lot to the first floor of the facility was observed with the top-end of the handrail loose from the wall, easily movable. The MS and MA both validated the handrail was loose, and the MS stated he just had to screw it in tighter to secure it, then the MA stated they may have to add a piece of wood to fix it but that it would get fixed. During a record review of facility's policy & procedure (P&P) titled, Quality of Life - Homelike Environment, revised 1/10/25, Residents are provided with a safe, clean, comfortable and homelike environment.The facility staff and management shall maximize , to the extent possible, the characteristics include. cleanliness and order.

Based on observation, interview, and record review, the facility failed to maintain safe resident smoking practices by failing to ensure one of one sampled resident (Resident 17) did not have a lighter in her possession. This deficient practice had the potential to cause injury to Resident 17.Findings:During a review of Resident 17's admission Record, the admission Record indicated the facility admitted Resident 17 on 3/21/2025 with diagnoses that included acute respiratory failure with hypoxia (a serious condition that happens when your lungs cannot get enough oxygen into your blood), morbid obesity (more than 80 to 100 pounds above their ideal body weight), ataxic gait (a walking pattern that's unsteady and clumsy, like someone who's drunk), cardiomyopathy (a disease that affects the heart muscle, making it difficult for the heart to pump blood effectively), acute on chronic congestive heart failure ((CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), chronic kidney disease (your kidneys are damaged and can't filter blood properly, leading to a buildup of waste and other problems), anemia (a condition where your blood doesn't have enough red blood cells or hemoglobin, which are needed to carry oxygen throughout your body), a history of transient ischemic attack (a temporary disruption of blood flow to the brain that causes stroke-like symptoms), and cerebral infarction (a stroke that occurs when blood flow to a part of the brain is blocked, causing brain tissue to die due to lack of oxygen and nutrients) without residual deficits (the lasting impairments or problems that remain after an illness, injury, or medical treatment has run its course). During a review of Resident 17's History and Physical (H&P - a comprehensive document that records a patient's medical history and a detailed physical examination performed by a healthcare provider) dated 3/21/2025, the H&P indicated Resident 17 had the capacity (ability) to understand and make decisions. The H&P indicated Resident 17 had COPD (chronic obstructive pulmonary disease -a chronic lung disease causing difficulty in breathing). During a review of Resident 17's care plan titled non-compliant (not following the rules, directions, or requirements that are set by someone or something, like a law, a contract, or a doctor's instructions) with smoking policy - refuse to leave lighter with staff and not does follow smoking time, dated 3/22/2025, indicated interventions for Resident 17's cigarettes and lighter should be kept at the nurses station at all times.During a review of Resident 17's Interdisciplinary Team (IDT - a group of experts with different specialties who work together to solve a problem or help someone) Notes dated 6/8/2025 indicated Resident 17 was non-compliant with smoking schedule and policy; refuses to wear smoking apron and refuses to follow smoking schedule and storage of cigarette and lighter. The IDT note indicated MD (medical doctor) and resident were made aware of risks and possible negative outcomes of resident's behaviors.During a review of Resident 17's Minimum Data Set (MDS - a resident assessment tool) dated 6/19/2025, the MDS indicated Resident 17 had the ability to make herself understood and could underhand others. The MDS indicated Resident 17 used a wheelchair.During a review of Resident 17's Smoking Risk Managment assessment dated [DATE], the Smoking Risk Managment assessment indicated Resident 17 was a high-risk smoker. The Smoking Risk Managment indicated Resident 17 was impulsive- poor safety, requires supervision in regard to safety judgement. The smoking assessment indicated Resident had issues with balance while standing and walking, was jerking or unstable when making turns, had decreased muscular coordination, and required the use of an assistive device (cane, walker, or wheelchair). During a review of Resident 17's physician orders dated 7/18/2025, the physician orders indicated Resident 17 had an order for oxygen at 2 liters per minute (a unit that expresses a rate of flow) for respiratory (breathing) discomfort. During a review of Resident 17's Health Status Note dated 7/14/2024 at 7:07 AM, the Health Status Note indicated Resident 17 used oxygen inhalation (breathing in) via nasal cannula (a simple, flexible tube with two small prongs that fit into your nose for oxygen) at 2 liters per minute. During a review of Resident 17's Health Status Note dated 7/14/2024 at 2:04 PM, the Health Status Note indicated Resident 17 was aware of the smoking schedule and policy. The Health Status Note indicated Resident 17 was offered a smoking apron (a fire-resistant apron designed to protect people, particularly those in wheelchairs or with limited mobility, from accidental burns while smoking) every time she smokes but she refused, risk and possible negative outcomes explained but resident (Resident 17) continue not to follow facility smoking protocols (a set of rules or procedures that govern how something is done). During an interview with the Director of Nursing (DON) on 7/15/2025 at 1:25 PM. The DON stated she was aware Resident 17 was in possession of cigarette lighters. The DON stated Resident 17 ordered cigarette lighters from Amazon and Resident 17 was not compliant with the facility's care plan or smoking policy. The DON stated the facility could be at risk for fire if Resident 17 had a cigarette lighter in her possession, especially if she was using oxygen. The DON removed the lighters from Resident 17.During a concurrent observation and interview on 7/17/2025 at 1:03 PM with Resident 17 in the smoking patio, Resident 17 was observed seated in her wheelchair. Resident 17 stated she kept her lighters on her person and was observed storing one fluorescent green cigarette lighter and one fluorescent yellow cigarette lighter in a black bag in Resident 17's possession. Resident 17 stated she kept both cigarette lighters (green and yellow, fluorescent lighters) in empty cigarette boxes and stored them in her bag that she kept in her possession. Resident 17 stated she did not use the smoking apron provided by the facility. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy - Residents, dated 1/10/2025, the P&P indicated only facility-approved ashtrays and other smoking equipment/paraphernalia shall be used in resident living or sleeping areas. The P&P indicated the facility may impose smoking restrictions on residents at any time if it isdetermined that the resident cannot smoke safely with the available levels of support and supervision. The P&P indicated any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. The P&P indicated residents without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. The P&P indicated this facility may check periodically to determine if residents have any smokingarticles in violation of our smoking policies. Staff shall confiscate any such articles (items) and shall notify the Charge Nurse/Unit Manager that they have done so.

Based on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 7/15/2025 by failing to ensure puree diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding.) received rice texture in form that meet their needs and in accordance with the International Dysphagia Diet Initiative (IDDSI - a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) when the texture of the pureed rice was thick and stuck to the spoon and the roof of the mouth.This failure had the potential to result in meal dissatisfaction and increased choking risk for residents on pureed diet.Findings:1.During an observation of the tray line (tray line-a system of food preparation, in which trays move along an assembly line) service for lunch on 7/15/2025 at 12:00PM, the pureed rice looked thick and sticky. During the serving of the pureed rice observed the rice stuck to the serving scoop. During a concurrent interview and taste test of the pureed rice with the Dietary Supervisor (DS) on 7/15/2025 at 12:30PM, the pureed rice looked dry and thick. The pureed rice was stuck on the spoon and did not fall on the plate when spoon was tilted. During the taste test, the pureed rice was stuck to the roof of the mouth, and it was difficult to clear from the mouth. The DS agreed that the rice is sticky, and stated residents would need to drink fluids to clear the mouth. The DS stated sticky texture was hard for residents to swallow and could cause choking. The DS stated the cook needed to add more liquid to the puree rice to create a softer texture.During an interview with the cook (Cook1) on 7/15/2025 at 12:35PM, Cook1 stated cook1 added water to the rice and blended the mixture and did not need to add any thickener. Cook1 stated the pureed food should not be sticky or dry and should fall from the spoon easily when spoon is tilted. Cook1 stated cook1 should added more liquid to make the pureed rice soft. During a review of the facility's recipe titled Recipe: Pureed (IDDSI Level 4) Starch (Rice, Pasta, Polenta, Potatoes) (dated 2023) the recipe indicated, 1)complete regular recipe.2)puree on low to a paste.3)Gradually add warm milk4)add thickener if needed.5)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. The finished pureed item must pass IDDSI level 4 testing requirements (the fork drip, fork pressure, and spoon tilt test.During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated that Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test. During a review of facility's policy and procedure (P&P) titled Food Preparation (dated 2023) the p&p indicated, The facility will use approved recipes, standardized to meet the resident census. Recipes are specific as to portion yield, method of preparation, quantities of ingredients.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when:1.The temperature of the walk-in refrigerator was 45 degrees Fahrenheit, and the gasket (door seal) of the walk-in refrigerator glass display door was broken, not allowing for the glass door to close tight. The temperature of the milk located by the glass display door was 44 degrees Fahrenheit. 2.Dishwasher 1 (DW1) working in the dish machine area did not wash hands and/or replace gloves when removing the clean and sanitized dishes form the dish machine.3.The base of the Dietary tray card holders was rusted. (Card Holder with a round base which sets firmly on resident meal tray with a holder to grip the diet cards-diet cards have the resident name and the diet order with resident preferences and allergies written on them).4. Food brought to residents from outside the facility was stored in the resident's food refrigerator unsealed, 5. The resident refrigerator was not clean and had brown color stains on the bottom shelf. The freezer section was not clean and had a thick layer of ice and brown stains on it. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in residents who received food from the facility and including residents who had food stored in the resident refrigerator. Findings:1.During a concurrent observation in the facility kitchen and interview with the Dietary Supervisor (DS) on 7/15/2025 at 9:00 AM, the temperature of the walk-in refrigerator was 45 degrees Fahrenheit. The DS stated the refrigerator door was kept open for food delivery and during breakfast service.During a concurrent observation of the facility kitchen and interview with DS on 7/16/2025 at 8:50AM, the temperature of the walk-in refrigerator was 44 degrees Fahrenheit (F). During the same observation the gasket of the walk-in refrigerator glass display door was broken, not allowing for the glass door to close tight. The DS stated the temperature of the walk-in refrigerator that morning (7/16/2025) was 38 degrees F. The DS stated the broken gasket of the glass display door allowed warm air to enter the refrigerator throughout the day. During the same observation and interview, the temperature of the milk located by the glass display door was checked with the facility thermometer and was 44 degrees F. The DS stated that cold food had to be kept at 41 degrees or lower and the milk was not kept at the right temperature and would be discarded. The DS stated food not kept at temperatures of 41 and below could go bad and make the residents sick. During a concurrent observation in the facility kitchen and interview with DS on 7/16/2025 at 12:01PM the temperature of the Walk in refrigerator was 42degrees F.During a review of facility's policy and procedures titled Procedure for Refrigerated Storage (Dated 2023), the policy indicated Refrigerator 41 degrees F or lower.to keep food at a specific temperature, the air temperature in the refrigerator usually must be about 2 degrees F lower. For example, to hold chicken at 41 F, the air temperature must be 39F.During a review of facility's policy and procedures titled Refrigerator and Freezer (Dated 2023) indicated, How to keep your refrigerator and freezer working efficiently: 1) close the door when not in use and do not prop open, 2) Periodically, check door gaskets and replace, if damaged.During a review of the 2022 U.S. Food and Drug Administration Food Code 3-501.16 titled Time/Temperature control for safety food, hot and cold holding indicated, except during preparation, cooking or cooling, time/temperature control for safety food shall be maintained at 135degrees F or above, and at 41 degrees F or below. 2. During an observation in the dishwashing area on 7/15/2025 at 8:20AM, Dishwasher (DW1) was observed rinsing soiled dishes and loading the dirty dishes in the dish machine. DW1 had gloves on his hands, and after the dish machine stopped DW1 wore new gloves without washing hands and proceeded to remove the clean and sanitized dishes from the dish machine without washing hands. DW1 was then observed with gloves on, started cleaning the dishwashing area counters with soap and water, then removed gloves dried hands with paper towel and wore new gloves without washing hands and proceeded to remove and store away clean and sanitized dishes.During an interview with DW1 on 7/15/2025 at 8:30AM, DW1 confirmed by stating he (DW1) did not wash his hands after removing gloves and before touching the clean dishes. DW1 stated that not washing hands could contaminate clean dishes.During an interview on 7/15/2025 at 8:35AM, the DS stated staff could cross contaminate the dishes when moving from dirty dishes to clean dishes without washing hands. During a review of facility's policy and procedure titled Handwashing procedure (dated 2023) indicted, Hand washing is important to prevent the spread of infections. When hands need to be washed: after handling soiled dishes and utensils.During a review of the 2022 U.S. Food and Drug Administration Food Code, Code 2-301.14 titled When to wash. The Code indicated, Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and E) After handling soiled equipment or utensils. 3.During a tray line observation in the facility kitchen for lunch service (tray line-a system of food preparation, in which trays move along an assembly line) on 7/15/2025 at 11:50AM, the dietary card holders were placed on resident's meal tray. The base of the Dietary tray card holders was observed to be rusted.During an interview on 7/15/2025 at 3:00PM, the DS stated the card holders are made of metal. The DS stated the card holders were washed in the dishwasher and the chemicals used eroded the metal card holder. The DS stated the card holders were rusty and look unsightly. The DS stated the rust could result in contamination of resident's meal trays.During a review of facilities policy and procedures titled Sanitation (dated 2023) indicated, All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas.4.During an observation in the resident refrigerator located in the utility room on the 2nd floor on 7/16/2025 at 9:20AM, there was one open package of hot dogs in the freezer section of the small refrigerator. The freezer was covered with a thick layer of ice. The open package of hot dogs was stored on the thick layer of ice, there were brown color stains on the ice. There were brown color stains and drippings on the bottom shelf of the refrigerator.During a concurrent observation and interview with Infection prevention nurse (IP) on 7/16/2025 at 9:20AM, IP stated resident leftover food had to be covered, labeled and dated. The IP stated food that was not covered could be exposed and get contaminated.During an interview with housekeeping supervisor (HS) on 7/16/2025 at 9:30AM, the HS stated housekeeping was responsible for cleaning the refrigerator and defrosting the ice in the freezer. The HS did not have a record of the refrigerator cleaning and did not know when the refrigerator was last cleaned.During a review of facility's policy titled Foods Brought by Family/Visitor (not dated), Indicated, Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Container will be labeled with the resident's name, the item and the use by date.During a review of facility's policy titled Refrigerator and Freezer (dated 2023) indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of our foods. Refrigerator and freezer should be on a weekly cleaning schedule, wipe up spills immediately.

Based on observation, interview and record review, the facility failed to ensure four of five trash bins in the dumpster area were maintained in a sanitary manner. One trash bins had the lid open and three trash bins were rusted, broken and had corrosion that resulted in holes exposing the content inside the trash bins. This deficient practice had the potential for harborage and feeding of pests.Findings:During an observation in the main dumpster area located outside of the facility kitchen back door on 7/15/2025 at 9:30AM; one large recycle bin lid was not covered, there were boxes inside the bin and flies inside and around the bin. Three large trash dumpsters were corroded resulted in large holes and the trash was seen through the holes, the trash bins had orange color rust and broken at the bottom. There was cigarette butts stuck under the open seam of the trash bins.During a concurrent observation and interview with dietary supervisor (DS) and maintenance supervisor (MS) on 7/15/2025 at 9:30AM, the MS stated the three large trash bins were old, rusted and there were large holes which could result in rodents and other pests going in the trash. The MS stated the lids of the trash bins had to be closed to prevent rodents and flies from going inside. The DS stated open trash bins attracted flies and other pests and creates an unsanitary environment in the trash area and the facility.During a review of the facility's policy titled, Miscellaneous Areas-Garbage and Trash (dated 2023) indicated, Adequate, clean, vermin-proof areas must be provided for storage or garbage and rubbish, Garbage and trashcans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed, the trash collection area is a potential feeding ground for vermin and rodents and must kept clean-if a commercial rubbish service is used, arrangements must be made for periodic exchange of trash bins.A review of Food and Drug Administration (FDA) Food Code 2022, code number 5-501.113 titled Covering receptacles, indicated: receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 10) had a follow up on coordinating a Preadmission Screening and Resident Review Level II (PASRR II- this evaluation determines the individuals specific needs and whether specialized services are required, ensuring the least restrictive setting for their care).This failure had the potential for Resident 10 to have a lack of necessary mental health services.Findings:During a review of Resident 10's admission Record, the admission Record indicated the facility admitted Resident 10 on 4/28/2023 with diagnosis of schizophrenia (a mental illness that can affect thoughts, mood, and behavior), 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 10's Minimum Data Set (MDS - a resident assessment tool) dated 5/10/2025, the MDS indicated the resident was alert and oriented to person but not time with good recall. The MDS indicated Resident 10 did not feel down, depressed, hopeless, or with no little interest in doing things. The MDS indicated the resident had hallucinations (sensory experiences that seem real but are not, involving things like seeing, hearing, or feeling things that aren't actually present).During an observation on 7/15/2025 at 11:47 AM in the activities room, Resident 10 was sitting in her wheelchair eating and participating in activities. Resident 10 stated she liked the care she received at the facility.During a concurrent interview and record review on 7/16/2025 at 11:00 AM with Register Nurse Supervisor 2 (RN 2), the PASRR Level I dated 4/28/2023 and Level II dated 5/12/2023 were reviewed. The PASRR Level I indicated a Level II mental Health Evaluation was required. The PASRR Level II indicated unable to complete Level II Evaluation due to the individual was isolated as a health or safety precaution and the case would be now closed, and to reopen please submit a new Level I screening. RN 2 stated a PASRR representative would call and interview the resident, and in the interview would determine if a representative would need to come out and perform an assessment. RN 2 reviewed the PASRR website and stated that there was no Level I or II PASRR submitted as indicated. RN 2 stated the licensed nurse (unidentified) who received the initial phone call would resubmit for another Level I PASRR. RN 2 stated Resident 10 would be at risk of not receiving the proper mental health assistance without a resubmission of a PASRR Level I or II.During a concurrent interview and record review on 7/16/2025 at 2:15 PM with RN 2, the Notice of PASRR Level I Screening Results dated 7/16/2025 were reviewed. RN 2 stated she (RN 2) submitted a new one on 7/16/2025.During an interview on 7/15/25 at 11:30 AM with the Director of Nursing (DON), the DON stated the registered nurse (unidentified) who took the call should have resubmitted a new Level I PASRR. The DON stated every Registered Nurse (in general) was aware how to resubmit for another PASRR I. The DON stated per the policy within 24 hours the resubmission should occur. The DON stated Resident 10 would be at risk of a lack of mental health services.During a review of the facility's policy and procedure titled, Preadmission Screening & Resident Review (PASRR) dated 1/10/2025, indicated, facility will participate in the Initial Assessment process within 24 hours of submitting the completed Level I Screening or upon request of the Level II Contractor and coordinate with the Level II Contractor to ensure the PASRR process is completed before admitting the individual to the facility. Facility will be required to restart the PASRR case closed by the Level II Contractor as an Attempt or Unavailable due to facility not providing required documentation to the Level II Contractor.

Based on observation, interview, and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and monitor interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who was assessed as a high fall risk, the facility failed to develop a plan of care with interventions to address the resident's identified risk for falls and failed to ensure Resident 1 received two or more person physical assist when turning. These deficient practices resulted in Resident 1 suffering a fall with injuries and having to be taken to the general acute hospital (GACH) where he was found to have a massive brain bleed and pronounced brain dead the day following day. Findings: A review of the Admission Record indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS, an assessment and care screening tool) dated 5/30/19 indicated Resident 1 was totally dependent on staff for day-to-day, basic self-care tasks (i.e., activities of daily living-ADLs). The MDS indicated Resident 1 required two or more people to physically assist him with bed mobility, transfers, and bathing. The MDS also indicated Resident 1 had severely impaired daily decision-making skills. A review of the Order Summary Report dated 9/12/19 indicated Resident 1 was prescribed [MEDICATION NAME] (an anticoagulant that is used to prevent blood clots) 40 milligrams (mg) subcutaneously (medication administered under the skin) daily. A review of the Care Plan dated 8/31/19 indicated Resident 1 was at risk for bleeding due to the use of [MEDICATION NAME]. Care plan interventions included to handle Resident 1 gently and carefully during care. A review of Resident 1's fall care plan initiated on 9/1/19 indicated Resident 1 was a high fall risk due to cognitive impairment and poor trunk control, and required total assistance with ADLs related to the use of medical tubings. The care plan goal indicated Resident 1 would have no fall or injury daily for three months and the interventions included to assist with all transfers. The care plan intervention did not indicate Resident 1 required two person assistance during transfers, bed mobility, and bathing. A review of the Progress Notes dated 9/4/19 at 11:33 a.m. indicated the Certified Nursing Assistant 1 (CNA 1), while providing nursing care, turned Resident 1 to his left side to remove the dirty linen from underneath him. Upon turning the resident, the note indicated Resident 1 exhibited jerking movement that caused the resident's legs to slide off the bed and resulted in the resident's fall to the ground. A review of the Change of Condition (C[NAME]) form dated 9/4/19 at 11:50 a.m. indicated Resident 1 was found on the floor beside his bed, lying on his side, and facing the window. The C[NAME] also indicated Resident 1 was wearing a cranial helmet, and his nephrostomy tube had become dislodged. The C[NAME] indicated there was no bleeding at the site and a dry dressing was applied. The C[NAME] also indicated licensed nurses completed a body assessment and revealed Resident 1 was awake with no [MEDICAL CONDITION] activity. The C[NAME] indicated there were no bruises or open wounds, and Resident 1 had no facial grimacing. The C[NAME] indicated licensed nurses conducted a neurological exam (assessment of the sensory and motor responses), which revealed Resident 1's pupils (opening in the center of the iris (structure that gives eyes color)) were equal, round, and reactive to light. The C[NAME] indicated Resident 1's physician was notified and an order was received to transfer Resident 1 via paramedics to the nearest hospital. A review of the General Acute Care Hospital (GACH 1) neurosurgery consult dated 9/4/19 at 5:21 p.m. indicated Resident 1 had a computerized tomography (CT) scan of the head (a special x-ray machine that takes pictures of the brain, skull, sinuses and blood vessels) which demonstrated a massive intraventricular hemorrhage (bleeding inside the spaces of the brain) and [DIAGNOSES REDACTED] (abnormal accumulation of cerebrospinal fluid (CSF-a clear colorless body fluid found in the brain and spinal cord)). Resident 1 had pupils that were non-reactive and had no motor response to pain. An emergent ventriculostomy (catheter placed into the ventricles (fluid filled empty space) of the brain to drain the CSF) was indicated to relieve the [DIAGNOSES REDACTED]. A review of Resident 1's previous computed tomography of the brain from a GACH (GACH 2) dated 7/15/19 indicated there was no previous [MEDICAL CONDITION] at the time of the scan. A review of the Anesthesia Record dated 9/4/19 at 5:01 p.m. indicated Resident 1 underwent a ventriculostomy (a neurosurgical procedure that involves creating a hole (stoma) within a cerebral ventricle for drainage. It is done by surgically penetrating the skull, dura mater, and brain such that the ventricle of the brain is accessed). A review of the [MEDICAL CONDITION] Consultation dated 9/5/19 at 9:22 a.m. indicated Resident 1 had a massive [MEDICAL CONDITION], and his pupils were fixed, dilated, and unresponsive. The consultation also indicated Resident 1's overall prognosis was poor. A review of the Progress Record dated 9/6/19 indicated Resident 1 was declared brain dead by two physicians on 9/5/19 and Resident 1's family was notified. A review of GACH 1's discharge summary dated 9/18/19 indicated Resident 1 was placed on comfort care. GACH 1's discharge summary indicated Resident 1 was pronounced dead on 9/10/19. During an observation and concurrent interview on 9/12/19 at 12:28 p.m. in the presence of an interpreter (CNA 2), CNA 1 stated on 9/4/19, at about 11:30 a.m., Resident 1 had a bowel movement and needed to be cleaned. CNA 1 stated she raised Resident 1's bed about 2.5 feet from the floor. CNA 1 stated she started cleaning Resident 1's left side. After cleaning the left side, CNA 1 stated, she moved to the right side of Resident 1's bed. CNA 1 started cleaning Resident 1's right side and turned Resident 1 to the left side to remove the dirty linen. At that point, CNA 1 stated Resident 1's body jerked and fell off the bed. CNA 1 stated she tried to stop the fall, but Resident 1 had still fallen onto the floor. CNA 1 stated Resident 1 was lying on his side, facing the window. CNA 1 stated she screamed for help. During a telephone interview on 9/12/19 at 1:05 p.m., registered nurse supervisor 1 (RNS 1) stated he was called to Resident 1's room when Resident 1 fell from the bed. RNS 1 stated he assessed Resident 1, who was wearing a cranial helmet. RNS 1 stated the ventilator tubing had disconnected during the fall but was immediately reconnected to the ventilator by the respiratory therapist. RNS 1 stated Resident 1 had no obvious injuries. RNS 1 stated Resident 1's physician was notified and an order to transfer Resident 1 via paramedics to the nearest hospital was given. During an interview with the licensed vocational nurse 1 (LVN 1) on 9/12/19, at 1:14 p.m., LVN 1 stated Resident 1 fell on [DATE], at about 11:33 a.m. LVN 1 stated when cleaning Resident 1, there should always be two people assisting. LVN 1 stated CNA 1 should have called for help to clean Resident 1. LVN 1 stated CNA 1 could have called another staff member to help clean Resident 1. During an interview with CNA 1 on 9/12/19 at 2:20 p.m., CNA 1 stated she did not ask for help to clean Resident 1 because everybody was busy. CNA 1 stated Resident 1 had a bowel movement and she had to clean him. During an interview with the MDS nurse on 9/12/19 at 3:13 p.m., the MDS nurse stated Resident 1 was totally dependent with ADLs and required two person physical assistance with bathing, bed mobility, and transfers. The MDS nurse stated Resident 1's two-person assistance during care should have been followed. During a telephone interview with the Director of Nursing (DON) on 9/13/19 at 3:33 p.m., the DON stated Resident 1's fall could have been prevented if CNA 1 had another staff to assist her while providing peri-care to Resident 1. A review of the undated facility policy titled Safety and Supervision of Residents indicated staff should use various sources to identify risk factors for residents, including the information obtained from the medical history, physical examination, observation of the resident, and the MDS.

Based on observation, interview, and record review, the facility failed to identify and evaluate accident risks and hazards, and did not implement and monitor / modify interventions when necessary for one of three sampled residents (Resident 1). For Resident 1, who had history of fall, major depressive disorder, and verbalized he was sad, the facility failed to closely observe Resident 1 for worsening of depression / suicidal thinking, and failed to monitor the resident with routine checks and document the outcome, per facility policy. This deficient practice caused Resident 1 to attempt suicide, falling down 12 flights of stairs, which resulted in a concussion (brain injury that is caused by a sudden blow to the head), a skull fracture, and a cervical spine fracture (broken neck). Approximately two weeks later, Resident 1 required spine surgery (which connects the skull to the neck). Findings: A review of the Admission Face Sheet indicated Resident 1 was admitted to the facility, on 1/7/17, with [DIAGNOSES REDACTED]. A review of the Medication Administration Record (MAR) dated 1/8/17, indicated Resident 1 received Phenobarbital 97.2 mg, via gastrostomy tube (Gtube) once per day for epilepsy. The Nurse's Drug Guide 2017, indicated Phenobarbital was classified as a sedative - hypnotic, with adverse effects of anxiety, thinking abnormalities, dizziness, confusion and depression. A review of the care plan, dated 1/10/17, indicated Resident 1 had a history of [REDACTED]. According to the Minimum Data Set (MDS - an assessment and care plan screening tool), dated 4/19/17, Resident 1 had moderate cognitive impairment, and had the ability to usually understand and be understood by others. The MDS, under section G0110, Functional Status (activities of daily living self-performance), indicated Resident 1 required assistance with a one person physical assist for bed mobility, transferring, and locomotion on unit. The MDS, under section G0600 for mobility devices, indicated Resident 1 used a wheelchair aid in ambulation. Further review of the MDS indicated depression was not documented as an active [DIAGNOSES REDACTED]. A review of the progress notes, dated 7/3/17, indicated Resident 1 verbalized he was sad and depressed. A review of the care plan, dated 7/3/17, indicated Resident 1 had episodes of depression manifested by anti-depressant medication. The care plan interventions included to encourage verbalization of feelings and concerns, monitor Resident 1's activity, behavior, spend time with resident on a one to one basis, and social service department to do room visit regularly and check needs and concerns. A review of the MAR, dated 7/3. 7/4, 7/7 and 7/8/17, indicated Resident 1 had episodes of isolation. A review of the MAR dated 7/4/17 indicated Resident 1 received Lexapro (antidepressant) 10 mg daily for self isolation related to major depressive disorder. The Nurse's Drug Guide 2017, indicated Lexapro had a black box warning, was associated with suicidal thinking, and to closely observe for worsening of depression or suicidality. However this was not included in Resident 1's care plan. According to the July 2017 MAR there was no documentation of monitoring Resident 1 for adverse reactions to the Phenobarbital or the Lexapro. A review of the round the clock monitoring form, dated 7/8/17, indicated the time and the initials of the person monitoring Resident 1, however the outcomes of the monitoring were not documented, per facility policy. The facility's undated policy and procedure titled, Routine Resident Checks, indicated the staff shall make routine resident checks to help maintain resident safety and well-being. The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs. The charge nurse shall keep documentation related to the routine checks, including the time, identity of the person making checks, and any outcomes of each checks. A review of the summary of incident form, documented by the Administrator, dated 7/8/17, indicated the facility had an outside patio which had a door going down to ground level, and the door had a latch and alarmed when it was opened. The summary of incident indicated Resident 1 was found outside, beside the kitchen, lying on his left side with the wheelchair beside the resident. Resident 1 was noted with a laceration on top of the scalp, 911 was called, and Resident 1 was transferred to the general acute care hospital (GACH) for further evaluation and treatment. A review of the GACH 1 transcription report, dated 7/9/17, indicated Resident 1 was a [AGE] year old male, who stated he wanted to kill himself and threw himself down 12 flights of stairs. The final [DIAGNOSES REDACTED]. Resident 1 had a skull fracture, C2 / C3 spine fractures, and a cervical spine fracture (broken neck). The report indicated Resident 1 was transferred to GACH 2 due to need of specialized care. During an observation, on 7/20/17, at 8 a.m., while conducting a facility tour with Registered Nurse 1 (RN 1), the gate on the facility's second floor patio which led to the first floor, had 15 steps of stairs, and was observed unlocked and not secured with an alarm. During a concurrent interview, RN 1 stated the second floor patio gate remained unlocked due to fire hazard, and an alarm was attached to the gate in order to alert the facility's staff when someone was attempting to open the gate. During an interview with the Assistant Director of Nursing (ADON), on 7/20/17, at 11:45 a.m., she stated when they found Resident 1 downstairs, they did not hear the alarm system turn on. ADON stated no one was with Resident 1 during the time he fell , and no one witnessed the incident. Furthermore, ADON stated the resident reported to her that he fell off from the second floor patio. On 7/20/17, at 12:15 p.m., during an interview, Certified Nursing Assistant 2 (CNA 2), stated she saw Resident 1 roaming around the facility in his wheelchair around 11:45 a.m., on the date of the incident (7/8/17). CNA 2 stated when she heard Resident 1 had fallen and was found on the first floor, she did not hear the patio gate alarm noise turn on at any time inside the facility. During an interview, on 7/20/17, at 1:20 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 had expressed feelings of being sad and depressed to him, and he reported it to the Psychiatrist immediately. LVN 1 stated they should have closely monitored Resident 1 to prevent accidents or falls. A review of the surgical progress note from GACH 2 indicated Resident 1 had an occiput (the back of the head or skull) to C5 fusion surgery (a spine surgery which connects the skull to the neck) on 7/20/17.

Based on observation, interview, and record review, the facility repeatedly failed to adequately address and resolve grievances voiced by six of seven alert and oriented residents attending the resident group meeting, and in accordance with the Resident Council minutes dating from August 9, 2011, to June 8, 2012. The residents voiced concerns regarding the staff speaking in non-English languages while providing care, and the staff's slow response (greater than 45 minutes) when called via the nurse call light system. This deficient practice resulted in the residents feeling anger, despair, hopelessness, embarrassment, and disempowered. Findings: On June 28, 2012, at 10:30 a.m., six of the seven alert and oriented residents attending the group meeting, and a review of the resident council minutes, indicated the residents had on more than one occasion expressed dislike for the staff speaking a language other than English while providing care to them. It was also indicated six of the seven residents had on more than one occasion voiced concerns regarding the staff''s slow response to the residents' calls for help on the nurse call light system. A review of the Resident Council Meeting (monthly meetings run by the residents) minutes for ten months from August 9, 2011 to June 8, 2012 revealed the following: On August 9, 2011, it was documented the residents voiced concerns regarding the evening shift and night shift staff using languages other than English, and the certified nursing assistants (CNA) using cell phones while providing care to the residents. On September 2, 2011, it was documented the residents stated the problem with the staff using non-English languages and using cell phones while providing care was "un-resolved." On November 4, 2011, it was documented the residents expressed concerns about the facility staff using languages other than English while caring for them, and while talking to them. Review of an Inservice Training Report dated November 7, 2011, indicated the facility Director of Staff Development (DSD) gave an inservice to 56 of the facility's greater than 200 employees. The Inservice Training Report indicated the content of the inservice included: Using a language the resident's cannot understand is a violation of the residents' rights. The report further indicated non-observance of the facility's policy to speak English only in the resident rooms, nursing stations, hallways, activity area, and other public areas of the facility would result in verbal and written reprimands, suspensions, and other measures. Review of the minutes of a Utilization Review and Quality Assurance meeting held on November 11, 2011, indicated the facility's Activity department reported the residents' concerns regarding the facility staff using languages other than English. The recommendations of the committee to address the problem was to conduct inservices, remind the staff to speak in a language that can be understood by the residents when rendering care, and an admonition (counsel or warning) that employees caught speaking foriegn languages within the hearing distance of the residents would be subject to disciplinary action. On January 6, 2012, the residents expressed concerns regarding the facility staff not responding to the residents' requests for help. Review of the minutes of a Utilization Committee and Quality Assurance meeting held on January 13, 2012, indicated the Activity Department again reported the residents' concerns regarding the facility staff using languages other than English. Review of the minutes of the meeting indicated the Utilization Review and Quality Assurance committee's recommendations to address the problem were the same as the recommendations they had made at the November 11, 2011, meeting. A review of an Inservice Training Report dated February 16, 2012, indicated the DSD gave an inservice on answering resident call lights in a timely manner to 85 of the facility's greater than 200 employees on February 16, 2012. Review of the inservice content indicated the DSD emphasized to the staff the resident's call lights were to be answered within 3 minutes, answering call lights was the duty and responsibility of every staff menber, not just CNAs, and staff responding promptly to the residents' call lights promoted residents' rights. At the June 8, 2012, Resident Council meeting the residents again voiced complaints regarding the facility staff using languages other than English around them. The facility's Nursing Department's response to the residents' concerns was to give an inservice to 31 of the facility's greater than 200 employees. The content of the inservice was the same as that in the inservices and Utilization Review and Quality Assurance recomendations on January 13, 2011, November 7, 2011, November 11, 2011, and February 16, 2012. On July 3, 2012, at 12:04 p.m., when asked about the multiple complaints from the residents regarding the staff speaking a language other than English while providing care, the facility Administrator stated, "Some of our staff has been here a long time and English is a challenge." The administrator stated if the staff continue to use non-English languages while rendering care to the residents he would have to consider disciplinary actions. On July 3, 2012, at 2 p.m., during a Quality Assessment and Assurance (QA) meeting with the Administrator, it was stated that current issues the QA committee are developing plans for did not include the residents' ongoing complaints regarding staff's slow response to call lights, or the ongoing complaints regarding non-English speaking in the resident care areas. During the same interview, when asked how the QA committee planned to revise their plan of action to address the residents' concerns about slow call light response and the staff using non-English in the resident care areas, the Administrator stated the QA committee would conduct inservices and institute disciplinary actions. After each instance of complaints from the Resident Council, the facility held staff inservices and informed the staff disciplinary actions would be taken for infractions, therefore this is not a revised plan. On July 19, 2012 at 8:57 a.m., during a phone interview, the facility's Director of Staff Development (DSD) reviewed the facility's Staff Disciplinary binder and stated one employee had been disciplined for refusing to respond to a resident's call light, and no employees had been disciplined within the last year for speaking languages other than English in the resident care areas. The DSD stated since the survey, she is now monitoring the staff in the hallways and other resident care areas in order to remind them to speak English, and has started verbally counciling staff speaking non-English in the resident care areas. Examples of what resulted from the facility's failure to address and resolve the above listed grievances are as follows: On July 3, 2012 at 11:05 a.m., Resident 21 stated she has often had to wait greater than 45 minutes for the staff to answer her call light. Resident 21 related an incident that occurred shortly after her admission to the facility. The nursing staff had administered a laxative to her to relieve constipation, when she felt the laxative begin to take affect she called for assistance using her nurse call light. Resident 21 stated she waited 15 minutes, then called again, but still did not get a response. After waiting another 30 minutes, the resident stated she lost control and had an accident where the liquid stool saturated her clothes and bed. The resident stated by the time the staff came she was extremely uncomfortable and embarrassed. Resident 21 stated she did not like it when the facility staff spoke spanish or tagolog while providing care for her because it was rude. A review of Resident 21's admission record indicated she was admitted to the facility on [DATE]. On June 28, 2012 at 10:30 a.m., and again on June 29, 2012, at 2:30 p.m., Resident 15 became visibly upset and angry when asked about the mention of the staff speaking non-english language in the resident care areas. Resident 15's voice was raised, she was shaking and waving her arms around stating, "After you left the shower room they started speaking spanish over my head. I'm sitting there without any clothes on and they are just jabbering away. I know they were talking about me. I'm tired of hearing it. Every day they talk over my head like I'm not even there. I can't even interrupt them to make them listen to me." On June 27, 2012, at 3:20 pm, Resident 20 stated the staff are loud all of the time. He stated "The staff are always heard yelling at one another and are harder to control than a bunch of pre - school kids." Resident 20 informed the surveyor the staff always speak in their own language at the nursing stations, in the hallways and in the resident rooms while providing care. The resident stated he has complained directly to the staff and the director of nursing more than once. He stated that when you complain to the staff they don't care, and act as if they have a sense of entitlement and act like it's their home. He stated the licensed staff are the worst and on several occasions they have gotten so loud they have awakened him from his sleep. Resident 20 stated he's frustrated and the staff makes him feel bad. He stated he knows the staff doesn't like him and they talk about him in their native language. Resident 20 stated he feels the staff are insensitive to the residents' concerns, needs and desires. On June 28, 2012, at 1:40 pm, Resident 17 stated the staff act like they run the facility and will not speak English. He stated the staff discriminate against the residents, are disrespectful and don't care about how the residents feel. Resident 17 stated the staff keep themselves segregated from the residents and others who don't speak their language. He stated the staff are noisy, loud, laughing all the time, talking over each other and making noise all of the time. The resident stated it doesn't matter what time of day it is, it happens on all shifts. He stated there have been times when he was talking to the charge nurse, another staff will come and start speaking their language and they end up ignoring him. Resident 17 stated he has gone to ask the nurse for pain medication and has waited five minutes or more until the staff stop speaking to each other in their language and focus on his needs. He stated it makes him very upset and it feels like they just dismiss whatever it is that he needs to continue talking with each other. Resident 17 stated things might not be so bad if the staff spoke English and he could tell if an emergency or something was going on and they could not take care of him right away. On July 2, 2012, at 1:50 pm, Resident 17 stated he had complained to the director of nursing about the staff speaking their own language. He stated he even put signs up in his room "English only" but the staff took them down when he went out for an appointment. He stated the staff don't listen even when you complain. Resident 17 stated it was rude, frustrating and he gets tired of hearing the non-English languages every day. On July 3, 2012 at 11:50 am, Resident 23 was heard yelling in a very loud voice, was visably upset with tears in her eyes and her body was trembling while calling for assistance. The resident stated she had been sitting in her diaper for at least thirty minutes waiting for a nurse to change her. The resident stated she had used the same diaper six times (urinated) while waiting for help. Resident 23 stated her diaper was saturated and urine was seeping out every where. Resident 23 stated she needed help now and was tired of being told that someone was coming. Resident 23 informed the surveyor that she was on [MEDICATION NAME] (a diuretic) and sometimes had difficulty holding her urine. On June 29, 2012, at 10:10 am, Resident 23 stated she had a problem with the staff speaking non-English languages. She stated it is a big problem in the facility. Resident 23 stated the CNAs, licensed staff, housekeepers and everybody does it. She stated there have been times when the staff are providing care, another staff comes along, they'll stop what they are doing and they'll start speaking to each other in their language. Resident 23 stated it makes her angry, makes her feel bad and it seems like they are talking about her. Sometimes she asks them what they are talking about, and she usually asks them to stop, but they just ignore her. Resident 23 stated sometimes when she asks for pain medication, the nurses will start speaking to one another in their native language and she has to wait. She stated the language situation interferes with the care she and her roommates are supposed to receive. Resident 23 stated she had a sign on her wall "English only" and someone took it down when she went to the hospital. The resident stated she reads her Bible a lot and continues to pray that the staff will be more respectful and speak English while providing care. On June 29, 2012, at 2:20 pm, during an interview Resident 12 stated she does not like it when the staff speak a different language in front of her. The resident stated she can't understand what they are saying and it makes her uncomfortable. Resident 12 stated it feels like they are talking about her and she doesn't like that. Cross refer to F241 - Dignity And Respect of Individuality

Based on observation, interview and record review the facility's staff failed to provide care for 7 of 24 sample residents (10, 12, 15, 17, 20, 21, 23) in a manner that made them feel dignified and respected as follows: Resident 10 was continent of bowel and bladder function and stated he would prefer to wear underwear, however, the staff had the resident wearing an incontinence pad (adult diaper). Two direct care staff were heard speaking a non-english language while standing at the bedside providing care to Resident 12. Six of the seven residents attending the group meeting and a review of the resident council minutes indicated the residents had on more than one occasion expressed dislike for the staff speaking a language other than english while providing care. Six of seven residents attending the group meeting, and review of the resident council minutes, indicated the residents had on more than one occasion voiced concerns regarding the staff's slow response to the resident's calls for help on the nurse call light system. Resident 15 was observed physically shaking, with tears in her eyes while explaining how angry she felt when the staff spoke non-english languages while providing care for her. Residents 17 and 20 stated they were frustrated and described the staff as insensitive, uncaring, and discriminatory when they spoke non-english languages in front of the residents. Resident 21 expressed feeling embarrassed and ashamed while sitting in a stool saturated incontinent pad (adult diaper) for an extended period of time waiting for the staff to answer the call light. Resident 23 stated she felt very uncomfortable when the staff spoke non- english languages while providing care for her, and feared they were talking about her. The failure of the facility's staff to provide care in a dignified manner, as stated in their policy, created feelings of anger, frustration, disrespect, discomfort, and embarrassment for the residents. Findings: a. On July 3, 2012 at 11:05 a.m., Resident 21 stated she has often had to wait greater than 45 minutes for the staff to answer her call light. She stated the staff will sometimes state her nurse is on a break, or just state someone would be in, but no one came. Resident 21 stated when she was first admitted to the facility she had needed to use incontinence pads (adult diaper), because she had limited mobility and bladder sensation due to having had a stroke. She stated although she had limited mobility and sensation, she was always aware when she had soiled the incontinence pad, and would call for the staff to come change it. Resident 21 related an incident that occurred shortly after her admission to the facility. The nursing staff had administered a laxative to her to relieve constipation, when she felt the laxative begin to take affect she called for assistance using her nurse call light. Resident 21 stated she waited 15 minutes, then called again, but still did not get a response. After waiting another 30 minutes, the resident stated she lost control and had an accident where the liquid stool saturated her clothes and bed. The resident stated by the time the staff came she was extremely uncomfortable and embarrassed. During the same interview, Resident 21 stated she did not like it when the facility staff spoke Spanish or Tagolog while providing care for her because it was rude. A review of Resident 21's admission record indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 21's admission minimum data sets (MDS), a comprehensive assessment and screening tool, dated March 20, 2012, indicated the resident was cognitively intact with a score of 14, (cognitive score of 13-15 indicative of fully intact ability to understand others and make yourself understood at all times). A review of Resident 21's physician's orders [REDACTED]. The orders also indicated the resident's bed side rails were to be up when the resident was in bed, indicating she had to utilize the call light system to get help. A review of the facility's undated Resident Dignity and Privacy policy indicated the facility's definition of resident dignity was the staff would assist the residents to maintain and enhance his or her individual self-esteem and self-worth in all interactions. b. On June 28, 2012 at 10:30 a.m., and again on June 29, 2012, at 2:30 p.m., Resident 15 became visibly upset and angry when asked about the mention of the staff speaking non-english language in the resident care areas. Resident 15's voice was raised, she was shaking and waving her arms around stating, "After you left the shower room they started speaking spanish over my head. I'm sitting there without any clothes on and they are just jabbering away. I know they were talking about me. I'm tired of hearing it. Every day they talk over my head like I'm not even there. I can't even interrupt them to make them listen to me." A review of Resident 15's Admission Record indicated she was admitted to the facility on [DATE]. A review of Resident 15's admission Minimum Data Set (MDS), and assessment and screening tool, dated June 28, 2012, indicated the resident's cognitive score was 15, indicating the resident was fully cognitively intact. The MDS further indicated the resident was dependent on the facility staff for assistance with dressing, toilet use, bed mobility and personal hygiene. A review of the Resident Council Minutes dated June 8, 2012, indicated the residents had expressed a concern regarding staff speaking a language other than the resident's, and a desire for the facility staff to speak english only while providing care. To address the residents' concerns/grievances, the facility conducted an in-service on June 8, 2012, which 31 of the facility's 256 employees attended. During the group meeting on June 28, 2012, at 10:30 a.m., 6 of the 7 alert and oriented residents attending the meeting stated they still hear the facility staff speaking either spanish or tagolog in the hallways and in residents' bedrooms on a daily basis. c. On June 27, 2012, at 1:20 pm, the staff on nursing station II were heard speaking a non-English language in low voices amongst themselves while the surveyor sat at the nursing station. Resident 20 stopped at the nursing station and asked "Why is everyone being so quiet?" On June 27, 2012, at 3:20 pm, Resident 20 stated the staff are loud all of the time. He stated "The staff are always heard yelling at one another and are harder to control than a bunch of pre - school kids." Resident 20 informed the surveyor the staff always speak in their own language at the nursing stations, in the hallways and in the resident rooms while providing care. The resident stated he has complained directly to the staff and the director of nursing more than once. He stated that when you complain to the staff they don't care, and act as if they have a sense of entitlement and act like it's their home. He stated the licensed staff are the worst and on several occasions they have gotten so loud they have awakened him from his sleep. Resident 20 stated he's frustrated and the staff makes him feel bad. He stated he knows the staff doesn't like him and they talk about him in their native language. Resident 20 stated he feels the staff are insensitive to the residents' concerns, needs and desires. On July 2, 2012, at 11:20 am, Resident 20 stated he takes anti - anxiety medication daily and the majority of his anxiety comes from the staff. He stated a good 60 % of his anxiety on any given day could be attributed to the staff's disrespectful behavior. Resident 20 stated the certified nursing assistants (CNA) come into his room talking loud, speaking to each other in their native language and are so disrespectful. He stated the licensed staff are just as bad and are equally disrespectful. Resident 20 stated it makes him feel angry, frustrated and anxious when the staff act how they want and ignore the resident's feelings. Resident 20 stated the staff are out of control and it drives him crazy. A review of the medical record indicated Resident 20 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Anxiety can create feelings of uneasiness and dread, and anxiety is related to situations perceived as uncontrollable or unavoidable.). A resident care plan dated October 17, 2011, addressed the concern of Resident 20's mood and behavior. The nursing interventions included encouraging the resident to express feelings of anger and frustration. However, despite Resident 20 expressing his anger and frustration with the staff's lack of respect, the staff continued to speak their native languages in the presence of the residents. A History and Physical dated October 18, 2011, indicated Resident 20 has the capacity to understand and make decisions. A physicians order dated October 24, 2011, indicated Resident 20 was to receive [MEDICATION NAME] 40 milligrams (mg) daily for depression. An order dated December 5, 2011, indicated Resident 20 was to receive [MEDICATION NAME] 1 mg every twelve hours as needed for anxiety. An order dated January 9, 2012, indicated Resident 20 was also to receive [MEDICATION NAME] 15 mg on a daily basis for anxiety. A Psychoactive/Sedative assessment dated [DATE], indicated Resident 20 was on psychoactive medication for anxiety and depression manifested by constant pacing, restlessness and verbalization of sadness. The interventions included encouraging the resident to verbalize his feelings and to identify and remove any obvious causes of his behaviors. Through interviews with Resident 20 he had expressed his feelings with the staff and identified some of the causes for his anxiety. However, the staff continued to contribute to the resident's feeling of anxiety and depression by continuously being loud and speaking their native languages in the presence of Resident 20. The Minimum Data Set (MDS) assessment dated [DATE], indicated Resident 20 had clear speech, could make himself understood and clearly understood others. The MDS indicated there were no concerns with the resident's cognitive status, mood or behavior. On May 24, 2012, a physicians order was written for Resident 20 to receive trazadone 50 mg every evening for depression. A review of the physicians orders indicated Resident 20 was on a total of three psychoactive medications daily in addition to the as needed medication. d. On June 28, 2012, at 1:40 pm, Resident 17 stated the staff act like they run the facility and will not speak English. He stated the staff discriminate against the residents, are disrespectful and don't care about how the residents feel. Resident 17 stated the staff keep themselves segregated from the residents and others who don't speak their language. He stated the staff are noisy, loud, laughing all the time, talking over each other and making noise all of the time. The resident stated it doesn't matter what time of day it is, it happens on all shifts. He stated there have been times when he was talking to the charge nurse, another staff will come and start speaking their language and they end up ignoring him. Resident 17 stated he has gone to ask the nurse for pain medication and has waited five minutes or more until the staff stop speaking to each other in their language and focus on his needs. He stated it makes him very upset and it feels like they just dismiss whatever it is that he needs to continue talking with each other. Resident 17 stated things might not be so bad if the staff spoke English and he could tell if an emergency or something was going on and they could not take care of him right away. On July 2, 2012, at 1:50 pm, Resident 17 stated he had complained to the director of nursing about the staff speaking their own language. He stated he even put signs up in his room "English only" but the staff took them down when he went out for an appointment. He stated the staff don't listen even when you complain. Resident 17 stated it is rude, frustrating and he gets tired of hearing the non-English languages every day. A review of the medical record indicated Resident 17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A resident care plan dated December 20, 2010, addressed Resident 17's psychosocial status. The nursing interventions included providing the resident with emotional support, encouraging the resident to express his feelings and to use active listening techniques in response. According to the interviews conducted with Resident 17 during the survey, the facility's staff did not provide the emotional support needed, did not use active listening techniques and continued to use non-English languages in the presence of the residents. The Minimum data set (MDS), an assessment and screening tool, dated March 28, 2012, indicated Resident 17 had clear speech, could be understood and understood others. The MDS indicated there were no concerns identified with the resident's cognitive status, mood or behavior. A review of the Interdisciplinary Team Review notes for March and June 2012, indicated Resident 17 had no concerns with the nursing care he was receiving. However, the information documented by the staff contradicted the information provided by the resident during the interviews conducted during the survey as indicated. e1. On July 3, 2012 at 11:50 am, Resident 23 was heard yelling in a very loud voice, was visably upset with tears in her eyes and her body was trembling while calling for assistance. The resident stated she had been sitting in her diaper for at least thirty minutes waiting for a nurse to change her. The resident stated she had used the same diaper six times (urinated) while waiting for help. Resident 23 stated her diaper was saturated and urine was seeping out every where. Resident 23 stated she needed help now and was tired of being told that someone was coming. Resident 23 informed the surveyor that she was on [MEDICATION NAME] (a diuretic) and sometimes had difficulty holding her urine. A review of the medical record indicated Resident 23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Resident Care Plan dated March 13, 2012, addressed Resident 23's toileting needs. The goals included cleaning the resident and keeping the resident dry after each episode of incontinence on a daily basis. The nursing interventions included answering the call light promptly. A review of the Care Area assessment dated [DATE], indicated Resident 23's problem with urinary incontinence was to be care planned to ensure the resident's dignity would be preserved. The Minimum Data Set (MDS), and assessment and screening tool, dated June 26, 2012, indicated Resident 23 had clear speech, could make herself understood and could clearly understand others. The MDS indicated the resident was frequently incontinent of bladder function and required extensive assistance with her toileting needs. On July 3, 2012, at 12 pm, the licensed vocational nurse (LVN) stated the CNA assigned to Resident 23 had gone to lunch earlier and had just returned. LVN 4could not explain why no other staff was avilable to clean the resident while the assigned CNA was at lunch. She agreed the resident should not have had to wait so long for care to be provided. e2. On June 29, 2012, at 10:10 am, Resident 23 stated she had a problem with the staff speaking non-English languages. She stated it is a big problem in the facility. Resident 23 stated the CNAs, licensed staff, housekeepers and everybody does it. She stated there have been times when the staff are providing care, another staff comes along, they'll stop what they are doing and they'll start speaking to each other in their language. Resident 23 stated it makes her angry, makes her feel bad and it seems like they are talking about her. Sometimes she asks them what they are talking about, and she usually asks them to stop, but they just ignore her. Resident 23 stated sometimes when she asks for pain medication, the nurses will start speaking to one another in their native language and she has to wait. She stated the language situation interferes with the care she and her roommates are supposed to receive. Resident 23 stated she had a sign on her wall "English only" and someone took it down when she went to the hospital. The resident stated she reads her Bible a lot and continues to pray that the staff will be more respectful and speak English while providing care. A review of a Psychosocial Information and Assessment sheet dated March 13, 2012, indicated Resident 23 was alert, oriented x3 (to person, place and time), and was verbal in English. A review of the medical record indicated Resident 23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A resident care plan reviewed on June 13, 2012, addressed Resident 23's mood and behavior. The nursing interventions included encouraging the resident to express feelings of anger and frustration. However, the facility's staff failed to encourage or respond to the resident's expressions of anger and frustration due to the staff's continuously speaking non-English languages while providing her care. The MDS dated [DATE], indicated Resident 23 had clear speech, could make herself understood and could clearly understand others. The MDS indicated there were no concerns identified with the resident's cognitive status. f. On June 28, 2012, at 9:50 am, Resident 12 was observed during morning care. CNA 25 and 29 gave the resident a bed bath, however, they were heard speaking a non-English language with one another while providing care to the resident. On June 29, 2012, at 2:20 pm, during an interview Resident 12 stated she does not like it when the staff speak a different language in front of her. The resident stated she can't understand what they are saying and it makes her uncomfortable. Resident 12 stated it feels like they are talking about her and she doesn't like that. A review of the medical record indicated Resident 12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Admission Nurses Notes dated January 25, 2012, indicated Resident 12 was alert and verbally responsive. A History and Physical dated February 7, 2012, indicated Resident 12 had the capacity to understand and make decisions. On June 29, 2012, at 11:05 am, CNA 29 stated it is not okay to speak another language in front of the resident if the resident speaks English. CNA 29 stated the resident may feel like yau are talking about them and they may feel bad. g. On June 27, 2012, at 4:15 pm, Resident 10 was observed sitting on his bed dressed in regular clothing, however, he had a diaper on instead of regular underwear. Resident 10 stated he knows when he has to use the bathroom and had a urinal at his bedside. The resident stated he usuaully uses the urinal and goes to the bathroom. Resident 10 also stated he would prefer to use his own underwear instead of a diaper. Resident 10 stated he does not feel good wearing a diaper, but he guesses it was easier for the staff. With the resident's permission to open his dresser for clothing, two pair of his personal underwear were observed. On July 2, 2012, at 2 pm, Resident 10 stated some staff do say it is okay to use the diaper, but he does not want to. The resident stated he can and does want to use the bathroom. Resident 10 stated it feels terrible to sit in a diaper full of mess and have someone else clean you up, especially if you can do for yourself. A review of the medical record indicated Resident 10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A bowel and bladder assessment dated [DATE], indicated Resident 10 was continent, able to stand up and walk with assistance and required assistance with his toileting. Assessments from August 2011 through May 2012, indicated Resident 10 remained continent of bowel and bladder function. The Interdisciplinary Team Review dated May 3, 2012, indicated Resident 10 remained alert, oriented and able to make his needs known. The Minimum Data Set (MDS), an assessment and screening tool, dated May 8, 2012, indicated Resident 10 felt it was very important to choose what clothing he would wear on a daily basis. The MDS indicated Resident 10 was always continent of urine function and required extensive assistance with his toileting needs. A review of the Care Area assessment dated [DATE], indicated Resident 10's activity of daily living functional status would be care planned to prevent further decline and maintain an optimal functional level. A Resident Care Plan reviewed May 2012, addressed Resident 10 requiring extensive assistance with his toileting needs. The goals included maintianing the resident's current level of functioning if possible and allowing the resident to continue using the toilet without episodes of incontince. However, the all of staff were not trying to attain the same goal for Resident 10 by having him wear a diaper instead of underwear. A review of the Nursing Assistant Flow Sheet May and June 2012, indicated Resident 10 was continent and usually went to the bathroom on the day and evening shift. However, the resident was considered incontinent of bowel function the majority of the time on the night shift. According to the Weekly Progress Notes for June 2012, Resident 10 was considered continent of bowel and bladder function. On July 2, 2012, at 2:30 pm, the registered nurse supervisor (RN 23)stated the resident was continent of bowel and bladder function and should not be wearing a diaper. She stated the staff should encourage the resident to wear his own underwear and to use the bathroom. Cross Refer to F166 - Right to Prompt Efforts To Resolve Grievance