Every finding on record at Whittier Hills Health Care CTR

Based on interview and record review, the facility failed to develop and implement a comprehensive resident specific care plan for one out of three sampled residents (Resident 1) by failing to ensure to implement a care plan for Resident 1, who had a gastrostomy tube (G-tube, a device surgically inserted through the abdominal wall directly into the stomach to provide long-term nutrition, hydration, and medication to individuals unable to eat enough by mouth) and had a behavior of refusing tube feedings. This deficient practice had the potential to result in confusion of resident's care and negatively affect the residents psychosocial wellbeing.Findings:During a review of Resident 1's admission Record (AR), the AR indicated the resident was readmitted on [DATE] with anoxic brain damage (occurs when the brain is completely deprived of oxygen, leading to widespread brain cell death within minutes), expressive language disorder (a communication condition where individuals have difficulty putting thoughts into words, resulting in a limited vocabulary, improper grammar, and trouble forming complex sentences), encounter for attention to gastrostomy (surgical procedure that creates a small opening through the abdominal wall into the stomach). During a review of Resident 1's History and Physical Assessment (H&P) dated 8/15/2026 indicated resident was alert and oriented by name, followed commands, anxious, and non-verbal. During a review of Resident 1's Minimum Data Set (MDS, an assessment and screen tool) dated 3/3/2026, indicated Resident 1's cognition was intact. The MDS indicated resident had unclear speech and had the ability to express ideas and wants and understood verbal content. The MDS indicated Resident 1 had a feeding tube. During a review of Resident 1's Order Summary Report dated 3/4/2024 indicated a physician order was made for Enteral Feed Order every 4 hours Glucerna 1.5 at 237 milliliters (ml, unit of measure) via G-tube bolus ( a single, relatively large dose of a substance administered rapidly into the body to quickly achieve an effective concentration) every 4 hours, 1422 ml total volume, 2136 calories (kcals), 117 grams (g, unit of measure) protein, 1090 ml water. During a review of Resident 1's Medication Administration Record dated 4/2026 to 6/2026 indicated Resident 1 refused her Enteral Feed of Glucerna on the following dates:On 4/1/2026 at 4 [NAME] 4/2/2026 at 12 AM and 4 [NAME] 4/6/2026 at 12 AM and 4 [NAME] 4/29/2026 at 4 [NAME] 5/9/2026 to 5/11/2026 at 12 AM and 4 [NAME] 5/16/2026 to 5/18/2026 at 12 AM and 4 [NAME] 5/21/2026 at 12 AM and 4 [NAME] 6/3/2026 to 6/5/2026 at 12 AM and 4 AM During a review of Resident 1's care plans, no care plan was indicated for resident's refusal of enteral feeding for Glucerna. During a telephone interview on 6/9/2026 at 3:09 PM, Licensed Vocational Nurse (LVN) 1 stated she would usually document on progress notes when Resident 1 refuses her feeding bolus. LVN 1 stated Resident 1 was on monitoring for refusing because it was a common behavior for her and everyone was aware. LVN 1 stated when Resident 1 refuses anything she would document and inform Registered Nurse Supervisor (RNS). During an interview on 6/9/2026 at 2:21 PM, Resident 1 stated that she sometimes refuses her feeding between the hours of 12 AM to 4 AM. During an interview on 6/9/2026 at 3:43 PM, the Director of Nursing (DON) stated she has heard from the staff that Resident 1 wants specific staff assigned to her and refuses care. The DON stated when a resident refuses any care she expects her staff to document when they are refusing care, try using different staff, attempting to provide care multiple times, and to update the care plan. The DON stated she also expects her staff to notify the resident's family/responsible party and the Physician. During a concurrent interview and record review of Resident 1's care plans on 6/9/2026 at 3:48 PM, the DON confirmed no care plan was created for Resident 1's refusal of enteral feeding. The DON stated it was important to have a care plan for Resident 1's refusal of tube feeding to make sure staff knows the plan of care of resident's history of refusing. The DON stated if the interventions are not working the staff can try different interventions and add more interventions to the care plan. A review of the facility's policy and procedure (P&P) titled Comprehensive Resident Centered Care Plan dated 12/2023 indicated the resident has the right to refuse or discontinue treatment. The P&P indicated in the event that a resident refuses certain services posing a risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternate means to address risk.

Based on observation, interview, and record review, the facility failed to properly manage and document medications for two of five sampled residents (Resident 1 and Resident 2) by failing to: 1.Document Resident 1's meropenem (intravenous [IV- into the vein] medication used to treat severe bacterial infections) dose on 4/13/2026 and 4/15/2026 at 10 PM. 2. Properly manage Resident 1's medications when three white pills were observed in a medicine cup on the resident's bedside table. 3. Assess Resident 1's ability to safely manage the residents' medications. 4. Document Resident 2's Zosyn (IV medication used to treat severe bacterial infections) dose on 4/15/2026 at 10 PM. This deficient practice placed Resident 1 and Resident 2 at risk for medication errors, including missed, duplicated, or incorrect doses, potential adverse drug reactions, and unsafe medication use.Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses that included cellulitis (potentially serious bacterial infection of the deeper layers of the skin and the tissue beneath) of corpus cavernosum (two sponge-like columns of tissue running along the shaft of the penis) and penis, specified polyneuropathies (a condition where many nerves outside the brain and spinal cord were damaged, causing widespread numbness, tingling, burning pain, and muscle weakness) and functional quadriplegia (complete immobility where a person could not move their arms or legs due to severe frailty or advanced disease, rather than a direct spinal cord injury). During a review of Resident 1's Initial admission Record dated 8/25/2025 at 10:13 PM, the Initial admission Record indicated the resident did not desire to self-administer drugs. The Initial admission Record indicated if the resident said yes a Self-administration of Medications IDT Determination Evaluation would have been triggered. During a review of Resident 1's History and Physical (H&P) dated 9/12/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 1's Physician's Order dated 10/9/2025 at 7:07 PM, the Physician's Order indicated for the resident to have methocarbamol (a prescription muscle relaxer used for short-term relief of acute muscle pain, spasms [a sudden, involuntary (uncontrollable) tightening or contraction of a muscle], strains, or sprains) oral tablet 500 milligram (mg, unit of measurement), give one tablet by mouth three times a day for spasms. During a review of Resident 1's Physician's Order dated 10/9/2025 at 9:58 PM, the Physician's Order indicated for the resident to have gabapentin (a prescription medication primarily used to treat neuropathic pain [nerve pain]) oral tablet 800 mg, give one tablet by mouth every six hours for neuropathy. Per nurse practitioner (NP, a registered nurse with advanced graduate education who provided high-quality primary, acute, and specialty care), okay to take together with Norco (prescription medication combining a strong opioid pain reliever [hydrocodone] and a common pain reliever [acetaminophen/Tylenol] used to treat moderate to severe pain) every six hours per resident's request. Hold if resident was sedated (being in a very calm, relaxed, or sleepy state caused by medication) or respiratory rate (RR, the number of breaths a person took per minute, usually measured at rest by counting how many times the chest rose). During a review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 1/16/2026, the MDS indicated the resident's cognition was intact (sufficient judgement and self-control to manage the normal demands of the environment). The MDS indicated the resident's active diagnoses included cellulitis of corpus cavernosum and penis, specified polyneuropathies, and functional quadriplegia. During a review of Resident 1's Physician's Order dated 3/25/2026 at 1:48 PM, the Physician's Order indicated for the resident to have hydrocodone-acetaminophen oral tablet 10-325 mg, give one tablet by mouth every six hours for moderate to severe pain, pain level 4-10. During a review of Resident 1's Physician's Order dated 4/8/2026 at 4:35 PM, the Physician's Order indicated for the resident to have meropenem IV reconstituted (the process of adding a liquid [diluent] to a powered medication to turn the medication into a usable liquid solution for IV injection) 500 milligrams (mg- a unit of measurement). Use 500 mg intravenously every eight hours for positive Escherichia coli (E. coli, bacteria commonly found in the intestines of humans and animals) and extended-spectrum beta-lactamases (ESBL, enzymes produced by bacteria that make them resistant to many common antibiotics) to sacrococcyx wound (a pressure sore [bedsore] located on the tailbone or lower spine) for 10 days. During a review of Resident 1's IV Medication Administration Record (MAR) dated 4/1/2026 to 4/30/2026, the IV MAR indicated there was no documentation that the resident received meropenem on 4/13/2026 and 4/15/2026's 10 PM dose. During a concurrent observation and interview in Resident 1's room on 4/16/2026 at 12:40 PM, a medicine cup with three white pills were observed on the resident's bedside table. Resident 1 stated he knew what each pill was taken for; gabapentin for my nerves, Norco for my pain, and the other one was to relax my muscles. Resident 1 stated the three pills were his afternoon medications and were left on his bedside table because he was on the phone and asked the nurse to leave them there. During an interview on 4/16/2026 at 12:54 PM, Licensed Vocational Nurse (LVN) 1 stated when passing medications, the facility staff would need to wait until the residents took their medications completely and should not have left any medication at the resident's bedside before leaving their room. LVN 1 stated the facility staff needed to ensure the resident took the medication properly and if the facility staff left before the resident took the medication the resident might not have taken the medication or the medication could have been taken by another resident and that would not have been okay. During an interview on 4/16/2026 at 3:09 PM, Registered Nurse Supervisor (RNS) stated when providing IV medications, the facility staff should have documented the medication that was given after administration otherwise that would have meant the medication was not given. RNS stated if there was no documentation, that could have meant the resident missed the medication and infections required a certain level of antibiotics in their body to fight the infection and without the antibiotic the resident's body was not able to fight at the limit that was expected because the resident was underdosed. During a continued interview on 4/16/2026 at 3:09 PM, RNS stated she was unsure if she documented Resident 1's 10 PM meropenem dose for 4/15/2026 but should have been documented to prove the medication was given. During an interview on 4/16/2026 at 3:47 PM, Director of Nursing (DON) stated facility staff should have been documenting once a medication was given to know the medication was actually given and the resident's records were accurate. The DON stated if there was no documentation the medication was given, this could have been implied that the medication was missed. During a concurrent interview and record review of Resident 1's IV MAR on 4/16/2026 at 4:04 PM, the DON stated there was no documentation for the resident's meropenem on 4/13/2026 and 4/15/2026 at 10 PM but there should have been. The DON stated without documentation, this implied that the medication was not given and must be investigated. During an interview on 4/16/2026 at 4:07 PM, the DON stated the process for medication pass was to pour, pass, and sign and follow the six rights of medication administration (right resident, right medication, right dose, right route, right time, and right documentation). The DON stated medication should never have been left at the bedside and the facility staff should have made sure the resident took the medication before leaving the resident's room otherwise the resident might not have taken the medication or someone else could have taken the medication. During a continued interview on 4/16/2026 at 4:07 PM, the DON stated facility staff should not have been documenting medications were administered before the resident actually took the medication because the facility staff would be saying the resident already took the medication when they did not and that was not the facility's process. During a concurrent interview and record review of Resident 1's Initial admission Record on 4/16/2026 at 4:15 PM, the DON stated the resident was not interested in taking his own medications therefore should not have been taking the medications on his own and the facility staff should have been watching him take his medications. The DON stated that without a proper evaluation done, Resident 1 might have forgotten to take the medication or someone else could have taken the medication if the medication was left at the bedside. 2. During a review of Resident 2's AR, the AR indicated the resident was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (DM, chronic metabolic disease that occurred when the body did not produce enough insulin or could not use insulin properly), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and chronic kidney disease (when the kidneys were damaged and could not filter blood the way they should have). During a review of Resident 2's H&P dated 6/12/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated the resident's cognition was intact. The MDS indicated the resident's active diagnoses included type 2 DM, Parkinson's disease, and renal insufficiency (occurred when kidneys could not long adequately filter waste, toxins, and excess fluids from the blood), renal failure, or end-stage renal disease (ESRD, permanent kidney failure where kidneys could no longer filter waste or mange fluids well enough for survival). During a review of Resident 2's Physician's Order dated 4/10/2026 at 6:06 PM, the Physician's Order indicated for the resident to have Zosyn IV solution 3-0.375 gram (gm, a metric unit of weight and mass)/50 milliliters (ml, a metric unit used to measure small amounts of liquid volume), use 3.375 gm intravenously every eight hours for wound infection for seven days. During a review of Resident 2's IV MAR dated 4/1/2026 to 4/30/2026, the IV MAR indicated there was no documentation that the resident received Zosyn on 4/15/2026's 10 PM dose. During an interview on 4/16/2026 at 3:09 PM, RNS stated she was unsure if she documented Resident 2's 10 PM Zosyn dose for 4/15/2026 but should have been documented to prove the medication was given. During a concurrent interview and record review of Resident 2's IV MAR on 4/16/2026 at 4:05 PM, the DON stated there was no documentation for the resident's Zosyn on 4/15/2026 at 10 PM but there should have been. The DON stated without documentation, this implied that the medication was not given and must be investigated. During a review of the facility's undated policy and procedure (P&P) titled Self-Administration of Medications, the P&P indicated, Each resident will be informed of his/her right to self-administer medications. The Interdisciplinary Team will assess and determine if the practice is safe. Medications to be self-administered are specifically ordered and monitored by the facility nursing staff. Such orders will be periodically reassessed to assure that they may still be given safely. The P&P indicated If the resident requests to self-administer drugs the ID team will determine if the practice is safe before the resident may exercise this right. The Physician's Orders for such drugs will be clarified to include: May keep at bedside. The P&P indicated, Storage of non-legend drugs at the bedside shall meet the following conditions: The manner of storage shall prevent access by the other residents; lockable drawers or cabinets need to be used unless alternate procedures, including storage on a resident's person or in a lock drawer or cabinet are ineffective; the facility shall record in the resident's health record the bedside medications used by the resident, based on observation by the nursing staff and/or information supplied by the resident; the quantity of each drug supplied to the resident for bedside storage shall be recorded in the health record each time the drug is so supplied. During a review of the undated P&P titled, Specific Medication Administration Procedures, the P&P indicated for General Procedures to Follow for All Medications: After administration, return to card and document administration in Medication Administration Record (MAR); these guidelines refer to all medications. The P&P indicated for Oral Medication Administration Procedure: Pour the correct number of tablets or capsules into the medication cup. Administer medication and remain with resident while medication is swallowed. After administration, return to cart and document administration in Medication Administration Record (MAR). During a review of the facility's P&P titled Six Rights of Medication Administration revised May 2019, the P&P indicated The six rights of medication administration are as follows in order to ensure safety and accuracy of administration. 1. Right Resident - Resident is identified prior to medication administration. 2. Right Time - Medications are administered within prescribed time frames. 3. Right Medication order - Medications are checked against the order before they are given. 4. Right Dose - Medications are administered according to the dose prescribed. 5. Right Route - Medications are administered according to the route prescribed. 6. Right Documentation - Document administration or refusal of the medication after the administration or attempt.

Based on interview and record review, the facility failed to provide and explain the process for obtaining a copy of resident's medical records upon request for one of two sampled residents (Resident 1) in accordance with the facility's policy and procedure titled Protected Health Information (information in the medical record that can be used to identify an individual). This deficient practice resulted in violation of Resident 1's and Responsible Party's (RP 1) right to obtain a copy of the resident medical records, in accordance with facility policy.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus ( in which your blood glucose, or blood sugar, levels are too high), dementia (diseases that affect memory, thinking, and the ability to perform daily activities). During a review of Resident 1's Interdisciplinary Team- (IDT) Care plan review with effective date 2/10/2026 authored by Social Service Assistant (SSA) and attended by Registered Nurse (RN) 1, Rehabilitation Staff (RS) 1 and Activity Director (AD), an IDT conference was conducted. The care plan review also listed Resident 1 and RP 1 as attendees. The IDT record did not include topics that were discussed during the IDT care plan review with the IDT and Resident 1's RP. The IDT record was not signed and dated by the SSA who authored the IDT care plan review. During an interview on 3/26/2026 at 1:15 PM with Resident 1's RP 1, RP 1 stated she had requested an IDT meeting in February 2026 to request Resident 1's medical records. RP 1 stated SSA told her during the meeting she would take care of the request. RP 1 stated after weeks of waiting for the records she called to follow up with SSA, but the facility receptionist would just tell her the SSA was unavailable and would not get anyone else to assist her. RP 1 stated after more attempts to speak to the SSA, RP 1 was eventually transferred to Medical Records Director (MRD) who informed RP 1 that MRD was not aware of her request from February 2026 and that she needed to fill out a form for the request. RP 1 stated she was not informed by the SSA when she made her initial request during the IDT meeting in February 2026. During an interview with MRD on 3/26/2026 at 2:20 PM, MRD stated a few days ago she received a phone call from RP 1 asking why she had not received Resident 1's medical records she had previously requested. MRD stated she had not received or informed that a request from RP 1 was communicated to the SSA. MRD stated she explained to RP 1 that she needs to come in and fill out a request form. MRD stated SSA no longer worked in the facility and had not communicated to her that RP 1 had requested Resident 1's medical records during their IDT meeting in February 2026. MRD stated if she had known she would have contacted RP 1 and explained the facility process to acquire the medical records. During an interview on 3/26/2026 at 2: 42 PM with the AD, the AD stated she was present during Resident 1's IDT care plan review on 2/10/2026 and remembered Resident 1's RP asking SSA for Resident 1's medical records. The AD stated she remembered SSA stating she would get the records for RP 1. During a review of the facility's policy and procedure (P&P) titled Protected Health Information with a revision date of 11/2024 indicated, 7. A resident may have access to his or her records within twenty-four (24) hours (excluding weekends or holidays) of the resident's written or oral request.

Based on interview and record review, the facility failed to ensure an Advance Directives (AD-a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were obtained and accessible in residents medical records for four of four sampled residents (Residents 1, 8, 16, 35, 95 and 201). This deficient practice had the potential for residents' medical treatment provisions to not be carried out, according to the resident's request during emergency situations and/or when a resident was incapacitated (the clinical state in which a patient is unable to participate in a meaningful way in medical decisions). Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated was readmitted to the facility on [DATE] with a diagnosis of encephalopathy (disease that affects the brain) and dementia (progressive brain disorder that impaired reasoning, memory and thinking). During a review of Resident 1's History and Physical (H&P) signed and dated [DATE], indicated that Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated [DATE], had a severely impaired cognition (thinking). 2. During a review of Resident 8's AR, the AR indicated Resident 8 was readmitted to the facility on [DATE] with a diagnosis of dementia and metabolic encephalopathy. During a review of Resident 8's H&P signed and dated on [DATE], indicated that Resident 8 did not have capacity to understand and make decisions. 3.During a review of Resident 8's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognition. During a review of Resident 16's AR, the AR indicated Resident 16 was admitted to the facility on [DATE] with a diagnosis of hypertension (HTN – high blood pressure) and depression (feeling severe sadness and hopelessness). During a review of Resident 16's H&P signed and dated on [DATE], indicated that Resident 16 can make needs known but cannot make medical decisions. During a review of Resident 16's MDS dated [DATE], the MDS indicated the resident had a moderately impaired cognition. 4. During a review of Resident 95's AR, the AR indicated Resident 95 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus (DM – high blood sugar) and HTN. During a review of Resident 95's H&P signed and dated on [DATE], indicated that Resident 95 had the capacity to make decisions. During a review of Resident 95's MDS dated [DATE], the MDS indicated the resident had a moderately impaired cognition. During a concurrent interview and record review with the Social Services Designee (SSD) on [DATE] at 3:50 PM, it was identified that Resident's 1, 8, 16 & 95 electronic medical chart did not have the advance directive notification form. SSD stated that her initial assessment note indicated the advance directive notification form was located in Resident 1, 8, 16 & 95 hard chart. During a concurrent interview and record review with the SSD on [DATE] at 4 PM, it was identified that Resident's 1, 8, 16, & 95 hard chart did not have the advance directive notification form. SSD stated that maintaining the AD notification form ensures compliance with the federal law, protects resident's rights and provides documentation that the resident or responsible party was properly informed of their medical care. A review of the facility's P&P titled Advance Directives and Associated Documentation revised 4/2025, indicated the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. The facility recognizes and respects the resident's right to choose their treatment and make decisions about care to be received at the end of their life. The P&P indicated that the policy of this facility to implement the resident decisions and directives that are in compliant with State and/or Federal Law and the policies of this facility. The P&P indicated that the AD is written instruction that relates to the provision of health care when the individual is incapacitated, such as a Living Will, Durable Power of Attorney for Health Care or the Natural Death Act and these documents allow the individual to identify choices related to their medical treatment or designate someone to make treatment choices for them should they lose decision making capacity for themselves. 5. During a review of Resident 135's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included acute on chronic systolic (congestive) heart failure (chronic condition where the heart cannot pump blood efficiently, causing blood to back up and fluid to build up in the lungs, legs, and body), cellulitis (spreading skin infection) of right lower limb, and muscle weakness. During a review of Resident 135's History and Physical (H&P), dated [DATE], the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 135's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated [DATE], the MDS indicated the resident had intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 135's Social Services Assessment/Evaluation dated [DATE] indicated Resident 135 had an Advance Health Care Directive in place. During a review of Resident 135's Physician Orders for Life Sustaining Treatment (POLST, a form that contains written medical orders for healthcare professionals regarding specific medical treatment that can or cannot be done at the end-of-life) dated [DATE], the POLST indicated the resident did not have an Advance Directive. The POLST indicated Resident 135 was a full code (a patient wants all available life-saving measures—including CPR, defibrillation, intubation, and mechanical ventilation—performed if their breathing or heart stops). During a concurrent interview and record review of Resident 135's medical chart on [DATE] at 3:21 PM, the Medical Records Director (MRD) confirmed there was no advance directive in Resident 135's chart. MRD stated if the advance directive should be in the chart. During a concurrent interview and record review of Resident 135's Social Services Assessment/Evaluation and POLST on [DATE] at 3:42 PM, the Social Services Director (SSD) stated Resident 135's assessment indicates resident has an advance directive. SSD could not find an advance directive on the electronic medical record. SSD stated the advance directive should be in the chart so that it will be easily accessible to facility staff. SSD stated she did not know why the Social Services Assistant (SSA) 1 would document there was an advance directive. SSD stated she would be checking SSA 1's work from now on. The SSD stated the importance of having the Advance Directive in the chart was to know what the resident wishes are and how to provide the care to them in case of an emergency. 6. During a review of Resident 201's AR, the AR indicated the resident was admitted on [DATE] with diagnoses that included Chronic obstructive pulmonary disease (COPD, lung and airway diseases that restrict your breathing) with acute exacerbation, hypertension (high blood pressure), and difficulty in walking. During a review of Resident 201's History and Physical (H&P), dated [DATE], the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 201's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognition. During a review of Resident 201's Social Services Assessment/Evaluation dated [DATE] indicated Resident 201 had an Advance Health Care Directive in place. During a review of Resident 201's POLST dated [DATE], the POLST indicated the resident did not have an Advance Directive. The POLST indicated Resident 201 is a DNR (Do not resuscitate) with selective treatment described as comfort focused treatment with hospitalization only if needs cannot be met in current location. During a concurrent interview and record review of Resident 201's medical chart on [DATE] at 3:23 PM, Admissions Coordinator (AC) stated the advance directive is usually found in the chart behind the POLST. AC stated when he interviewed the resident's representative for the POLST there was no advance directive at the time. AC stated the advance directive fulfills the resident's and family's wishes and should be in the physical chart. During a concurrent interview and record review of Resident 201's Social Services Assessment/Evaluation and POLST on [DATE] at 3:36 PM, the SSD stated Resident 201's assessment indicates resident has an advance directive. SSD confirmed and could not find an advance directive on the electronic medical record. SSD stated the advance directive should be uploaded on the electronic medical record if they have one. During a concurrent interview and record review of Resident 201's Social Services Assessment/Evaluation on [DATE] at 4:18 PM, SSA 1 stated it was an honest mistake that she selected Resident 201 had an advance directive. SSA 1 stated she believes Resident 201 was probably confused with the POLST and Advance Directive at the time. SSA 1 stated she should have followed up with AA to make sure both the POLST and Social Services Assessment matched. During an interview on [DATE] at 5:09 PM, the Director of Nursing (DON) stated the Advance directive should be in the resident's chart to indicate their wishes in the case of an emergency. A review of the facility's policy and procedure (P&P) titled Advance Directives and Associated Documentation dated 4/2025 indicated to obtain copy of the advance directive and conservatorship/guardianship documents and place in the resident health record.

Based on observation, interview, and record review, the facility failed to accurately assess functional limitation in range of motion (limited ability to move a joint that interferes with daily functioning or places a resident at risk for injury) for three of four sampled residents (Resident 8, 12, and 49) reviewed for limited range of motion ([ROM] full movement potential of a joint) during their Minimum Data Set ([MDS] a federally mandated resident assessment tool) assessments. Specifically, (1) Resident 8's MDS assessments dated 10/15/2025 and 1/19/2026; (2) Resident 12's MDS assessments dated 10/16/2025 and 1/16/2026; and (3) Resident 49's MDS assessments dated 10/8/2025 and 1/8/2026 were inaccurately completed. These failures had the potential to affect the provision of Resident 8, 12, and 49's care, including the provision of activities of daily living ([ADLs] basic tasks that individuals perform to maintain their daily lives and independence) and ROM exercises, and provided inaccurate information to the Federal database. Findings: 1. During a review of Resident 8's Face Sheet (summary of a resident's information), the Face Sheet indicated the facility originally admitted Resident 8 on 10/10/2025 and readmitted on [DATE]. Resident 8's Face Sheet indicated Resident 8's diagnoses included dysphagia (difficulty swallowing) following a cerebral infarction (brain damage due to a loss of oxygen to the area), lack of coordination, and metabolic encephalopathy (disease that affects the brain, causing changes in its function). During a review of Resident 8's MDS, dated [DATE], the MDS indicated that Resident 8's arms and legs had no functional limitation in ROM. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 had clear speech, expressed ideas and wants, usually understood verbal content, and had intact cognition (clear ability to think, understand, learn, and remember). The MDS indicated Resident 8 required partial/moderate assistance (helper does less than half the effort) for eating and dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for toileting, showering, dressing, rolling to either side in bed, and transferring from lying to sitting on the side of the bed. The MDS indicated that Resident 8's arms and legs had no functional limitation in ROM. During a review of Resident 8's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 1/19/2026, the OT Evaluation indicated Resident 8 had within functional limits ([WFL] sufficient joint movement without significant limitation) ROM in the right arm and the left elbow. The OT Evaluation indicated Resident 8 had impaired ROM in the left shoulder, wrist and hand. During a review of Resident 8's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 1/19/2026, the PT Evaluation indicated Resident 8 had WFL ROM in both legs. The PT Evaluation indicated Resident 8 was dependent for rolling to either side in bed and transferring from lying to sitting on the side of the bed. During a review of Resident 8's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated recommendations for a Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) program. OT Discharge Summary indicated Resident 8's RNA program included ROM exercises to both arms, three times per week as tolerated. During a review of Resident 8's PT Discharge summary, dated [DATE], the PT Discharge Summary did not include RNA for ROM exercises. During a review of Resident 8's physician's orders, dated 1/30/2026, the physician's orders indicated RNA for ROM exercises to both arms, three times per week as tolerated. During a concurrent observation and interview on 2/25/2026 at 8:16 a.m. with Restorative Nursing Aide 1 (RNA 1) in the resident's room, Resident 8's RNA session was observed. Resident 8 was observed lying in bed and moving the right arm without any assistance. Resident 8's left arm was observed in complete elbow extension (straightened), wrist extension (bent upward), and the left-hand fingers positioned in a closed fist. RNA 1 was observed to physically move Resident 8's left arm for ROM exercises at the shoulder, elbow, wrist, and hand joints. RNA 1 was observed placing a rolled towel in Resident 8's left hand. Resident 8 was observed asleep while RNA 1 provided ROM exercises on Resident 8's right arm. RNA 1 stated Resident 8 usually moves the right arm when Resident 8 was more awake but doesn't move that one (the left arm) at all. During a follow-up interview on 2/25/2026 at 8:45 a.m. with RNA 1, RNA 1 stated Resident 8 received ROM exercises to both arms. RNA 1 stated Resident 8 cannot move or assist with ROM exercises on the left arm. RNA 1 stated the rolled towel was placed in Resident 8's left hand to help open the fingers. RNA 1 stated Resident 8 did not have any ROM exercises for both legs. During an interview on 2/25/2026 at 11:46 a.m. with Physical Therapist 1 (PT 1), PT 1 stated Resident 8 should have received RNA for ROM exercises on both legs, especially the left leg which was weak. During an interview on 2/26/2026 at 12:06 p.m. with the MDS Nurse 1 (MDSN 1), MDSN 1 stated the MDS (in general) was an assessment to determine the care provided to the residents. MDSN 1 stated the MDS should be accurate to ensure residents were receiving the correct care. MDSN 1 stated the MDS included information gathered from the resident's clinical records, discussions with the residents and their family, and observations of the resident. MDSN 1 stated each resident's MDS was transmitted to the Federal database upon completion. During a review of Page GG-5 of the Resident Assessment Instrument ([RAI] full resident assessment which includes the MDS) User Manual, revised 10/1/2025, the RAI User Manual defined functional limitation in ROM as Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk for injury. During a concurrent interview and record review on 2/26/2026 at 12:30 p.m. with the MDSN 1 and MDS Nurse 2 (MDSN 2), Resident 8's MDS assessments, dated 10/15/2025 and 1/19/2026, and the RAI User Manual, revised 10/2025, were reviewed for functional limitation in ROM. MDSN 1 stated Resident 8's diagnoses included cerebral vascular accident ([CVA] stroke, loss of blood flow to a part of the brain), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and difficulty with coordination. MDSN 1 stated hemiplegia could result in weakness of one side of the body. MDSN 2 stated Resident 8's MDS assessments indicated Resident 8 had no functional limitation in ROM to both arms and legs. MDSN 2 reviewed the RAI User Manual's definition of functional limitation in ROM. MDSN 2 stated she did not know the definition of functional limitation in ROM as indicated in the RAI User Manual. MDSN 2 stated Resident 8's MDS assessments, dated 10/15/2025 and 1/19/2026, were inaccurate and should have indicated Resident 8 had functional limitation in ROM on one arm and one leg. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment and Associated Processes, revised 4/2025, the P&P indicated that the resident assessment will be comprehensive and accurate to develop, review, and revise the resident's comprehensive care plan. The P&P indicated Each individual who completes a portion of the assessment will electronically sign and certify the accuracy of that portion of the assessment. 2. During a review of Resident 12's Face Sheet, the Face Sheet indicated the facility admitted Resident 12 on 8/25/2025 and readmitted on [DATE]. The Face Sheet indicated Resident 12's diagnoses included malignant neoplasm (cancerous tissue growth) of the spinal cord and functional quadriplegia (paralysis from the neck down, including arms and legs, usually due to a spinal cord injury). During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's arms and legs had no functional limitation in ROM. During a review of Resident 12's OT Evaluation and Plan of Treatment, dated 10/10/2025, the OT Evaluation indicated Resident 12 had WFL active range of motion ([AROM] performance of an exercise to move a joint without any assistance or effort of another person) in the right arm and WFL AROM in the left elbow, wrist, and hand. The OT Evaluation indicated Resident 12's passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) in the left shoulder was limited to 0-90 degrees (unit of joint measurement) for shoulder flexion (lifting the arm overhead, normal 0-180 degrees) and shoulder abduction (lifting the arm upward and away from the body, normal 0-180 degrees) due to pain. During a review of Resident 12's PT Evaluation and Plan of Treatment, dated 10/10/2025, the PT Evaluation indicated Resident 12 had WFL ROM and impaired strength in both legs. During a review of Resident 12's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated recommendations for RNA to provide PROM exercises to both legs, three times per week as tolerated. During a review of Resident 12's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated recommendations for RNA to provide AROM to both arms and active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to the left shoulder, five times per week as tolerated. During a review of Resident 12's physician's orders, dated 12/1/2025, the physician's order indicated RNA for AROM to both arms and AAROM to the left shoulder, five times per week as tolerated. Another physician's order, dated 12/1/2025, indicated RNA for PROM exercises to both of Resident 12's legs, three times per week as tolerated. During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12 had clear speech, expressed ideas and wants, understood verbal contents, and had intact cognition. The MDS indicated Resident 12 required setup or clean-up assistance (helper sets up or cleans up while resident completes the activity, helper assists only prior to or following the activity) for eating, personal hygiene, and oral hygiene. The MDS indicated Resident 12 was dependent for toileting, bathing, lower body dressing, rolling to either side in bed, transferring from lying to sitting on the side of the bed, and transferring from bed/chair-to-chair. The MDS indicated Resident 12's arms and legs had no functional limitation in ROM. During a concurrent observation and interview on 2/24/2026 at 2:34 p.m. with Restorative Nursing Aide 3 (RNA 3) in the resident's room, Resident 12's RNA session was observed. Resident 12 was alert and awake. Resident 12 stated RNA 3 has been providing ROM due to Resident 12's inability to feel and move both legs. RNA 3 was observed providing PROM to both legs at the hip, knee, and ankle joints. RNA 3 was observed performing ROM exercises on Resident 12's left shoulder, elbow, wrist and hand. Resident 12 was observed following RNA 3's verbal cues for AROM exercises on the right shoulder, elbow, wrist, and hand. During an interview on 2/24/2025 at 3:27 p.m. with RNA 3, RNA 3 stated Resident 12 received PROM to both legs due to Resident 12's inability to move either leg. RNA 3 stated Resident 12 received AAROM to the left arm and performed AROM on the right arm. During an interview on 2/26/2026 at 12:06 p.m. with MDSN 1, MDSN 1 stated the MDS (in general) was an assessment to determine the care provided to the residents. MDSN 1 stated the MDS should be accurate to ensure residents were receiving the correct care. MDSN 1 stated the MDS included information gathered from the resident's clinical records, discussions with the residents and their family, and observations of the resident. MDSN 1 stated each resident's MDS was transmitted to the Federal database upon completion. During a review of Page GG-5 of the RAI User Manual, revised 10/1/2025, the RAI User Manual defined functional limitation in ROM as Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk for injury. During a concurrent interview and record review on 2/26/2026 at 12:30 p.m. with the MDSN 1 and MDSN 2, the RAI User Manual's definition of functional limitation in ROM was reviewed. MDSN 2 stated she did not know the definition of functional limitation in ROM as indicated in the RAI User Manual. During a concurrent interview and record review on 2/26/2026 at 12:56 p.m. with the MDSN 1 and MDN 2, Resident 12's MDS assessments, dated 10/16/2025 and 1/16/2026, were reviewed. MDSN 1 stated Resident 12's MDS assessments indicated Resident 12's arms and legs had no functional limitation in ROM. MDSN 1 stated Resident 12's MDS assessments were inaccurate because MDSN 1 did not know the RAI User Manual's definition of functional limitation in ROM. MDSN 1 stated Resident 12's MDS assessments should have indicated Resident 12 had functional limitation in ROM on one arm and both legs. During a review of the facility's P&P titled, Resident Assessment and Associated Processes, revised 4/2025, the P&P indicated that the resident assessment will be comprehensive and accurate to develop, review, and revise the resident's comprehensive care plan. The P&P indicated Each individual who completes a portion of the assessment will electronically sign and certify the accuracy of that portion of the assessment. 3. During a review of Resident 49's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 49 on 7/2/2023 and readmitted on [DATE]. The Face Sheet indicated Resident 49's diagnoses included the presence of a left artificial knee joint, infection of the left artificial knee joint, and muscle weakness. During a review of Resident 49's OT Evaluation and Plan of Treatment, dated 9/5/2025, the OT Evaluation indicated Resident 49 had WFL AROM in both arms. During a review of Resident 49's PT Evaluation and Plan of Treatment, dated 9/5/2025, the PT Evaluation indicated Resident 49 had a history of multiple left knee surgeries including a fusion (surgical procedure that joints the thigh bone and the shinbone to avoid any rotation and movement in the knee) of the left knee in 5/2025. The PT Evaluation indicated Resident 49 was found to have a midshaft fracture of the tibia (break in the central, narrowest portion of the shinbone) in the left leg which was immobilized with a cast. The PT Evaluation indicated Resident 49 had within normal limits ([WNL] normal joint movement) ROM in the right leg and the left hip. The PT Evaluation indicated Resident 49's left knee and ankle ROM were not assessed due to the presence of a cast. During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49's arms and legs had no functional limitation in ROM. During a review of Resident 49's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated recommendations for RNA to provide AROM to both arms, five times per week as tolerated. During a review of Resident 49's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated recommendations for RNA to provide AROM exercises to the right leg and the left hip, three times per week as tolerated. During a review of Resident 49's physician's orders, dated 12/1/2025, the physician's orders indicated RNA for AROM to both arms, five times per week as tolerated. Another physician's order, dated 12/31/2025, indicated RNA for AROM exercises to Resident 49's right leg and left hip, five times per week as tolerated. During a review of Resident 49's MDS, dated [DATE], the MDS indicated Resident 49 had clear speech, had difficulty communicating some words, usually understood verbal content, and had severely impaired cognition. The MDS indicated Resident 49 was independent with eating, oral hygiene, personal hygiene, upper body dressing, and rolling to either side in bed. The MDS indicated Resident 49 required supervision or touching assistance (helper provides verbal cues and/or touching and/or steadying assistance as resident completes the activity) for lower body dressing and transferring from lying to sitting on the side of the bed. The MDS indicated Resident 49 required substantial/maximal assistance (helper does more than half the effort) for toileting and transferring from the bed/chair-to-chair. The MDS indicated Resident 49's arms and legs had no functional limitation in ROM. During an observation on 2/24/2026 at 2:04 p.m. with Restorative Nursing Aide 2 (RNA 2) in the resident's room, Resident 49's RNA session was observed. Resident 49 was observed awake, alert, and lying in bed with the head-of-bed elevated. Resident 49 was observed to follow RNA 2 demonstration and verbal cues for ROM exercises while Resident 49 performed AROM exercises to both shoulders, elbows, wrists, and hand joints. Resident 49 was observed with a cast on the left leg from the knee to the foot, exposing the left toes. Resident 49 was observed to follow RNA 2's verbal cues to perform AROM exercises to the right leg and the left hip. During an interview on 2/24/2026 at 2:17 p.m. with RNA 2, RNA 2 stated Resident 49 performed AROM of both arms, the right leg, and the left hip. During an interview on 2/26/2026 at 12:06 p.m. with MDSN 1, MDSN 1 stated the MDS (in general) was an assessment to determine the care provided to the residents. MDSN 1 stated the MDS should be accurate to ensure residents were receiving the correct care. MDSN 1 stated the MDS included information gathered from the resident's clinical records, discussions with the residents and their family, and observations of the resident. MDSN 1 stated each resident's MDS was transmitted to the Federal database upon completion. During a review of Page GG-5 of the RAI User Manual, revised 10/1/2025, the RAI User Manual defined functional limitation in ROM as Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk for injury. During a concurrent interview and record review on 2/26/2026 at 12:30 p.m. with the MDSN 1 and MDSN 2, the RAI User Manual's definition of functional limitation in ROM was reviewed. MDSN 2 stated she did not know the definition of functional limitation in ROM as indicated in the RAI User Manual. During a concurrent interview and record review on 2/26/2026 at 12:53 p.m. with MDSN 1 and MDSN 2, Resident 49's MDS assessments, dated 10/8/2025 and 1/8/2026, were reviewed. MDSN 1 stated Resident 49's MDS assessments should have indicated Resident 49 had functional limitation in ROM on one leg. During a review of the facility's P&P titled, Resident Assessment and Associated Processes, revised 4/2025, the P&P indicated that the resident assessment will be comprehensive and accurate to develop, review, and revise the resident's comprehensive care plan. The P&P indicated Each individual who completes a portion of the assessment will electronically sign and certify the accuracy of that portion of the assessment.

Based on observation, interview, and record review, the facility failed to ensure daily nursing staffing data was posted. On 2/23/2026, review of the posted Census and Daily Hours Per Patient Day (DHPPD, refers to the actual hours of work performed per patient day by a direct caregiver) and Nursing Staffing Assignment and Sign-In Sheet (NSA, a document to safeguard and ensure adequate, qualified staffing was present to provide resident care) revealed the most recent documents available were date 2/19/2026 and 2/20/2026, indicating the facility failed to post the required daily nursing staffing information for 2/21/2026, 2/22/2026, and 2/23/2026. This deficient practice had the potential to prevent resident's, staff, and visitors from having access to accurate daily staffing data. Findings: During an observation in the facility's lobby on 2/23/2026 at 8:22 AM, the DHPPD was dated for 2/19/2026 and the NSA was dated for 2/20/2026. During an interview on 2/23/2026 at 9:18 AM, the Director of Staff Development (DSD) stated the purpose of the DHPPD and NSA was to know the ratio of how many residents to licensed staff was needed to make sure all resident's needs were met. The DSD stated the DHPPD and NSA should have been posted daily and updated throughout the day depending on facility staff who call off or if there were any changes. The DSD stated the DHPPD and NSA was posted for anyone to see, including staff to know who was working and if there were enough staff to accommodate each resident. During a concurrent observation and interview on 2/23/2026 at 9:27 AM, the DSD stated the DHPPD and NSA posted was not correctly because the date was from last week. The DSD stated the DHPPD and NDS should have been updated because they should have been posted daily even on the weekends so the staff could have a realistic view of how many staff were in the facility. During an interview on 2/26/2026 at 11:20 AM, the Director of Nursing (DON) stated the purpose of the DHPPD and NSA was to make sure there was enough Certified Nursing Assistant's (CNA) to provide direct care, Licensed Vocational Nurses (LVN) to provide medication administration, and Registered Nurses (RN) to provide intravenous (IV) medication and do admissions/discharges for each resident in the facility. The DON stated the DHPPD and NSA should have been posted daily and as needed with any changes to ensure there were enough staff to take care of the residents. The DON stated the DHPPD and NSA were posted so family members and everyone could visibly see how many staff were in the building and how many nurses and CNAs were there in the facility taking care of the residents. During a review of the facility's policy and procedure (P&P) titled, Nursing Services/Posted Nurse Staffing Information dated November 2016, the P&P indicated It is the policy of this facility to post the nursing staffing data on a daily basis at the beginning of each shift. The nurse posting will be readily accessible to residents and visitors. The P&P indicated, The daily PPD will include the facility name, current date, total number and the actual hours worked by the following. The licensed and unlicensed nursing staff directly responsible for resident care per shift. 1. Registered Nurses. 2. LVN. 3. CNA. 4. Resident census.

Based on observation, interview, and record review, the facility failed to ensure proper food handling and maintain the food service area in a clean and sanitary manner in accordance with the United States Food and Drug Administration (FDA) Food Code 2022 and the facility's policies and procedures (P&P) titled Storage of Food and Supplies, when: 1.The ground cinnamon spice container lid was partially open on the shelf above the food preparation area by the stove area. 2.The two hot water machine spouts (the part where the hot water flows into the pot or cup) were covered in a white chalky build-up. 3.The side salads and desserts on the lunch trays were not covered during transportation from the metallic delivery food cart to the resident's room. Findings: During an observation on 2/23/2026 at 8:15 AM in the facility's kitchen, the ground cinnamon spice container lid was observed partially opened on the shelf above the food preparation area by the stove area. During an observation on 2/23/2026 at 8:20 AM in the facility's kitchen, the two hot water machine spouts were covered in a white chalky build-up. During a concurrent observation and interview on 2/24/2026 at 12:15 PM with the Dietary Supervisor (DS), the DS stated that the ground cinnamon spice lid was not closed all the way and the two hot water machine spouts were covered in a white chalky build-up. The DS stated, all container lids were supposed to be closed all the way to prevent cross-contamination of the resident's foods. The DS stated, the hot water machine spouts were cleaned every day, and the chalky build-up was the hot water calcification (mineral deposits that settle out of hard water [water containing high mineral content] when heated) because the facility had hard water. During a concurrent record review and interview on 2/24/2026 at 12:30 PM with the Dietary Supervisor Assistant (DSA), the facility's kitchen Daily Cleaning Log, dated 2/22/2026 to 2/28/2026 was reviewed. The DSA stated that the coffee machines were cleaned on 2/22/2026 and 2/23/2026. The DSA stated, the daily cleaning of the coffee machine included cleaning the immediate surface area around the hot water machines, checking the exterior of the two hot water machines for visible cracks or dents, and wiping the two hot water machines down including the hot water spouts. During an observation on 2/24/2026 at 1 PM in the facility's boardroom, Registered Nurse (RN) 1 was observed delivering the regular diet test tray from the hallway to the boardroom, and the peach cobbler dessert was not covered. During a concurrent observation and interview on 2/25/2026 at 12:10 PM with Certified Nurse Assistant (CNA) 3 in Station 1's hallway by the metallic delivery food storage cart, CNA 3 stated, Resident 25's dessert bowl on her lunch tray was not covered. CNA 3 was observed delivering Resident 25's lunch tray from the metallic delivery food storage cart down the hallway to Resident 25's room. During another concurrent observation and interview on 2/25/2026 at 12:15 PM with CNA 4 in Station 1's hallway by the metallic delivery food storage cart, CNA 4 was observed carrying Resident 207's lunch tray from her room into the hallway to put inside the metallic delivery food storage cart. CNA 4 stated that Resident 207's salad cup and dessert bowel were not covered on her lunch tray. CNA 4 stated that the salad cup and dessert bowels were never covered on the food trays coming out of the metallic delivery food storage cart because the trays transported in the metallic delivery food storage cart from the kitchen. During an observation on 2/25/2026 at 12:21 PM in the hallway in front of the kitchen, the lunch trays inside the metallic food delivery food storage cart for Station 2 were observed, and the salad cups and dessert bowls on the lunch trays were not covered. During an interview on 2/25/2026 at 12:41 PM with the Dietary Supervisor (DS), the DS stated, the salads and desserts on the resident's trays were not usually covered because the CNAs transfer the trays from transportation cart directly to the resident's room. During a review of the United States Food and Drug Administration (FDA) Food Code, dated 2022, the Food Code indicated that foods shall be protected from cross contamination by storing the food in packages, covered containers, or wrapping. During a review of the FDA Food Code, dated 2022, the Food Code indicated that equipment that dispenses or vends liquids shall be designed that the delivery tube or chute and orifices are protected dust, insects, rodents, and other contaminations. During a review of the facility's P&P titled Sanitation, dated 2023, the P&P indicated that all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. During a review of the facility's P&P titled Storage of Food and Supplies, dated 2023, the P&P indicated dry bulk foods (flour, sugar, dry beans, food thickener, spices, etc.) should be stored in seamless metal or plastic containers with tight covers or bins which easily sanitized.

Based on interview and record review, the facility failed to ensure the Social Services Director (SSD) met the qualifications required for a social worker in a facility with more than 120 residents bed capacity in the facility . The SSD who was hired by the facility on 9/15/2025 as SSD could not provide documented evidence that at least one year of supervised social work experience in a healthcare setting and working directly with individuals prior to the start of employment at the facility. This deficient practice had the potential not to perform the necessary task of experienced SSD which could result improper discharge planning needs, not receiving medically related social services needs of the residents that could negatively impact the well being including the psychosocial well-being of all residents. Findings: During a review of the SSD's Employee File, indicated the SSD's date of hire at the facility was 8/15/2025 and had a Personnel Action/Change Form dated 9/15/2025. The Personnel Action/Change form indicated an employee status change of title from Medical Records Director (MRD) to SSD. The form indicated an employee status change of department from Medical Records to Social Services included Direct Support Professional 2, Case Manager, Program Manager, and Lead Case Manager. SSD's employee file indicated SSD held a Bachelor of Science degree in Elementary Education with previous job title of MRD prior to accepting the SSD position. The file also indicated the SSD had a Certificate of Completion for Social Service Designee dated 12/2/2024. A review of the SSD's Application for Employment indicated the SSD previously held positions as Marketing Liason and MRD. During an interview on 2/26/2026 at 3:48 PM, the SSD stated she received training for Social Services Designee that was 45 hours long. The SSD stated she had a certification for counseling for 180 hours that was supervised by a social worker which the SSD and the facility could not provide documented evidence. The SSD stated she held Social Services positions at previous facility of 56 bed and 99 beds. The SSD stated she covered for the SSD when Social Services Designee was gone at previous facilities, which she considered as her experience as SSD. The SSD stated when she applied to facility she applied for medical records which was why she did not include Social Services positions on her application. The SSD stated when she accepted the position at facility for SSD on 9/15/2025 she did not sign a job description of SSD. The SSD stated she applied verbally for the SSD position with the Administrator (ADM) and the ADM hired her for the role. The SSD stated the facility was aware about her previous employment history. During an interview on 2/26/2026 at 4:26 PM, Administrator (ADM) stated SSD was initially hired as MRD. ADM stated when the position for SSD opened, SSD asked him she wanted to be considered for the position. ADM stated they hired SSD thinking it would be a good fit and they would be hiring internally. ADM stated he and Human Resources staff looked at SSD's previous job history and did not have her fill out a new application because she was already cleared for background check and in the software system. ADM stated although SSD was hired internally, a signed job description of the SSD role was not part of her employee file which should had been. ADM stated the purpose of having a signed job description was to make sure the employee understood the exact job description of their position/title. During a review of the facility's Job Description for Director of Social Services, the description indicated the following qualifications: Education: Must have, as a minimum, a bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to sociology, special education, rehabilitation counseling, and psychology. Experience: Must have, as a minimum, 5 years of experience as a Social Worker, preferably in a hospital, long-term care facility, or other related health care facility.

Based on observation and interview, the facility failed to adhere to infection control practices for 1 of 3 residents (Resident 204) that were reviewed for Enhanced Barrier Precaution (Infection control measures that require all staff to wear Personal Protective Equipment (PPE-gown and gloves during high-contact resident care) in accordance to the facility infection control practice policy when two medical transportation personnel entered Resident 204's room without performing hand hygiene and while wearing gloves from a prior task. Resident 204 had Enhanced Barrier Precautions signage posted due to the presence of a dialysis catheter (medical device that give access into the blood stream to filter out waste products from the blood). This deficient practice had the potential to expose Resident 208, who has an invasive dialysis catheter, to harmful pathogens, increasing the risk for infection. Findings: During a review of Resident 204's admission Record (AR), the AR indicated Resident 204 was readmitted to the facility on [DATE] with a diagnosis of dementia (impaired thinking) and end stage renal disease (kidneys do not work anymore). During a review of Resident 204's History and Physical (H&P) signed and dated on 2/15/2026, indicated that Resident 204 did not have capacity to understand and make decisions. During a review of Resident 204's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 2/3/2026, the MDS indicated the resident had a severely impaired cognition (thinking). During an observation on 2/26/2026 at 10:13 AM in Resident 204's room, a room designated as an EBP, two transportation staff entered the room wearing gloves did not perform hand hygiene prior to entry and did not don (put on) on isolation gown as required PPE. The transportation staff had made direct contact with Resident 204 to transfer her onto a gurney for a dialysis appointment. During an observation and interview on 2/26/2026 at 10:16 AM, the Infection Prevention Nurse (IPN) reported seeing two transportation staff in room [ROOM NUMBER], an Enhanced Barrier Precautions (EBP) room, transferring Resident 204 to a gurney without wearing gown and clean gloves. The IPN stated the staff used the same gloves worn upon entering the room and left the room without removing their gloves or performing hand hygiene. IPN explained that this practice increased infection risk for Resident 204, who has an indwelling dialysis catheter, and created a risk of cross contamination. The IPN stated that organisms could be transferred to staff hands and clothing and subsequently spread to the dialysis center, transport vehicle, or other residents. During a review of the facility P&P titled IPCP Standards and Transmission-Based Precautions revised 3/2024, indicated EBP: used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs). The P&P indicated PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with: Indwelling medical devices include, but are not limited to central lines, peripherally inserted central catheter (PICC) lines, urinary catheters, feeding tubes, and tracheostomies. The P&P indicated Examples of high-contact resident care activities requiring gown and glove use include indwelling urinary catheter

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 23) with indwelling catheter (a flexible, hollow tube inserted into the bladder to continuously drain urine into an external drainage bag) drainage bag was covered to maintain privacy and dignity when the resident's catheter was visible to individuals walking past Resident 23's room. This deficient practice had violated the resident's rights for privacy and the potential to affect the resident's self-esteem and dignity. Findings: During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted the resident on 2/6/2026, with diagnoses including disorders of urinary system (affecting how the body filtered waste and removed urine, often caused by infections, blockages, or chronic disease), type 2 Diabetes Mellitus (DM, a disorder characterized by difficult in blood sugar control and poor wound healing), and acute kidney failure (a sudden, often temporary, loss of kidney function that occurred over a few hours or days). During a review of Resident 23's History and Physical (H&P) dated 2/9/026, the H&P indicated the resident did not have the capacity to make medical or financial decisions. During a review of Resident 23's Physician's Order dated 2/9/2026 at 4:14 PM, the Physician's Order indicated indwelling catheter #16/10 milliliter (ml, unit of volume) to close drainage system for obstructive uropathy (a blockage in the urinary tract that prevented urine from flowing freely, causing urine to back up into the kidneys)/wound management, every shift. During a review of Resident 23's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 2/10/2026, the MDS indicated the resident had moderate cognitive impairment (a person was experiencing noticeable and significant difficulties with thinking, learning, remembering, and other cognitive skills that impact their daily life). The MDS indicated the resident had an indwelling catheter. During an observation in Resident 23's room on 2/23/2026 at 2:16 PM, the resident's indwelling catheter was hanging on the right side of the bed without a cover. The resident's indwelling catheter had containing roughly approximately 250 ml of urine in the bag and could be seen while walking past the resident's room. During an interview on 2/25/2026 at 10:26 AM, Certified Nursing Assistant (CNA) 1 stated she ensured residents with an indwelling catheter had the catheter bag that was covered and the bag was placed in a basin. CNA 1 stated the indwelling catheter should have always been in a privacy bag to maintain privacy and dignity. CNA 1 stated if the indwelling catheter were not placed in a private bag the people who come in and out of the resident's room could see and the resident could have felt ashamed or uncomfortable. During an interview on 2/25/2026 at 11:07 AM, Licensed Vocational Nurse (LVN) 1 stated Resident 23's indwelling catheter should have always been covered with a dignity bag and placed on top of a basin to maintain infection control and hygiene. LVN 1 stated if the resident's indwelling catheter were not covered, that could affect the resident's dignity because they were unable to control their body and ability to urinate. During an interview on 2/26/2026 at 9 AM, the Director of Nursing (DON) stated Resident 23's indwelling catheter should have had a dignity bag covering the catheter to maintain the resident's dignity. The DON stated the indwelling catheter should have always been covered so the catheter would not be exposed or people could see the catheter. The DON stated if the indwelling catheter were not covered, that would be a dignity concern, and the resident could be embarrassed. During a review of the facility's policy and procedure (P&P) titled, Resident Rights: Dignity and Privacy dated November 2021, the P&P indicated, It is the policy of this facility that all residents be treated with kindness, dignity, and respect. The P&P indicated Resident's shall be examined and treated in a manner that maintains the privacy of their bodies. Privacy of a Resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene, except when staff assistance is needed for the resident's safety. During a review of the facility's P&P titled, Indwelling Urinary Catheter Care dated December 2023, the P&P indicated, It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) to promote hygiene, comfort, and decrease the risk of infection. The P&P indicated, Cover the drainage bag with a privacy bag to maintain dignity.

Based on observation, interview, and record review, the facility failed to ensure two of three residents (Resident 35 and Resident 8) received services in the facility with reasonable accommodation of resident needs to ensure that the call light (device used by residents to communicate needs to the nursing staff) was within reach and accessible to the resident, specifically placed on the resident's non-dominant side and out of reach. This deficient practice had the potential to limit Resident 35 and Resident 8's ability to request assistance, safety, and timely access to care. Findings: 1.During a review of Resident 35's admission Record (AR), the AR indicated the facility admitted the resident on 11/17/2022, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial weakness or reduced motor function affecting one entire side of the body, including the arm, leg, and sometimes the face), contracture (a stiffening/shortening at any joint, that reduced the joint's range of motion) – left hand, and degenerative disease of nervous system (incurable, progressive conditions where nerve cells in the brain or spial cord lose function and die over time). During a review of Resident 35's Occupational Discharge summary dated [DATE] to 3/18/2024, the Discharge Summary indicated the resident's Functional Skills Assessment showed a self-care score of zero (from zero to 12; 12 being the highest [function]) and a mobility function score of zero (from zero to 12; 12 being the highest [function]). During a review Resident 35's Physician's Order dated 7/26/2024 at 3:05 PM, the Physician's Order indicated Restorative Nursing Assistant (RNA, a specialized Certified Nursing Assistant [CNA] who helped resident's regain or maintain their physical strength and independence after an illness or injury) to apply bilateral resting hand splints (a rigid or flexible device used to immobilize, support, and protect injured bones, joints, or tissues while they healed) and right elbow extension splint five times a week every day, up to five hours. During a review of Resident 35's History and Physical (H&P) dated 7/22/2025, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 35's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 12/31/2025, the MDS indicated the resident had moderate cognitive impairment (a person was experiencing noticeable and significant difficulties with thinking, learning, remembering, and other cognitive skills that impact their daily life). The MDS indicated the resident was dependent (helper did all of the effort and the resident did none of the effort to complete the activity) on facility staff for all self-care areas including mobility. During a review of Resident 35's Limited Physical Mobility to Press Call Light related to Contractures Care Plan dated 2/25/2026, the Care Plan goal indicated the resident would demonstrate the appropriate use of adaptive devices to increase mobility and interventions included providing supportive care and assistance with mobility as needed. During a concurrent observation and interview in Resident 35's Room on 2/23/2026 at 1:54 PM, the resident's left hand was in a closed position unable to open or move fingers. The resident's call light was observed not within reach and tucked behind the resident's left shoulder. Resident 35 stated the call light should have been in front of me and not being able to reach the call light made her feel awful because she was unable to call facility staff. During a concurrent observation and interview in Resident 35's Room on 2/23/2026 at 2:05 PM, CNA 2 stated the call light should have been right next to Resident 35 where the resident could reach the call light otherwise the resident would not be able to call the facility staff and something could happen to the resident. During an interview on 2/25/2026 at 11:03 AM, the Licensed Vocational Nurse (LVN) 1 stated the resident's call light should have been within reach to be able to use the call light. LVN 1 stated if the resident needed help, using the call light was the most important way to call the facility staff. LVN 1 stated Resident 35 was unable to use her left arm and the resident's call light should have been near her dominant hand to be able to press the call light if she needed anything. During an interview on 2/26/2026 at 8:40 AM, the Director of Nursing (DON) stated the resident's call light should have been within the resident's reach to be able to call facility staff if Resident 35 needed help. 2. During a review of Resident 8's admission Record (AR), the facility admitted Resident 8 on 10/10/2025, and was readmitted on Resident 8 on 1/17/2026 with diagnoses that included metabolic encephalopathy (reversible brain dysfunction caused by chemical imbalance), dementia (a progressive state of decline in mental abilities), and lack of coordination and memory deficit (memory loss) following a cerebral infarction (CVA [cerebrovascular accident], stroke, loss of blood flow to a part of the brain). During a review of Resident 8's care plan, revised 1/10/2026, the care plan indicated Resident 8 was at risk for fall and injury related to left frontal cavernoma (irregularly formed and leaky blood vessels located at the front of the brain), CVA with left-sided weakness and impaired mobility. The care plan's interventions included ensuring the call light was within reach and encouraging Resident 8 to use it to call for assistance as needed, keeping need items with reach, and ensuring a safe environment by having clutter-free floors and a working and reachable call light. During a review of Resident 8's Minimal Data Set (MDS, a resident's assessment), dated 1/19/2026, the MDS indicated Resident's 8 cognitive (a resident's thought process) skills were intact. The MDS indicated that Resident 8 was dependent (helper does all the effort) on the facility's staff for ADLs such as performing toileting hygiene and bathing. The MDS indicated Resident 8 was dependent on facility's staff for repositioning in bed and transferring from a lying to sitting position or from chair/bed to chair. The MDS indicated Resident 8 was frequently incontinent (loss of control) of bowel. During a review of Resident 8's history and physical (HP), dated 1/20/2026, the HP indicated Resident 8 did not have the capacity to understand and make decisions. During a concurrent observation and interview on 2/23/2026 at 10:35 AM in Resident 8 room, Resident 8 was observed lying in bed with the call light clipped to her pillow on the Resident 8 stated she had pressed the button for staff but did not know where the button was. Resident 8 attempted to reach for it with her right hand to her crossing over her body and had difficulty accessing it. Resident 8 stated she had pressed the button for staff but did not know where the button was. During a concurrent observation and interview on 2/23/2026 at 10:45 AM in Resident 8's room with Certified Nurse Assistant (CNA) 5. CNA 5 stated that Resident 8 was lying in bed and the call light was by the left side of her head and clipped to her pillow. CNA 5 stated Resident 8 could not move her left arm, but she was able to use her right arm to reach and press the call light. During an interview on 2/26/2026 at 12:23 PM with Registered Nurse (RN), 1 RN 1 stated that the call light should be within reach of the resident to call for assistance such as calling for assistance to change their adult diaper, asking for pain medications, or asking for assistance to the restroom. RN 1 stated, if the resident had one-sided weakness or difficulty moving one side of the body, the call light should be past mid-line of the body and closer to the more functional side of the body. RN 1 stated, if a resident cannot reach the call light, it may lead to a delay in care. During a review of the facility's policy and procedure (P&P) titled, Routine Procedures: Call Light/Bell dated May 2017, the P&P indicated It is the policy of this facility to provide the resident a means of communication with nursing staff. The P&P indicated, Leave the resident comfortable. Place the call device within resident's reach before leaving room.

Based on observation, interview, and record review, the facility failed to provide one of 29 sampled residents (Resident 17) with an admission agreement (legally binding contract between a resident and a nursing facility, detailing the rights, responsibilities, services, and costs for care) in Resident 17's preferred language. This deficient practice had the potential for preventing Resident 17 from being informed of their rights, including contact information for the Ombudsman (trained advocates who investigate complaints, protect rights, and improve quality of life for residents) and the State agency. Findings: During a review of Resident 17's Face Sheet (summary of a resident's information), the Face Sheet indicated the facility admitted Resident 17 on 9/7/2025 with diagnoses including difficulty walking, dysphagia (difficulty swallowing) following a cerebral infarction (brain damage due to a loss of oxygen to the area), and hemiparesis (weakness of the arm, leg, and trunk on the same side of the body). During a review of Resident 17's Minimum Data Set ([MDS] a resident assessment tool), dated 12/5/2025, the MDS indicated Resident 17's preferred language was Spanish. The MDS indicated Resident 17 had clear speech, understood verbal content, expressed ideas and wants, and had moderately impaired cognition (ability to think, understand, learn, and remember). During a concurrent observation and interview on 2/24/2026 at 1:20 p.m. in the dining room, Resident 17 did not know how to contact the Ombudsman and State agency. The dining room was observed without any posted Ombudsman and State agency information. During a concurrent interview and record review on 2/26/2026 at 10:23 a.m. with the admission Coordinator (AC), Resident 17's admission agreement, dated 9/7/2025, was reviewed. The AC stated Resident 17 signed the admission agreement, which included the Ombudsman and State Agency contact information. The AC stated Resident 17's preferred language was Spanish and stated Resident 17's admission agreement was written in English. The AC stated it would be difficult for Resident 17 to refer to the admission agreement for the Ombudsman and State agency information since it was not in Resident 17's preferred language. During a concurrent interview and record review on 2/26/2026 at 2:23 p.m. with the Director of Marking and Admissions (DOMA), the DOMA stated the residents (in general) should receive an admission agreement in their preferred language to easily understand the information. During a review of the facility's policy and procedure (P&P) titled, Resident Rights and Responsibilities, dated 4/2025, the P&P indicated the facility informed residents both orally and in writing of their rights as a resident. The P&P also indicated the facility will inform the resident of their rights and responsibilities in a language that is both clear and understandable to the resident.

Based on observation, interview, and record review, the facility failed to notify the physician when two of three sample residents (Resident 8 and 194) with significant change in condition by failing to: 1.Resident 8 had pain and discoloration on her left foot's second toe and pain from her hemorrhoid (swollen veins in the anus and lower rectum [temporary storage chamber for stool before allowing the stool to pass through the anal canal to exit the body]). These failures resulted in the lack of and delay in Resident 8 medical management and coordination which did not address Resident 8 issues regarding her left foot second toe pain and discoloration and her hemorrhoid pain and follow up until the recertification survey team (from 2/23/2026 to 2/26/2026) conducted an investigation on 2/24/2026 into Resident 8's medical care. 2. For Resident 194 the facility failed to inform the Medical Director when the primary physician did not respond to the call or text when the resident complained of 3 out of 10 right hip and shoulder pain on the numerical pain scale (a tool used to quantify pain intensity, from 0 - no pain to 10 - worst pain experienced), and had a skin tear on the back of the right shoulder and right ear pain after the fall on 1/29/2026 at the facility. As a result of this deficient practice, Resident 194 did not receive care and services to evaluate the cause of ear pain, shoulder and hip pain from 1/29/2026 at the time of fall to 2/2/2026. Findings: 1.During a review of Resident 8's admission Record, the facility admitted Resident 8 on 10/10/2025 and the facility readmitted Resident 8 on 1/17/2026 with diagnoses that included metabolic encephalopathy (reversible brain dysfunction caused by chemical imbalance), dementia (a progressive state of decline in mental abilities), and memory deficit (memory loss) following a cerebral infarction (CVA [cerebrovascular accident], stroke, loss of blood flow to a part of the brain). During a review of Resident 8's care plans, revised on 12/28/2025, the care plan indicated Resident 8 was at risk for alteration in gastro-intestinal status related to hemorrhoids. The care plans interventions, initiated on 1/17/2026, indicated to apply Procotozone -HC External Cream 2.5% (prescription topical steroid cream used to temporarily relieve pain, swelling, and itching from hemorrhoids) to the rectum topically every 24 hours as needed for hemorrhoids and to apply after bowel movements. During a review of Physician 1's Convalescent Podiatry Care Evaluation and Treatment, dated 11/3/2025 and 1/5/2026, Physician 1 indicated Resident 8's five toenails on her left foot were thickened, discolored, brittle with subungual debris (collection of blood trapped underneath the toenail) and were painful upon palpation. Physician indicated that Resident 8 had 10 mycotic (fungal), hypertrophic (thicken nails), painful, and incurvated toenails (a severely curved, rounded, or C-shaped toenail that curls downwards, often leading to pain, pressure, and, if it punctures the skin, an ingrown nail). Physician 1 had trimmed Resident 8 nails with a nail clipper and Dremel (a small handheld motorized tool to grind and smooth down nails) and recommended to apply Clotrimazole 1% cream (antifungal skin cream to treat skin infections caused by fungus) topically to the affected area daily. During a review of Resident 8 Order Summary Report, the order, dated 1/17/2026, indicated to apply Proctozone - HC External Cream 2.5% to the rectum topically every 24 hours as needed for hemorrhoids after bowel movement. During a review of Resident 8 Order Summary Report, the order, dated 1/18/206, indicated Resident 8 may be seen and treated by a Podiatrist (physician specializing in diagnosing, treating, and preventing conditions of the foot, ankle, and lower leg). During a review of Resident 8's Minimal Data Set (MDS, a resident assessment tool), dated 1/19/2026, the MDS indicated that Resident 8's cognitive (a resident's thought process) skills were intact. The MDS indicated that Resident 8 was dependent (helper does all the effort) on the facility staff for her activities of daily living (ADLs, activities such as bathing, dressing, and toileting a person performs daily) and dependent on the facility staff for repositioning in bed and transferring from a sitting to lying position and from chair or bed to chair transfer. The MDS indicated that Resident 8 was frequently incontinent (loss of control of bowel or bladder) of bowel. During a review of Resident 8's History and Physical (HP), dated 1/20/2026, the HP indicated Resident 8 did not have the capacity to understand and make decisions. During an observation on 2/25/2026 at 8:16 AM with Restorative Nurse Assistant (RNA) 1 in Resident 8's room, RNA 1 removed the Resident 8's left sock, the second toe appeared red near the nail bed. RNA 1 touched the toe, causing the resident to scream in pain, and the resident again expressed pain when the sock was replaced. RNA 1 told the resident she would notify the nurse about the pain. During a concurrent observation and interview on 2/26/2026 at 8:11 AM in Resident 8's room, Resident 8 was observed pointing to her left foot with her pointer stick and stated pain on my 2nd finger, and stated, sometimes it hurts in the morning or sometimes in hurts in the afternoon. Resident 8 stated she did not know how long her left second toe had been hurting. During a concurrent observation and interview on 2/26/2026 at 8:20 AM with Treatment Nurse (TN) 2, in Resident 8's room, while TN 1 was providing maintenance treatment to Resident 8's Sacro coccyx area (tailbone area), she stated that Resident 8 has active hemorrhoids sometimes like today. RN 2 stated, Resident 8 currently has a small pink and reddish hemorrhoid, and the way to treat it was to push it back in. TN 1 was observed applying A&D ointment (skin barrier cream) to her finger and pushing Resident 8's hemorrhoid back into the lower rectum area. During a concurrent observation and interview on 2/26/2026 at 8:36 AM with Certified Nurse Assistant (CNA) 5, in Resident 8's room, CNA 5 removed the resident's left sock and noted that her second toenail was longer than the others with discoloration at the nail bed. When the sock was put back on, Resident 8 grimaced, yelled that her 2nd finger hurts, and asked for it to be removed while pointing to her left foot. After CNA 5 removed the sock again, the resident calmed down. CNA 5 stated he would notify the nurse about the resident's pain for medication. During a concurrent observation and interview on 2/26/2026 at 12:15 PM with CNA 5 and CNA 6, in Resident 8's room, CNA 5 and CNA 6 were observed cleaning and changing Resident 8's adult briefs. Resident 8 was observed repeatedly stating that her butthole hurts. CNA 6 was observed applying A&D ointment to her finger and told Resident 8 that she will apply cream to help her. During a concurrent interview and record review on 2/26/2026 at 12:50 PM with Registered Nurse (RN) 1, Resident 8 Skilled Nursing Evaluation form, dated 2/18/2026, 2/22/2026, 2/24/2026, and 2/25/2026 were reviewed. RN 1 stated, there was no documented evidence about Resident 8's left 2nd toenail pain or hemorrhoids. RN 1 stated, she was not aware of Resident 8's complaint of pain on the toenail pain or had active hemorrhoids. RN 1 stated, since she was not aware of Resident 8's change of condition (CoC) regarding her left 2nd toenail and hemorrhoids, Resident 8's Primary Care Physician was not notified. RN 1 stated, since there was no CoC, there would be no care plan related to Resident 8's active toenail pain and hemorrhoids. During the same interview on 2/26/2026 at 1:05 PM with RN 1, RN 1 stated, the licensed nurses were expected to do a thorough head-to-toe assessment upon shift change including removing resident's socks. RN 1 stated, on shower days, CNAs were expected to do a observe the resident's skin for any changes either in the shower or during sponge baths and that included moving the resident's socks. RN 1 stated, Resident 8's PCP needed to be notified about Resident 8's CoC for further orders and instructions related to Resident 8's medical care. During a review of the facility's policies and procedures (P&P) titled Change in Condition, dated April 2025, the P&P indicated that the facility needed to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being. The P&P indicated that it, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware examples included change in medical condition. 2. During a review of Resident 194's General Acute Care Hospital (GACH) 1's Discharge Summary record, the record indicated that Resident 194 was admitted to the hospital on [DATE] for altered mental status and was brought into the GACH emergency department for further evaluation. On 1/24/2026 Resident 194 was discharged from the GACH and admitted to the facility for rehabilitation care. During a review of Resident 194's admission Record, the facility admitted Resident on 1/24/2026 with diagnoses that included Acute Respiratory Failure (ARF, condition where the lungs cannot provide enough oxygen to the resident of the body's tissues) with hypoxia (the body's tissues does not receive enough oxygen to function properly), type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), and lobar pneumonia (PNA, an infection/inflammation in the lungs). The AR indicated that Resident 194 passed away on 2/2/2026 (nine days after admitted to the facility). During a review of Resident 194's Minimal Data Set (MDS, a resident assessment), dated 1/29/2026, the MDS indicated that Resident 194's cognitive (a resident's thought process) skills were moderately impaired. The MDS indicated that Resident 194 needed substantial assistance (helper does more than half the effort) with toileting hygiene and showering, functional mobility such as repositioning self in bed, transferring from a lying to sitting position, and transferring from bed/chair to chair. During a review of Resident 194's History and Physical (HP), dated 1/24/2026, the HP indicated that Resident 194 was alert and oriented to person, time, place, and situation, with clear speech and was able to make her needs known but cannot make medical decisions. During a review of Resident 194's Change of Condition Evaluation (CoC) record, dated 1/29/2026 timed at 11:15 PM, the CoC record indicated Resident 194 had fallen on the night of 1/29/2026. The CoC record indicated that Resident 194 had no changes in mental status, complained of 3 out of 10 right hip and shoulder pain on the numerical pain scale (a tool used to quantify pain intensity, from 0 - no pain to 10 - worst pain experienced), and had a skin tear on the back of the right shoulder. The CoC record indicated that the facility contacted PA 1 on 1/29/2026 at 11:39 PM, and pending response. During a review of Resident 194's Nursing PN, dated 1/29/2026 timed at 11:40 PM, the PN indicated that upon entering the room CNA found Resident 194 lying on her right side, and when interviewed Resident 194 stated she was trying to stand up and fell down. The PN indicated that Resident 194 complained of right shoulder, right hip, and right ear pain. During a review of Resident 194's Fall Risk Evaluation record, dated 1/29/2026, the record indicated that Resident 194 had one (1) or two (2) falls within the past three (3) months and was considered a fall risk. During a review of Resident 194's care plan, date initiated on 1/29/2026, the care plan indicated that Resident 194 had an unwitnessed fall. The care plan's interventions, initiated on 1/29/2026, included placing a fall mat by bedside, keeping the bed in low position, and monitoring/documenting/reporting as needed for 72 hours to the physician signs and symptoms of pain, bruising, change in mental status, new onset of confusion/inability to maintain posture or agitation. During a review of Resident 194's care plan, date initiated on 1/30/2026, the care plan indicated that Resident 194 had alteration in musculoskeletal status related to complaints of weakness and dizziness. The care plan's interventions, initiated on 1/30/2026, included anticipating resident's needs and monitoring for fatigue. During a review of Resident 194's PT Treatment Encounter Note(s), dated 1/30/2026, the record indicated that nursing advised not to get resident up to due episode of passing out. The record indicated that Resident 194 was responsive during therapy but seemed weak. During a review of the Skin/Wound Note PN dated 1/30/2026, timed at 4:16 PM, indicated a follow up skin assessment of Resident 194's wound after the fall with right shoulder skin abrasion measuring 3-centimeter (cm) X 3 cm with light bleeding. During a review of the Skin/Wound Note, dated 1/31/2026 at 10:44 PM, indicated Skin issue has not been evaluated on the front right shoulder abrasion that was acquired in-house. During a review of the PN dated 2/2/2026 timed at 11:02 AM, PA 1 informed of Resident 194's condition and RR asking to hold off on hospital transfer, per PA 1 continue to monitor the resident and report any new changes. During a review of COC report dated 2/2/2026 at 1:30 PM, indicated IDT met on 2/1/26 to discuss resident fall with the RR that on 1/29/26 at approximately 11:15PM CNA reported to LVN and RN that resident was on the floor. LVN and RN went to residents' room immediately and noted resident on the floor laying on her right side of bed with her back against the bed frame. RN assessed resident for ROM and was at baseline, noted with skin scrape to right shoulder. First aid was provided to right shoulder. Resident 195 complained of mild pain to right shoulder and right hip. LVN medicated resident for pain as ordered. Resident 195 was transferred back to bed by 2 staff assist. Resident 195 stated she was trying to stand up and fell down. During an interview on 2/25/2026 at 4:45 PM with Family Member (FM) 1, FM 1 stated the morning of 1/30/2026, she received a notification from the facility that Resident 194 had fallen the night prior (1/29/2026). FM 1 stated, she went to visit Resident 194 that morning (1/30/2026), and Resident 194 told FM 1 that she did not feel good and was having pain, but cannot recall the location of Resident 194's pain. FM 1 stated, facility did not mention to her what may have caused Resident 194 to fall on the night of 1/29/2026 and cannot recall if Resident 194 had an x-ray (medical imaging) after the fall. During the same concurrent interview and record review on 2/26/2026 at 1:15 PM with RN 1, Resident 194's CoC evaluation, dated 1/29/2026, was reviewed. RN 1 stated, Resident 194's CoC indicated that the facility attempted to notify PA 1 at 1/29/2026 at 11:39 PM, but the documented evidence of primary care physician (PCP) recommendation indicated Pending response from (PA 1). RN 1 stated, there was no documented evidence that Licensed Vocational Nurse (LVN) 3 attempted to notify PA 1 three times within the 11 PM to 7 AM shift on 1/29/2026 and no documented evidence of additional follow up notification during the 7 AM to 3 PM shift on 1/30/2026. RN 1 stated, because LVN 3 was not able to notify PA 1, LVN 3 needed to go up the chain of command and notify the Medical Director of Resident 194's CoC. RN 1 stated, if LVN 3 could not contact Resident 194's PCP or the On-Call Physician, Resident 194 should have been transferred to the GACH for further evaluation. During the same concurrent interview and record review on 2/26/2026 at 1:30 PM with RN 1, Resident 194's PN, dated 1/29/2026 timed at 11:40 PM, and Order Summary Report were reviewed. RN 1 stated, the PN indicated that Resident 194 complained of right shoulder, right ship, and right ear pain. RN 1 stated, there was no documented evidence of PA 1's recommendations such as orders for x-ray or imaging of Resident 194's right shoulder or hip or orders regarding Resident 194's right ear pain. RN 1 stated, Resident 194's new orders post-fall included to place Resident 194 in a low bed, place floor mats on bilateral sides of the bed, and wound care treatments for Resident 194's right shoulder abrasion. During a concurrent interview and record review on 2/26/2026 at 2:45 PM with the Assistant Director of Nursing (ADON), Resident 194's CoC Evaluation record, dated 1/29/2026 and PNs dated 1/29/2026 timed at 11:40 PM, 1/30/2026 timed at 6:55AM, 1/30/2026 timed at 11:01 AM, and 1/30/2026 timed at 11:10 AM, were reviewed. The ADON stated, the CoC indicated a pending response from PA 1, and the reviewed PN did not have any documented evidence of additional follow-up notification to PA 1. The ADON stated, because LVN 3 could not contact PA 1, it was the facility's standard of practice to notify the Director of Nursing (DON) and the Medical Director for further orders and evaluation. During the same concurrent interview and record review on 2/26/2026 at 3:55 PM with the DON, Resident 194's Order Summary Report was reviewed. The DON stated the only order from PA 1 was Resident 194's wound care treatment orders for her right should abrasion and no order for transfer to the hospital when the resident complained of shoulder pain, ear pain, weakness and dizziness. The DON stated, there was no need for x-rays because [Resident 194's] range of motion was at baseline. During the same concurrent interview and record review on 2/26/2026 at 4:05 PM with the DON, Resident 194's PN dated 1/29/2026 timed at 11:40 PM was reviewed. The DON stated that Resident 194 complained of right shoulder, right hip, and right ear pain. The DON stated, upon the facility's investigation on 2/1/2026, the DON stated she could not explain the reason for Resident 194 experience of right ear pain. The DON stated she was not informed by the license nurses that they were not able to get a hold of PA 1 or the other physician to report Resident 1's complaints of pain. During an interview on 2/26/2026 at 4:10 PM with PA 1, PA 1 stated he was Resident's 194's PA. PA 1 stated, since Resident 194 fell on 1/29/2026 during the 11 PM to 7 AM shift, PA 1 stated I was not the on-call provider at that time. PA 1 stated, I am not sure if they contacted another provider. PA 1 stated, he would have ordered an x-ray of [Resident 194's] right shoulder and hip because she was complaining of right shoulder and hip pain. PA 1 stated, he was not aware that Resident 194 was complaining of right ear pain. PA 1 stated, based on the LN 's assessment at the time of the fall, if the PCP cannot be reached, the LN should have consulted with the DON and the Medical Director for further instructions. During a review of the facility's policy and procedures (P&P) titled Fall Management System, dated April 2025, the P&P indicated that it was the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. During a review of the same facility's P&P titled Fall Management System, dated April 2025, the P&P indicated that when a resident sustains a fall, the Attending Physician shall be notified of the fall and the resident's status, provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. During a review of the facility's same P&P titled Change in Condition, dated April 2025, the P&P indicated if at any time the team recognized the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware, such as new complaints of pain or worsened pain. The P&P indicated in circumstances where immediate attention is warranted, the nurse shall use her clinical judgement and inform the physician based on the urgency of the situation. The Medical Director shall be notified if the primary physician or on-call physician could not be reached.

Based on interview and record review, the facility failed to ensure the reason for resident's discharge and notice of proposed discharge was completed for one of three sampled residents (Resident 193) reviewed for closed records as indicated in the facility's policy and procedure titled Criteria for Transfer and Discharge, This deficient practice had the potential to result in inappropriate information communicated to the receiving health care institution or provider. Findings: During a review of Resident 193's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus (chronic condition where the body resists insulin [hormone produced by the pancreas that regulates blood sugar by moving glucose [sugar] from the bloodstream into cells for energy] or fails to produce enough, causing high blood sugar), other schizoaffective disorders (chronic mental health condition combining schizophrenia symptoms [hallucinations, delusions, disorganized thinking] with mood disorder episodes [mania or depression]), and seizures. The AR indicated Resident 193 was discharged on 12/5/2025. During a review of Resident 193's Discharge summary dated [DATE] indicated Resident 193's Transfer/Discharge was necessary due to: the health and safety of individuals in the facility would be endangered. The summary indicated Resident 193 was transferred to hospital due to aggressive behavior. During a review of Resident 193's Notice of Proposed Transfer/discharge date d 12/5/2025 indicated resident's transfer/discharge was made for the following reason: the transfer or discharge was appropriate because resident's health had improved sufficiently and no longer required services provided by the facility. The Notice of Proposed Transfer/Discharge did not indicate a Resident/Representative Signature. During a concurrent interview and record review of Resident 193's Discharge Summary and Notice of Proposed Transfer/discharge on [DATE] at 4:58 PM, the Director of Nursing (DON) confirmed the reason of discharge on the discharge summary and notice of proposed transfer/discharge did not match. The DON stated the summary, and notice should match so that it gives the correct information about resident's reason for discharge. The DON confirmed there was no resident/representative signature on the Notice of Proposed Transfer/Discharge. The DON stated the form should be completed and include the correct information. A review of the facility's policy and procedure (P&P) titled Criteria for Transfer and Discharge, dated 4/2025 indicated when the facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.

Based on interview and record review, the facility failed to ensure the minimum data set (MDS, a standardized assessment and care screening tool) was completed and transmitted to Centers of Medicare and Medicaid Services (CMS) timely for 2 of 3 sampled residents (Resident 32 and Resident 71). This deficient practice failed to provide CMS specific resident information for quality care measure purposes and had the potential to affect the quality of care provided to the resident. Findings: During a review of Resident 32's admission Record (AC), the AC indicated the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus (your body does not use insulin properly), muscle weakness ( when muscles aren't as strong as they should be). During a review of Resident 32's History and Physical (H&P) dated 11/14/2025 indicated Resident 32 has the capacity to understand and make decisions. A review of Resident 32's MDS, dated [DATE] indicated this was a 5-day scheduled assessment. A review of facility's CMS submission Report indicated Resident 32's was last submitted on 3/10/2025. During a review of Resident 71's admission Record (AC), the AC indicated the resident was admitted to the facility on [DATE] with diagnoses that included Acute Respiratory Failure with hypoxia (when you don't have enough oxygen in your blood ), Type 2 diabetes mellitus (your body does not use insulin properly). During a review of Resident 71's History and Physical (H&P) dated 10/24/2025 indicated Resident 71 has the capacity to make their needs known but cannot make medical decisions. A review of Resident 71's MDS, dated [DATE] indicated this was a 5-day scheduled assessment. A review of facility's CMS submission Report indicated Resident 71's was last submitted on 2/24/2026. On 2/25/2026 at 2:15 PM, during an interview and concurrent record review of Resident 32'Smds. MDS nurse stated and Resident 71's 5 day scheduled assessment dated [DATE] with MDS coordinator, MDS coordinator stated she was responsible for completing Resident32's and Resident 71's 5-day MDS assessment and transmitting it to CMS. MDS coordinator stated, I forgot to complete transmit the MDS for Resident 32 and for Resident 71, I hadn't realized it until now. MDS coordinator stated MDS should be completed upon admission and transmitted within 14 days for both residents 32 and 71 per federal regulations and our faclity practice. During a review of the facility's policy and procedure (P&P) titled Resident assessment and associated processes with a revision date of 4/2025. The P&P indicated The facility will electronically encode, accurate, and complete MDS data to the Centers for Medicare & Medicaid Services system as soon as possible.

Based on observation, interview, and record review, the facility failed to provide care and services to prevent skin injury (a skin damage due to prolonged unrelieved pressure and friction) to ensure the resident's low air loss mattress was set according to the physician's order and within the appropriate weight range for one of two sampled residents (Resident 75). This deficient practice had the potential to place Resident 75 at risk for developing pressure injuries, impaired pressure redistribution, and potential skin breakdown. Findings: During a review of Resident 75's admission Record (AR), the AR indicated the facility admitted the resident on 7/21/2024, with diagnoses including pressure ulcer (localized, damaged areas of skin and underlying tissue caused by prolonged, unrelieved pressure - or pressure combine with shear - that cuts off blood flow) of right hip, abnormal posture, and adult failure to thrive (a decline caused by chronic diseases and functional impairments which could cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 75's Physician's Order dated 7/22/2024 at 4:45 PM, the Physician's Order indicated for the resident to have low air loss mattress (a therapeutic hospital mattress that used a pump to push air through tiny holes in the fabric, creating a cool, dry, floating sensation) for skin management, setting according to resident weight and check function every shift. During a review of Resident 75's History and Physical (H&P) dated 5/4/2025, the H&P indicated the resident did not have the capacity to understand and make decisions but could make needs known. During a review of Resident 75's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 1/21/2026, the MDS indicated the resident had severe cognitive impairment (Problems with a person's ability to think, learn, remember, use judgement, and make decisions) and was at risk of developing pressure ulcer/injuries and treatments included: pressure reducing device for chair, pressure reducing device for bed, nutrition/hydration intervention, and applications of ointments/medications. During a review of Resident 75's At Risk for Pressure Ulcer Development Care Plan revised 1/21/2026, the Care Plan indicated for the resident to have intact skin, free of redness, blisters (small, painful, fluid-filled bubbles that formed under the top layer of skin, usually on hands or feet) or discoloration with interventions that included administering treatments as ordered and monitoring for effectiveness, daily body checks, and having low air loss mattress for skin management setting according to resident weight and check function every shift. During a review of Resident 75's Weight Summary dated 2/23/2026, the Weight Summary indicated the resident's weight while sitting was 114 pounds. During an interview on 2/25/2026 at 11:17 AM, the Treatment Nurse (TN) 1 stated the TNs were in charge of setting the low air loss mattress setting for each resident and should have been consistent with each resident's weight. TN 1 stated for Resident 75, the resident had a history of wounds and needed to have a special mattress to protect the resident's skin and prevent skin break down. During a concurrent interview and record review of Resident 75's Physician's Order on 2/25/2026 at 11:29 AM, TN 1 stated the facility staff were not following the Physician's Order but should have been. TN 1 stated the resident's low air loss mattress setting should have been set to Resident 75's weight for the resident's safety. TN 1 stated if the setting was not correct the resident could have redness or skin breakdown because of the pressure from the mattress. During an interview on 2/26/2026 at 8:36 AM, the Director of Nursing (DON) stated the low air loss mattress setting should have been set according to the resident's weight. The DON stated having a low air loss mattress for Resident 75 was important because the resident was prone to skin breakdown and if the settings were not correct, the resident would be uncomfortable. During a concurrent interview and record review of Resident 75's Physician's Order on 2/26/2026 at 8:40 AM, the DON stated the facility staff did not follow the Physician's Orders for the mattress setting which could result in too firm and not comfortable, likely changing the skin or having skin irritation for Resident 75. During a review of the undated Low Air Loss Mattress User Manual, the User Manual indicated the Product Function: Analog Pressure Dial (adjusts how firm or soft the air-filled mattress felt by controlling the air pump pressure) - Adjust the dial to correspond to the patient's appropriate weight setting or comfort level. During a review of the facility's policy and procedure (P&P) titled, Continuum of Care: Admission dated 2/7/2025, the P&P indicated, Note and initiate physician orders. Initiate medications and treatment. During a review of the facility's P&P titled, Skin and Wound Monitoring and Management dated April 2025, the P&P indicated, It is the policy of this facility that a resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The P&P indicated In order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches as an appropriate and consistent with the resident's care plan: use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses), licensed nurse to document presence of pressure reducing devices on Treatment Administration Records as ordered. The P&P indicated, Confirm all orders have been implemented as ordered.

Based on observation, interview, and record review, the facility failed to provide range of motion ([ROM] full movement potential of a joint) intervention for two of four sampled residents (Resident 8 and 96) reviewed for ROM limitations. 1. For Resident 8, the facility failed to: -Measure Resident 8's left hand during the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation, dated 1/19/2026, in accordance with professional standards of practice. -Provide Resident 8 with ROM exercises for both legs from 1/24/2026 to 2/25/2026. -Perform AAROM to Resident 8's left arm in accordance with the physician's orders, dated 1/30/2026. 2. For Resident 96, the facility failed to provide ROM exercises to both arms and legs from 2/18/2026 to 2/26/2026 (nine days) following Resident 96's admission to hospice (interdisciplinary care that is designed to provide physical, emotional, social, and spiritual comfort of an individual in the last phases of life due to a terminal disease). This failure was not in accordance with the facility's policy and procedures (P&P) titled, ROM and Contracture Prevention, revised 5/2019, and End of Life Care; Hospice and/or Palliative Care, revised 4/2025. These failures had the potential for Resident 8 to experience an undetected decline in ROM of the left hand, decreased strength in the left arm, and decline in ROM of both legs. These failures also had the potential for Resident 96 to experience a decline in ROM of both arms and legs, which could lead to the development of contractures (stiffening/shortening at any joint that reduces the joint's range of motion). Findings: 1.During a review of Resident 8's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 1/19/2026, the MDS indicated Resident 8 had clear speech, expressed ideas and wants, usually understood verbal content, and had intact cognition (clear ability to think, understand, learn, and remember). The MDS indicated Resident 8 required partial/moderate assistance (helper does less than half the effort) for eating and dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required to complete the activity) for toileting, showering, dressing, rolling to either side in bed, and transferring from lying to sitting on the side of the bed. During a review of Resident 8's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 1/19/2026, the OT Evaluation indicated Resident 8 had within functional limits ([WFL] sufficient joint movement without significant limitation) ROM in the right arm and the left elbow. The OT Evaluation indicated Resident 8 had impaired ROM in the right shoulder, wrist, and hand. The OT Evaluation indicated Resident 8's right shoulder had 0-80 degrees (unit of joint measurement) of flexion (lifting the arm overhead, normal ROM measurement 0-180 degrees), right wrist had 0-40 degrees of extension (bending the wrist upward, normal ROM measurement 0-90 degrees) and 0-40 degrees of wrist flexion (bending the wrist downward, normal ROM measurement 0-90 degrees). The OT Evaluation indicated Resident 8's right thumb, index finger, middle finger, ring finger, and little finger were impaired but did not include measurements of each finger. During a review of Resident 8's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 1/19/2026, the PT Evaluation indicated Resident 8 had within functional limits ([WFL] sufficient joint movement without significant limitation) ROM in both legs. The PT Evaluation indicated Resident 8 was dependent for rolling to either side in bed and transferring from lying to sitting on the side of the bed. During a review of Resident 8's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated recommendations for a Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) program. The OT Discharge Summary indicated Resident 8's RNA program included active range of motion ([AROM] performance of an exercise to move a joint without any assistance or effort of another person) exercises for the right arm and active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) for the left arm, three times per week as tolerated. During a review of Resident 8's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated recommendations to continue with PT to promote increased muscle strength, balance, and safety awareness. During a review of Resident 8's physician's orders, dated 1/30/2026, the physician's orders indicated RNA for AROM exercises on the right arm and AAROM exercises on the left arm, three times per week as tolerated. During an interview on 2/24/2026 at 8:31 a.m. with the Director of Rehabilitation (DOR), the DOR stated the purpose of RNA (in general) was to maintain a resident's mobility to prevent any decline. The DOR stated the purpose of ROM exercises included to maintain a resident's mobility and prevent the development of contractures (stiffening/shortening at any joint that reduces the joint's range of motion). During a concurrent observation and interview on 2/25/2026 at 8:16 a.m. with Restorative Nursing Aide 1 (RNA 1) in the resident's room, Resident 8's RNA session was observed. Resident 8 was observed lying in bed and agreeable to the RNA exercises. Resident 8 was observed actively moving the right arm. Resident 8's left elbow was completely extended, the left wrist was extended, and the left hand was positioned in a closed fist. RNA 1 physically moved Resident 8's left arm for ROM exercises at the shoulder, elbow, wrist, and hand joints. Resident 8 complained of pain during elbow flexion (bending) but tolerated the exercises after RNA 1 decreased the degree of ROM provided. RNA 1 positioned a rolled towel in Resident 8's left hand. RNA 1 then moved to the right side of Resident 8's bed. RNA 1 physically moved Resident 8's right arm for ROM exercises at the shoulder, elbow, wrist, and hand joints since Resident 8 fell asleep. RNA 1 stated Resident 8 usually helps with the right arm when Resident 8 was more awake but doesn't move that one (the left arm) at all. RNA 1 stated Resident 8's RNA program included ROM exercises to both arms and did not include both legs. Resident 8 was observed moving the right leg to straighten the knee. Resident 8's left leg was fully extended on the bed. During a follow-up interview on 2/25/2026 at 8:45 a.m. with RNA 1, RNA 1 stated Resident 8 received AROM on the right arm and AAROM on the left arm. RNA 1 stated AAROM exercises (in general) meant a resident could help with the exercises. RNA 1 stated Resident 8 cannot move or assist with ROM exercises on the left arm. RNA 1 stated Resident 8 did not have RNA for ROM exercises to both legs. RNA 1 stated she placed the rolled towel in Resident 8's left hand to help open the fingers. RNA 1 stated Resident 8's left hand could develop contractures if it was constantly positioned in a closed fist. During a concurrent interview and record review on 2/25/2026 at 11:26 a.m. with the DOR, Resident 8's OT Discharge summary, dated [DATE], and PT Discharge summary, dated [DATE], were reviewed. The DOR stated the OT Discharge recommendations included RNA to provide Resident 8 with AROM to the right arm and AAROM to the left arm, three times per week. The DOR stated the PT Discharge recommendation indicated for Resident 8 to continue with PT services. The DOR reviewed Resident 8's PT documentation and stated Resident 8 did not receive additional PT services after the PT discharge on [DATE]. During a concurrent interview and record review on 2/25/2026 at 11:46 a.m. with Physical Therapist 1 (PT 1), Resident 8's PT Discharge summary, dated [DATE], was reviewed. PT 1 stated Physical Therapist 3 (PT 3) provided Resident 8's PT services when PT 1 was on vacation. PT 1 stated Resident 8 had minimal improvement with PT services. PT 1 stated Resident 8 required AAROM on the right leg and passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) on the left leg. PT 1 stated Resident 8's initial discharge plan was to return home with the family, but the family decided for Resident 8 to remain in the facility. PT 1 stated PT 3 should have notified the DOR regarding the recommendations for Resident 8 to continue therapy services. PT 1 stated Resident 8 did not receive any ROM intervention to both legs for approximately one month from PT discharge on [DATE] to today (2/25/2026). PT 1 stated Resident 8 should have received ROM exercises to both legs to prevent contractures and atrophy (loss of muscle), especially on Resident 8's left side which was weak. During a concurrent interview and record review on 2/25/2026 at 1:28 p.m. with Occupational Therapist 1 (OT 1), Resident 8's OT Evaluation, dated 1/19/2026, and OT Discharge summary, dated [DATE], were reviewed. OT 1 stated ROM limitations (in general) were measured with a goniometer (instrument used to measure angles of joint movement). OT 1 stated the OT Evaluation included measurements for Resident 8's PROM on the left shoulder and wrist. OT 1 stated the OT Evaluation indicated Resident 8's PROM on the left hand was impaired but did not include measurements. OT 1 stated Resident 8's left hand did not have a baseline (starting points used for comparison) measurement for ROM. OT 1 stated Resident 8 had some movement in the left arm and recommended RNA for AAROM exercises. OT 1 stated AAROM exercises allowed Resident 8 to contribute to the movement, decrease pain, and prevent Resident 8 from being completely dependent on the left arm. OT 1 stated the RNAs have not reported any changes with Resident 8's RNA program. During a review of the textbook titled, Occupational Therapy for Physical Dysfunction: 7th Edition, published in 2014, Chapter 7 titled, Assessing Abilities and Capacities: Range of Motion, Strength, and Endurance, the textbook indicated the OT used assessments to establish a patient's baseline abilities including specific measurements of joint ROM where limitations were noted. The textbook's Chapter 7 indicated a goniometer is the most common tool used for measuring joint motion of the arms. 2. During a review of the facility's P&P titled, End of Life Care; Hospice and/or Palliative Care, revised 4/2025, the P&P indicated the facility will continue to provide necessary care and services to assist the resident to achieve his or her highest practicable well-being. During a review of Resident 96's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 96 on 2/2/2023 and readmitted on [DATE]. The Face Sheet indicated Resident 96's diagnoses included atherosclerotic (thickening and hardening of the blood vessels) heart disease, acquired absence of the left toes, muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 96's MDS, dated [DATE], the MDS indicated Resident 96 had clear speech, had difficulty communicating some words or finishing thoughts but able if prompted or given time, and usually understood most of the conversation. The MDS indicated Resident 96 had severely impaired cognition. The MDS indicated Resident 96 required substantial/maximal assistance (helper does more than half the effort) for eating and dependent for oral hygiene, toileting, dressing, transferring from lying to sitting on the side of the bed, and char/bed-to-chair transfers. During a review of Resident 96's Joint Mobility Evaluation ([JME] brief assessment of a resident's range of motion in each joint of both arms and legs), dated 7/11/2025, the JME indicated Resident 96's intervention included RNA for PROM exercises to both arms and legs, three times per week as tolerated. The JME indicated Resident 98 had minimum ROM limitations (75-100 percent [%] of range intact) in both shoulders and severe ROM limitation (0-25% of range intact) in the left fingers. The JME indicated Resident 96 experienced a ROM decline in the left hand. During a review of Resident 96's physician's orders, dated 7/31/2025, the physician's orders indicate for the RNA to provide gentle PROM to both arms, three times per week as tolerated. Another physician order, dated 7/31/2025, indicated for the RNA to provide PROM to both legs, three times per week as tolerated. During a review of Resident 96's OT Evaluation and Plan of Treatment, dated 8/12/2025, the OT Evaluation indicated Resident 96 had WFL ROM in the right arm, left elbow, and left wrist. The OT Evaluation indicated Resident 96's left shoulder flexion was limited to 90 degrees, and the left hand had a clenched fist (formed by tightly curling the fingers into the palm) contracture at rest. The OT Evaluation indicated Resident 96 had a history of refusing a splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) and will continue to utilize joint mobilization techniques (skilled, manual therapy used to treat stiffness and restricted ROM) as tolerated to reduce Resident 96's further risk of contracture. During a review of Resident 96's PT Evaluation, dated 8/12/2025, the PT Evaluation indicated Resident 96 had WFL ROM in both hips and ankles. Resident 96's PT Evaluation indicated both knees extended to 90 degrees (bent into a right-angle position). During a review of Resident 96's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated recommendations for the RNA to provide gentle PROM to both arms, three times per week or as tolerated. During a review of Resident 96's PT Discharge summary, dated [DATE], the PT Discharge Summary indicated both of Resident 96's knees improved to 15 degrees of extension. Resident 96's PT Discharge Summary indicated recommendations for RNA to provide ROM to both legs. During a review of Resident 96's unsigned admission Orders/Hospice Certification, dated 2/16/2026, the admission Orders/Hospice Certification indicated Resident 96 was admitted to hospice care with a diagnosis of atherosclerotic heart disease. During a review of Resident 96's physician's orders, dated 2/17/2026, the physician's orders indicated to discontinue RNA for gentle PROM to both arms, three times per week as tolerated, due to Resident 96's hospice care. During a review of another physician's order, dated 2/18/2026, the physician's order indicated to discontinue Resident 96's RNA for PROM to both legs, three times per week as tolerated. During a review of Resident 96's JME, dated 2/24/2026, the JME indicated Resident 96 had a change in condition. The JME indicated Resident 96's interventions included nursing under hospice care. The JME indicated Resident 96 had minimum ROM limitations in both shoulders and severe ROM limitations in the left fingers. During an interview on 2/24/2026 at 8:31 a.m. with the DOR, the DOR stated the purpose of RNA (in general) was to maintain a resident's mobility to prevent any decline. The DOR stated the purpose of ROM exercises included to maintain a resident's mobility and prevent the development of contractures (stiffening/shortening at any joint that reduces the joint's range of motion). During an observation on 2/24/2026 at 12:14 p.m. in the dining room, Resident 96 was observed sitting upright in a Geri chair (chair that allows someone to get out of bed and sit comfortably in different positions while fully supported) for lunch. Resident 96 had a cup of ice cream placed on Resident 96's chest. Resident 96 used the left wrist to steady the cup against Resident 96's chest. Resident 96's left-hand fingers were bent at all joints into a nearly closed fist. Resident 96 scooped and ate the ice cream using the right arm. During an observation on 2/24/2026 at 12:17 p.m., Restorative Nursing Aide 4 (RNA 4) sat in front of Resident 96 to hold the cup while Resident 96 continued to use the right arm to eat the entire cup of ice cream. RNA 4 uncovered Resident 96 lunch plate which contained a scoop of white rice and shredded beef with vegetables. Resident 96 was observed using the right hand to eat the beef and rice with a fork. Resident 96 did not move the left arm during lunch. During an interview on 2/25/2026 at 8:45 a.m. with RNA 1, RNA 1 stated Resident 96 had RNA for ROM exercises to both arms and legs. RNA 1 stated Resident 96's RNA program was discontinued for the past week (2/17/26 and 2/18/26) since Resident 96 was admitted to hospice care [on 2/16/26]. During an observation on 2/25/2026 at 9:00 a.m. in the resident's room, Resident 96 was observed sleeping in bed. During an interview on 2/25/2026 at 9:53 a.m. with RNA 1, RNA 1 stated Resident 96 did not complain of any pain when Resident 96 was receiving RNA for ROM exercises prior to its discontinuation. During an observation on 2/26/2026 at 8:00 a.m. in the resident's room, Resident 96 was observed sleeping while turned to the right side. Resident 96 did not wake up with verbal cues. During an interview on 2/26/2026 at 8:46 a.m. with RNA 1, RNA 1 stated that prior to the discontinuation of RNA exercises, Resident 96 did not refuse ROM exercises but preferred RNA in the afternoon. RNA 1 stated Resident 96 was happy and had conversations during the ROM exercises. RNA 1 stated Resident 96 had more ROM limitations in the left arm and both legs. RNA 1 stated there was an order to discontinue RNA for Resident 96 last week (2/17/26 and 2/18/26). During a telephone interview on 2/26/2026 at 11:11 a.m. with Resident 96's Responsible Party (RP 1), RP 1 stated Resident 96 had stroke (loss of blood flow to part of the brain) a long time ago (unspecified period of time) affecting the left side of the body. RP 1 stated the facility did not ask and RP 1 did not request to stop Resident 96's RNA services for ROM exercises. During a concurrent interview and record review on 2/26/2026 at 12:11 p.m. with Physical Therapist 2 (PT 2) and Occupational Therapist 2 (OT 2). Resident 96's physician orders to discontinue RNA, dated 2/17/2026 and 2/18/2026, and JME, dated 2/24/2026, were reviewed. PT 2 stated RNA services (in general) allowed the residents to maintain their progress achieved during therapy intervention and prevented the development of contractures. PT 2 stated joint contractures affected a resident's mobility and function, including activities of daily living ([ADLs] basic tasks that individuals perform to maintain their daily lives and independence). PT 2 stated Resident 96's JME, dated 2/24/2026, indicated Resident 96 had minimal ROM limitations in both shoulders and severe ROM limitations on the left fingers. OT 2 stated the DOR notified the therapists of Resident 96's transition to hospice services and to discontinue RNA services. PT 2 and OT 2 stated they did not contact the family regarding the discontinuation of RNA services. During an interview on 2/26/2026 at 1:30 p.m. with the Director of Nursing (DON), the DON stated the facility's nursing staff should continue to provide services to a resident on hospice care with the added services of the hospice staff. The DON stated the provision of RNA services, including ROM exercises, application of splints, and ambulation (the act of walking), was under nursing services to prevent contractures, stiffness, and maintain a resident's mobility. The DON stated Resident 96 had ROM limitations and could experience a decline in ROM and increased stiffness without RNA services. The DON did not know the reason Resident 96 was discharged from RNA services. During a telephone interview on 2/26/2026 at 1:35 p.m. with the Hospice Medical Director (Hospice MD), the Hospice MD stated residents on hospice care (in general) should not have any limitation in receiving ROM and movement within the resident's tolerance. During a concurrent interview and P&P review on 2/26/2026 at 1:50 p.m. with the DON, Resident 96's physician orders to discontinue RNA services, dated 2/17/2026 and 2/18/2026, and the facility's P&P titled, ROM and Contracture Prevention, revised 5/2019, were reviewed. The DON stated Resident 96 has not received RNA for ROM to both arms (since 2/17/2026) for nine days and ROM to both legs for eight days (since 2/18/2026). Resident 96 could experience increased stiffness and contractures to both arms and legs without RNA services. The DON reviewed the facility's P&P titled, ROM and Contracture Prevention, and stated every resident, including residents on hospice services, should receive services to prevent ROM decline. During a review of the facility's P&P titled, ROM and Contracture Prevention, revised 5/2019, the P&P indicated the facility ensured residents received services, care, and equipment to assure that: Every resident maintains, and/or improves to his/her highest level of range of motion (ROM) and mobility, unless a reduction is clinical unavoidable; and Every resident with limited range of motion and mobility maintains or improves function unless reduced Range of Motion (ROM)/mobility is unavoidable based on the resident's clinical condition. During a review of the facility's policy and procedure (P&P) titled, ROM and Contracture Prevention, revised 5/2019, the P&P indicated the facility ensured that residents receive services and care to assure that Every resident maintains, and/or improves to his/her highest level of range of motion (ROM) and mobility, unless a reduction is clinically unavoidable. During a review of Resident 8's Face Sheet (summary of a resident's information), the Face Sheet indicated the facility admitted Resident 8 on 10/10/2025 and readmitted on [DATE]. Resident 8's Face Sheet indicated Resident 8's diagnoses included dysphagia (difficulty swallowing) following cerebral infarction (brain damage due to a loss of oxygen to the area), lack of coordination, and metabolic encephalopathy (disease that affects the brain, causing changes in its function).

Based on observation, interview, and record review, the facility did not ensure that two of three sample residents' (Resident 70 and Resident 204) fluid intake was not monitored to restrict fluid intake at 1000 milliliters (mL, unit of weight) per 24 hours while on hemodialysis (dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) as ordered by the physician and in accordance with the facility's policy and procedures titled Licensed Nurse Procedures: Fluid Restrictions, 1.Resident 70's total fluid intake was within the fluid restrictions parameters on 2/3/2026, 2/4/2026, 2/17/2026, 2/18/2026, and 2/24/206. 2.Resident 204's total fluid intake was accurately documented and fluid restrictions parameters on 2/13/2026 to 2/25/2026. These failures had the potential to place Resident 70 and Resident 204 at risk for altered hydration status which may lead to severe dehydration or fluid overload which may result in a hypotensive (low blood pressure) or hypertensive (high blood pressure) blood pressure emergency, edema (swelling), shortness of breath, heart failure (heart cannot effectively pump blood to the rest of the body) and may ultimately lead to hospitalization. Findings: 1.During a review of Resident 70's admission Record, the facility admitted Resident 70 on 11/8/2024, and the facility readmitted Resident 70 on 12/12/2025 with diagnoses that included Type 2 Diabetes Mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with Diabetic Chronic Kidney Disease (disease where high blood sugar and blood pressure damage the kidney's blood vessels over time causing the kidneys to stop working properly), End Stage Renal Disease (ESRD, irreversible kidney failure), and dependence on renal dialysis. During a review of Resident 70's History and Physical (HP), dated 9/12/2025, the HP indicated that Resident 70 can make her needs known but cannot make medical decisions. During a review of Resident 70's care plan, dated 1/29/2026, the care plan indicated that Resident 70 was at risk for renal insufficiency related to ESRD. The care plan's interventions included to monitor for signs and symptoms of fluid overload such as swelling, difficulty breathing, and weight gain over 2 pounds (lbs, unit of weight) over a day, and to monitor Resident 70 fluid intakes and output every shift with a fluid restriction of 1000 mL per 24 hours. During a review of Resident 70's care plan, dated 1/29/2026, the care plan indicated Resident 70 was dependent on renal dialysis related to ESRD. The care plan's interventions included monitoring vital signs and weight, and to monitor Resident 70 fluid intake and output every shift with a fluid restriction of 1000 mL per 24 hours. During a review of Resident's 70 Minimal Data Set (MDS, a resident assessment), dated 2/6/2026, the MDS indicated that Resident 70's cognitive (a resident's thought process) skills were moderately impaired and received a therapeutic diet (a physician prescribed diet). The MDS indicated that Resident 70 received dialysis. During a review of Resident 70's Order Summary Report, the order, dated 1/29/2026, the order indicated to monitor Resident 70 for intake and output each shift for a fluid restriction of 1000mL per 24 hours. The order indicated the following: Nursing: Day shift - 300mL, PM shift - 120mL, NOC shift - 100mL; Dietary: Breakfast -240mL, Lunch - 120mL, and Dinner 120mL. 2. During a review of Resident 204's admission Record, the facility admitted Resident 204 on 2/12/2025, and the facility readmitted Resident 204 on 2/10/2026 with diagnoses that include DM with Diabetic Chronic Kidney Disease, ESRD, and dependence on renal dialysis. During a review of Resident 204's MDS, dated [DATE], the MDS indicated that Resident 204's cognitive skills were moderately impaired. The MDS indicated that Resident 204 was on a therapeutic diet and received dialysis. During a review of Resident 204's care plan, initiated 2/10/2026, the care plan indicated Resident 204 was at risk for complications related to ESRD and hemodialysis. The care plan's interventions included monitoring and reporting any signs and symptoms of renal insufficiency such as changes in level of consciousness and changes in heart and lunch sounds, and monitoring Resident 204's intake and output with a fluid restriction of 1000mL per 24 hours. During a review of Resident 204's Order Summary Report, order, dated 2/10/2026, indicated to monitor Resident 204's intake and output every shift. During a review of Resident 204's care plan, initiated on 2/11/2026, the care plan indicated Resident 204 had the potential for nutritional problems related to her ESRD on dialysis three times a week, and DM. The care plan's interventions included providing therapeutic carbohydrate consistent renal diet (CCHO diet), monitoring intake at every meal, and monitoring Resident 204's intake and output with a fluid restriction of 1000mL per 24 hours. During a review of Resident 204's HP, dated 2/13/2026, the HP indicated that Resident 204 did not have the capacity to understand and make decisions. During a review of Resident 204's Order Summary Report, the order, dated 2/24/2026, indicated to monitor Resident 204 Intake and Output each shift for a fluid restriction of 1000mL per 24 hours. The order indicated the following: Nursing: Day shift - 300mL, PM shift - 120mL, NOC shift - 100mL; Dietary: Breakfast - 120mL, Lunch - 120mL, Dinner - 240mL. During a concurrent observation and interview on 2/26/2026 at 8:43 AM in Resident 70's room, Resident 70 was observed sitting in her wheelchair with three partially consumed 8 oz water bottles on her overbed table (an adjustable table with lockable wheels designed to roll over a bed or chair and provide a flat and stable surface). Resident 70 stated, she could not remember when she received the water bottles and was unsure how much water she drank today and stated that she just takes sips of water. During an interview on 2/26/2026 at 12:45 PM with Registered Nurse (RN) 1, RN 1 explained that it is important to monitor a dialysis resident's fluid intake to prevent fluid overload, which can cause increased blood pressure, abnormal lung sounds, and swelling. RN 1 stated the resident's fluid restriction is divided into two parts: nursing (fluids given with medications or between meals, monitored by licensed nurses) and dietary (fluids provided on meal trays, with Certified Nurse Assistants (CNAs) responsible for documenting intake during meals). During an interview and record review on 2/26/2026 at 1 PM, RN 1 reviewed Resident 70's MAR and Point of Care fluid intake records for February 2026. RN 1 stated that on 2/3/2026, 2/4/2026, 2/17/2026, 2/18/2026, and 2/24/2026, documentation showed Resident 70's fluid consumption exceeded more than the 1000 mL per day fluid restriction. RN 1 explained that CNAs typically report how much the resident drinks during meals, and licensed nurses are responsible for ensuring the resident's total daily fluid intake stays within the ordered limit. During a concurrent interview and record review on 2/26/2026 at 2:35 PM with the Assistant Director of Nursing (ADON), Resident 204's MAR from 2/13/2026 to 2/25/2026, the MAR did not document the resident's shift by shift fluid intake. The ADON explained that without numerical values, licensed nurses cannot determine the resident's actual fluid intake, and therefore Resident 204 may have exceeded her 1000 mL per day fluid restriction. During a review of the facility's policies and procedures (P&P) titled Licensed Nurse Procedures: Fluid Restrictions, revised May 2007, the P&P indicated it was important to ensure fluid needs are met while not exceeding limits established by the physician. The P&P indicated that nursing will note fluid restrictions and will complete Intake and Output.

Based on observation, interview, and record review, the facility failed to assess the pain level for one of two sampled residents (Resident 203), who verbalized pain during medication pass. This has the potential to result in Resident 203's unmet needs affecting the residents' quality of life. Findings: During a review of Resident 203's admission Record (AC), the AC indicated the resident was admitted to the facility on [DATE] with diagnoses that included During a review of Resident 203's History and Physical (H&P) dated 2/12/2026, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 203's Order Summary Report dated 2/26/2026, the Order Summary Report indicated a medication order for: 1.Acetaminophen/Tylenol (a medication used to treat pain) oral tablet 325 milligrams (mg a unit of measurement), give 2 tablet by mouth every 6 hours as needed for mild pain (1-3) with an order start date of 2/17/2026. 2.Tramadol HCL (a medication used to treat pain) oral tablet 50 mg (Tramadol HCL) give 1 tablet by mouth every 6 hours as needed for moderate pain (4-6) During a medication pass observation on 2/25/2026 at 8:48 AM with Licensed Vocational Nurse (LVN 2), Resident 203 asked LVN 2 for pain medication as his stomach hurt when he eats. LVN 2 reviewed the resident's medications, took out Tylenol and Tramadol, and asked the resident which one he preferred. Resident 203 chose Tramadol, stating he hadn't taken it in a while. LVN 2 then administered one tablet of Tramadol 50 mg. During a follow up interview with LVN 2 on 2/25/2025 at 8:55 AM, LVN 2 stated she forgot to assess Resident 203s pain. LVN 2 stated it is facility and nursing practice to ask a resident to rate their pain level from 1-101=lowest amount, 10=most painful) and ask questions as onset of pain, what makes it worst. LVN 2 stated, she forgot to conduct the pain assessment before administering the Tramadol HCL 50mg to Resident 203. LVN 2 stated it was important to ask the numeric pain level so that she could choose the appropriate pain medication for Resident 203's pain as he had a few different options based on his pain level. During an interview on 2/26/2025 at 1:39 PM, the Director of Nursing (DON) stated that when a resident verbalizes pain, nurses are required to perform a pain assessment first. This includes identifying the location of the pain, obtaining a numeric pain rating, and using that information to select the appropriate medication. The DON explained that failing to assess pain properly can lead to incorrect dosing or overmedicating a resident by not following the physician ordered parameters. During a review of the facility's policy and procedure (P&P) titled Pain Recognition and Management, with a revision date of 4/2025, the P&P indicated Pain will be identified and documented in the electronic health record (HER) using a scale 1-10 is most common

Based on interview and record review the facility failed to follow physician's orders for one of one sampled resident (Resident 4) who was receiving Hydrocodone (medication used to treat severe, chronic pain) as needed for moderate and severe pain. This deficient practice increased the risk of Resident 4 to experience adverse effects (unwanted and dangerous side effect of medications) that could lead to health complications, such as severe respiratory depression [breathing problems], coma, addiction, and severe low blood pressure. Findings: During a review of Resident 4's admission Record (AR), the AR indicated the resident was admitted on [DATE] with diagnoses that included toxic encephalopathy (brain dysfunction caused by exposure to toxins like solvents, heavy metals, industrial chemicals, drugs, or poisons), specified disorders of urinary system (include urinary tract infections, kidney stones, bladder control) , and extended spectrum beta lactamase (enzymes produced by bacteria that breakdown and cause resistance to common antibiotics that make infections hard to treat). During a review of Resident 4's History and Physical (H&P), dated 1/30/2026, the H&P indicated the resident had the capacity to make medical and financial decisions. During a review of Resident 4's Order Summary Report indicated the following orders: Dated 1/30/2026, indicated a physician order was made for HYDROcodone-Acetaminophen Oral Tablet 5-325 milligrams (mg, unit of measure) (Hydrocodone-Acetaminophen) Controlled Drug, Give 1 tablet by mouth every 4 hours as needed for moderate pain (4-7). Dated 2/2/2026, indicated a physician order was made for HYDROcodone-Acetaminophen Oral Tablet 5-325 mg (Hydrocodone-Acetaminophen) Controlled Drug * Give 2 tablet by mouth every 4 hours as needed for Pain Management, Give 2 by mouth every 4 hours as needed for severe pain (8-10) per Physician's Assistant (PA). During a review of Resident 4's Medication Administration Record (MAR) for February 2026 indicated that Resident 4 was administered Hydrocodone Acetaminophen Oral Tablet 5 325 mg, a controlled medication, with physician orders to administer one tablet every 4 hours as needed for moderate pain (4-7) and two tablets every 4 hours as needed for severe pain (8-10), as ordered by the Physician Assistant (PA). The MAR reflected the following administrations in which two tablets were given despite the resident reporting a pain level below 8-10, which was inconsistent with the physician's order: On 2/2/2026 at 4:30 PM, pain level 7 On 2/2/2026 at 8:57 PM, pain level 7 On 2/3/2026 at 8:14 PM, pain level 0 On 2/5/2026 at 6:21 PM, pain level 4 On 2/5/2026 at 10:32 PM, pain level 7 On 2/6/2026 at 7:15 PM, pain level 4 On 2/7/2026 at 11:58 PM, pain level 7 On 2/8/2026 at 4:18 AM, pain level 6 On 2/8/2026 at 8:45 AM, pain level 7 On 2/10/2026 at 8:36 PM, pain level 7 On 2/11/2026 at 6:35 PM, pain level 4 On 2/13/2026 at 1:10 AM, pain level 7 On 2/13/2026 at 2:35 PM, pain level 6 During a concurrent interview and record review of Resident 4's MAR on 2/26/2026 at 1:39 PM, the Director of Nursing (DON) stated the nurses should have followed the physician's orders because it indicates the parameters for the pain medication. The DON stated if the physician orders are not followed the resident could get sedated, drowsy, and overmedicated. During a concurrent interview and record review of Resident 4's MAR on 2/26/2026 at 2:04 PM, the Assistant DON (ADON) confirmed he gave Resident 4 two tablets of Hydrocodone for a pain level of 6 because the resident mentioned she wanted Hydrocodone and knew she was due for pain medication. The ADON stated if the physician order is not followed the resident could experience dizziness or sleepiness. A review of the facility's policy and procedure (P&P) titled Six Rights of Medication Administration, dated 5/2018 indicated the six rights of medication administration are as follow in order to ensure safety and accuracy of administration: Right Resident - Resident is identified prior to medication administration Right Time - Medications are administered within prescribed time frames. Right Medication order- Medications are checked against the order before they are given. Right Dose-Medications are administered according to the dose prescribed Right Route - Medications are administered according to the route prescribed Right Documentation - Document administration or refusal of the medication after the administration or attempt and note any concerns A review of the facility's P&P titled Pain Recognition and Management, dated 4/2025 indicated pain management was provided to residents who require such services, consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and the residents' goals and preferences.

Based on interviews and record reviews the facility failed to ensure one of two sampled residents (Resident 1), was free from significant medication errors (medications which causes the patient discomfort or jeopardizes his or her health and safety) by ensuring facility licensed nurses administered medications in accordance with the physician ' s orders and resident ' s plan of care. Resident 1, who had a diagnosis of Type 2 diabetes mellitus (a chronic condition characterized by high levels of sugar in the blood) was not given Apixaban (a medication used to prevent serious blood clots [gel-like clumps of blood] from forming due to a certain irregular heartbeat) as scheduled on [DATE]. In addition, the licensed nurses did not administer insulin (a hormone produced in the pancreas [gland behind the stomach], which regulates the amount of glucose in the blood) as indicated in the insulin sliding scale (insulin administration regimen which included administering more insulin if blood sugar levels are high) order to manage and control the resident ' s blood sugar levels. These deficient practices resulted to adverse reactions and health complications from missing doses of significant medications. On [DATE], Resident 1 was transferred to the general acute care hospital (GACH) Emergency Department (ED) with a blood sugar of more than 1000 mg/dL (the recommendation for someone who is diabetic is between 80 to 130 mg/dL). Resident 1 expired on [DATE] with diagnoses including cardiopulmonary arrest (the abrupt loss of heart function in a person who may or may not have been diagnosed with heart disease), acute respiratory failure (a serious condition that makes it difficult to breathe), and nonketotic hyperosmolar coma (also referred as diabetic coma [a potentially deadly condition that can develop as a result of illness in people with uncontrolled type 2 diabetes or when diabetes medications are not taken as directed]). Findings: A review of Resident 1 ' s Admission Record indicated the facility initially admitted the resident on [DATE] and readmitted on [DATE] with diagnoses including Type 2 diabetes mellitus (a chronic condition characterized by high levels of sugar in the blood), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and hypertension (high blood pressure). A review of Resident 1 ' s History and Physical dated [DATE], indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS, a standardized patient assessment and care planning tool) dated [DATE], indicated Resident 1 required extensive (weight-bearing support provided three or more times in 7 days) one-person physical assistance for bed mobility. The MDS indicated Resident 1 required total dependence (full staff performance every time during entire 7 day-day period) on one-person for dressing, eating, toilet use and personal hygiene. A review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST; a portable medical order for patients who are seriously ill or have advanced frailty tells all health care providers what they want during an emergency and what their goals of care are given their current medical condition) signed and dated [DATE] by Physician 1 and RP 1 indicated, Section A box - Do not attempt resuscitation/DNR ([Do Not Resuscitate] a physician order that means a person does not want to be resuscitated [the act or an instance of reviving someone from apparent death] in the event of a cardiac arrest) (allow natural death) was checked off. Section B indicated Comfort Focused Treatment box was checked off. The POLST further indicated Primary goal of maximizing comfort. Relieve pain and suffering with medication by any route as needed, use oxygen (a colorless, odorless, tasteless gas essential to living organisms), suction (a pump used to maintain an airway by removing secretions from the mouth, throat, or lungs), and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal. Request to transfer to hospital only if comfort needs cannot be met in current location. A review Resident 1 ' s care plan dated [DATE], for Diabetes Mellitus indicated Resident 1 ' s goal would be free from any signs and symptoms of hyperglycemia (excess of glucose in the bloodstream). The care plan interventions included to administer diabetes medication as ordered by the physician and to monitor/document/report to the physician signs and symptoms of hyperglycemia which included Kussmaul breathing (abnormal, deep, rapid, and labored breathing), stupor (a state of near unconsciousness), and coma (a state of profound unconsciousness caused by disease). A review of the facility ' s Medication Administration Record (MAR) Chat Codes found at the last page of Resident 1 ' s MAR for [DATE] to [DATE] included the following MAR code descriptions: 2= Hold/See Nurses Notes 7= Other/See Nurse Notes 10= hospitalized 14= No Insulin Required A review of Resident 1 ' s Order Summary Report (Physician Orders) indicated the following physician orders with order date range between [DATE] to [DATE]: 1. A review of Physician order dated [DATE], indicated to administer Apixaban 2.5 milligrams (mg- unit of measurement), via gastrostomy tube (g-tube; a surgically placed device used to give direct access to the person ' s stomach for supplemental feeding, hydration or medicine) two times a day. Further review of Resident 1 ' s [DATE] Medication Administration Record (MAR) for Apixaban 2.5 mg with order dated [DATE], two times a day (pre-scheduled at 7 AM and 10 PM) indicated the following information: a. On [DATE] scheduled at 7 AM with the initials of Licensed Vocational Nurse (LVN) 1 indicated the code 7 (Other/See Nurses Notes). b. The MAR indicated that Resident 1 ' s Apixaban 2.5 mg two times a day with order dated [DATE] was discontinued on [DATE] timed at 9:54 AM. A review of Resident 1 ' s physician order pages, or order summary reports did not indicate a discontinue order transcribed (written out) for Apixaban 2.5 mg two times a day on [DATE]. 2. A review of another Physician order dated [DATE], indicated to administer Apixaban 2.5 mg via g-tube two times a day. Further review of Resident 1 ' s [DATE] MAR for Apixaban 2.5 mg with order dated [DATE], two times a day (pre-scheduled at 9 AM and 3 PM), indicated the following information: a. On [DATE] scheduled at 3 PM with the initials of LVN 2 indicated the code 2 (Hold/See Nurses Notes). b. The MAR indicated that Resident 1 ' s Apixaban 2.5 mg two times a day with order dated [DATE]was put on hold from [DATE] timed at 3:18 PM to [DATE] timed at 5:13 PM. A review of Resident 1 ' s physician order pages, or order summary reports did not indicate a hold order transcribed (written out) for Resident 1 ' s Apixaban 2.5 mg two times a day on [DATE]. 3. A review of Physician order dated [DATE], indicated to inject Insulin Aspart (a fast-acting insulin [a synthetic hormone [man-made; not produced naturally in the body] which works by lowering the blood sugar level in the body] that starts to work about 15 minutes after injection) Solution: inject as per insulin sliding scale if ,d+[DATE]= 3 units, ,d+[DATE]= 4 units, 250- 299= 5 units, ,d+[DATE]= 7 units, 350- 399= 10 units, if blood sugar greater than 399 give 12 units, recheck then call MD (medical doctor), subcutaneously (applied under the skin) three times a day for Diabetes . Further review of Resident 1 ' s [DATE] MAR for Insulin Aspart Solution sliding scale with order dated [DATE] three times a day (pre-scheduled at 7 AM, 3 PM, and 10 PM) indicated the following information: a. On [DATE] scheduled at 3 PM - with the initials of LVN 2, indicated Resident 1 ' s blood sugar was 298 mg/dL (milligrams per deciliter). The MAR indicated LVN 2 administered 5 units of Insulin Aspart. b. On [DATE] scheduled at 10 PM - with the initials of LVN 2, indicated Resident 1 ' s blood sugar was 183 mg/dL. The MAR indicated LVN 2 administered 3 units of Insulin Aspart. c. On [DATE] scheduled at 7 AM - with the initials of LVN 1, indicated Resident 1 ' s blood sugar was NA (not included in the MAR ' s chat codes) and the code 7 (Other/See Nurses Notes). d. The MAR indicated that Resident 1 ' s Insulin Aspart Solution sliding scale with order dated [DATE] three times a day was discontinued on [DATE] at 10:02 AM. A review of Resident 1 ' s physician order pages, or order summary reports did not indicate a hold order transcribed (written out) for Resident 1 ' s Insulin Aspart Solution sliding scale three times a day on [DATE]. 4. A review of another Physician order dated [DATE], indicated to inject Insulin Aspart Solution as per sliding scale if blood sugar is 150 to 199 = 3 units, 200 to 249 = 4 units, 250 to 299 = 5 units, 300 to 349 = 7 units, 350 to 399 =10 units. The physician order indicated that if the blood sugar is greater than 399, to give 12 units, recheck then call MD (medical doctor), subcutaneously every 6 hours for Diabetes . Further review of Resident 1 ' s [DATE] MAR for Insulin Aspart Solution sliding scale with order dated [DATE] every 6 hours (pre-scheduled at 12 AM, 6 AM, 12 PM, and 6 PM), indicated the following information: a. On [DATE] scheduled at 12 PM, with the initials of LVN 1, indicated Resident 1 ' s blood sugar was NA and the code 7 (Other/See Nurses Notes). There was no other documented evidence indicated in the MAR what NA means. b. On [DATE] scheduled at 6 PM - with the initials of LVN 2, indicated Resident 1 ' s blood sugar was 410 mg/dL and the code 7 (Other/See Nurses Notes). There was no other documented evidence indicated in the MAR if insulin was administered to Resident 1. c. On [DATE] scheduled at 12 AM, with the initials of LVN 4, indicated Resident 1 ' s blood sugar was 399 mg/dL. The MAR indicated LVN 4 administered 10 units of Insulin Aspart. d. On [DATE] scheduled at 6 AM, with the initials of LVN 4, indicated Resident 1 ' s blood sugar was 378 mg/dL. The MAR indicated LVN 4 administered 10 units of Insulin Aspart. c. On [DATE] scheduled at 12 PM, with the initials of LVN 3, indicated Resident 1 ' s blood sugar was NA and the code 7 (Other/See Nurses Notes). There was no other documented evidence indicated in the MAR what NA means. f. On [DATE] scheduled at 6 PM, with the initials of LVN 2, indicated Resident 1 ' s blood sugar was 396 mg/dL. The MAR indicated LVN 2 administered 10 units of Insulin Aspart. g. On [DATE] scheduled at 12 AM, with the initials of LVN 4, indicated Resident 1 ' s blood sugar was400 mg/dL and the code 14 (No Insulin Required). There was no other documented evidence indicated in the MAR why insulin was not required and administered to Resident 1. h. On [DATE] scheduled at 6 AM with the initials of LVN 4, indicated Resident 1 ' s blood sugar was 397 mg/dL. The MAR indicated LVN 4 administered 10 units of Insulin Aspart. i. On [DATE] scheduled at 12 PM with the initials of LVN 1, indicated Resident 1 ' s blood sugar was NA and the code 7 (Other/See Nurses Notes). There was no other documented evidence indicated in the MAR what NA means. j. The MAR indicated that Resident 1 ' s Insulin Aspart Solution sliding scale with order dated [DATE] every 6 hours was put on hold from [DATE] timed at 3:27 PM to [DATE] timed at 5:12 PM. A review of Resident 1 ' s physician order pages, or order summary reports did not indicate a hold order transcribed (written out) for Resident 1 ' s Insulin Aspart Solution sliding scale every 6 hours on [DATE]. A review of untitled documents authored by LVN 1 and printed from the facility ' s electronic medical records provided by the facility to the California Department of Public Health (CDPH) on [DATE], indicated the following Resident 1 ' s order history/information: 1. Insulin Aspart Solution sliding scale every 6 hours was placed on hold on [DATE]timed at 3:27 PM. The facility document indicated hold per md order ' ' as the hold reason. The facility document indicated the Insulin Aspart Solution sliding scale every 6 hours resumed on [DATE]timed at 5:12 PM. The facility document indicated per family request as the reason to resume. 2. Apixaban 2.5 mg two times a day was placed on hold on [DATE] timed at 3:18 PM. The facility document indicated hold per md order ' ' as the hold reason. The facility document indicated the Apixaban 2.5 mg two times a day was resumed on [DATE]timed at 5:13 PM. The facility document indicated per family request ' ' as the reason to resume. A review of Resident 1 ' s Progress Notes for [DATE] indicated the following information about Resident 1 ' s Nurses Notes and Electronic MAR (eMAR) Notes: 1. On [DATE] timed at 9:44 AM, the eMAR Note authored by LVN 1 for Apixaban 2.5 mg indicated Resident (1) actively dying, DNR, family doesn ' t want further treatment. The Note did not indicate documented evidence Physician 1 was notified that RP 1 and RP 2 did not want to continue further treatments for Resident 1. 2. On [DATE] timed at 9:45 AM, the eMAR Note authored by LVN 1 for Resident 1 ' s Insulin Aspart sliding scale did not indicate what the code NA means as documented in the MAR dated [DATE] timed at 7 AM. The eMAR Note did not indicate that Insulin Aspart was administered to Resident 1. 3. On [DATE] timed at 9:55 AM, authored by LVN 1, indicated Resident 1 manifested changes in condition that included desaturation (means that the percentage of oxygen in the blood is lower than it should be), hypoxemia (a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath), and tachypnea (abnormally rapid breathing). The note indicated Resident 1 ' s blood pressure at ,d+[DATE] millimeter per mercury (mm/Hg; unit of measurement) (top number of blood pressure less than 120 is considered normal; bottom number of blood pressure below 80 is considered within normal), pulse of 123 beats per minute (normal pulse rate is between 60 and 100), respiration of 50 breaths per minute (normal respiratory rate is between 12 to 20 at rest) and oxygen saturation (the measure of how much oxygen is traveling through the body) of 90 percent (%) (normal levels are between 95% to 100%) while in room air (no oxygen supplement). The Note indicated LVN 1 notified Physician 1 and Responsible Party (RP) 2 of Resident 1 ' s change in condition on [DATE] at 10 AM. The Note did not indicate any new orders from Physician 1. 4. On [DATE] timed at 10:09 AM, indicated a Note authored by Registered Nurse (RN) 1. The Note indicated that around 9:44 AM, Resident 1 ' s oxygen saturation was 55 % and respiration of 40 . The Note indicated RN 1 checked resident ' s chart and noted to be DNR with comfort focused treatment. The Note indicated RN 1 asked RP 2 if RP 2 would like Resident 1 to be transferred to the acute hospital. The Note stated that RP 2 informed RN 1 to keep Resident 1 at the facility while RP 1 and RP 2 arrive at the facility to see the resident. The Note indicated that RN 1 paged Physician 1 to inform Physician 1 of RP 2 ' s decision. The Note indicated Waiting for call back for any orders at this time. 5. On [DATE] timed at 11:35 AM, indicated RN 1 ' s Note that RP 1 and RP 2 arrived at the facility. The Note indicated that RP 1 and RP 2 verified their decision to keep resident at the facility and no transfer. The Note did not indicate that RP 1 and RP 2 requested to discontinue or hold all of Resident 1 ' s medications. 6. On [DATE] timed at 12:47 PM, indicated an eMAR Note authored by LVN 1 for Resident 1 ' s Insulin sliding scale dated [DATE] timed at 12 PM and wrote NA. The eMAR Note did not indicate what the code NA means as documented in the MAR. The eMAR Note indicated Resident actively dying, DNR, family doesn ' t want further treatment. The eMAR Note did not indicate if Insulin Aspart was administered to Resident 1. The Note did not indicate Physician 1 ordered to discontinue or hold Resident 1 ' s medications. 7. On [DATE] timed at 6:10 PM, indicated an eMAR note authored by LVN 2 for Resident 1 ' s blood sugar result of 410 mg/dL and wrote 7 in the MAR. The eMAR note indicated B/S (blood sugar) 402 mg/dL. The eMAR note did not indicate if LVN 2 administered 12 units of insulin for a blood sugar of 410 mg/dL, or recheck Resident 1 ' s blood sugar, and called Physician 1, as indicated in the insulin sliding scale order. 8. On [DATE] timed at 12:10 PM, indicated an eMAR note authored by LVN 3 for Resident 1 ' s Insulin sliding scale dated [DATE] timed at 12 PM and wrote NA. The eMAR note indicated blood sugar (BS) was above sliding scale. The eMAR Note did not indicate Resident 1 ' s blood sugar reading. The eMAR note indicated LVN 3 administered 12 units of Insulin Aspart and made Physician 1 aware. The eMAR note did not indicate if Physician 1 had called or texted back with new orders. The eMAR note did not indicate if LVN 3 rechecked Resident 1 ' s blood sugar after 12 units of insulin was administered and called Physician 1 again as indicated in the insulin sliding scale order. 9. Further review of the Progress Notes did not include an eMAR note from LVN 4 during the 11 PM to 7 AM shift for the blood sugar result of 400 mg/dL, on [DATE] timed at 12 AM. The Progress Notes did not indicate the reason why LVN 4 documented the code 14 (No Insulin Required) in Resident 1 ' s MAR. 10. On [DATE] timed at 12:07 PM and 12:08 PM, indicated an eMAR note authored by LVN 1 for Resident 1 ' s MAR code indicating NA. The eMAR note indicated Resident 1 ' s BS above parameter, administered 12 units (insulin). MD (Physician 1) made aware. The eMAR note did not indicate if Physician 1 had called or texted back with new orders. The eMAR note did not indicate if LVN 3 rechecked Resident 1 ' s blood sugar after 12 units of insulin was administered and called Physician 1 again as indicated in the insulin sliding scale order. 11. On [DATE] timed at 1:50 PM, indicated a Nursing note authored by RN 2. The Note indicated that RP 1 and RP 2 requested to transfer Resident 1 to the GACH for further evaluation . The Note indicated that RN 2 called [DATE] emergency services at 1:50 PM. The Note indicated that Resident 1 left the facility at 2:11 PM with RP 1 and RP 2. The Note indicated RN 2 notified Physician 1. A review of the facility ' s glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in the blood) machine manufacturer's information indicated, Performing a control solution test with a revision date of [DATE], indicated that when the image HI appeared on the glucometer screen, that means the Blood glucose (blood sugar) is more than 600 mg/dL. Repeat the test using a new test strip. If this message appears again, contact a healthcare professional immediately! A review of Resident 1 ' s Chest X-ray result with date of exam [DATE] indicated No acute pneumonia (an acute disease that is marked by inflammation of lung tissue) . no pneumothorax (a collection of air outside the lungs) is visualized . The Impression indicated No acute disease in the chest. A review of the General Acute Care Hospital (GACH) Emergency Department (ED) Note dated [DATE] timed at 2:33 PM, indicated Resident 1 arrived at the ED with hypotension (low blood pressure) and shortness of breath. The vital signs indicated a temperature of 99.1, heart rate of 119, blood pressure of ,d+[DATE], and respirations of 44. The ED Note indicated Resident 1 ' s blood sugar levels taken by the glucose meter (a device for measuring the concentration of glucose in the blood) indicated >600 at 2:37 PM, 1075 at 2:49 PM, >600 at 5:14 PM, and >600 at 7:50 PM. The ED Note indicated under Medical Decision Making, indicated the GACH started Resident 1 on intravenous (IV; into a vein) fluids and antibiotics (medication that inhibit the growth of bacteria), insulin drip (insulin given through an intravenous line [IV] rather than by injection), and admitted to the intensive care unit (ICU [a department of a hospital in which patients who are dangerously ill are kept under constant observation]). A review of Resident 1 ' s General Acute Care Hospital (GACH) Discharge Summary dated [DATE] indicated Resident 1 arrived at the GACH ED with a blood sugar of more than 1000, BUN (Blood, Urea Nitrogen) of 145, and creatinine level of 4.45. The GACH Discharge Summary indicated Resident 1 expired on [DATE] with diagnoses including cardiopulmonary arrest (the abrupt loss of heart function in a person who may or may not have been diagnosed with heart disease), acute respiratory failure (a serious condition that makes it difficult to breathe), acute renal failure (a condition in which the kidneys suddenly cannot filter waste from the blood) on chronic, nonketotic hyperosmolar coma (also referred as diabetic coma [a potentially deadly condition that can develop as a result of illness in people with uncontrolled type 2 diabetes or when diabetes medications are not taken as directed]), dehydration (the loss of water and salts essential for normal body function), pneumonia, and septic shock (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues). During a telephone interview with RP 1 on [DATE] at 10:17 A.M., RP 1 stated a nurse (unable to recall who) called and informed her on [DATE] that Resident 1 was having trouble breathing. RP 1 stated that the nurse asked if RP 1 would like to have Resident 1 transferred to the GACH. RP 1 stated she told the facility not to transfer Resident 1 to the acute hospital until they come see Resident 1 in the facility. During a telephone interview with RP 2 on [DATE] at 10:32 A.M., RP 2 stated RP 1 and RP 2 arrived in the facility on [DATE] before noon. RP 2 stated LVN 1 left Resident 1 ' s room and informed them that she would come back soon to check Resident 1 ' s blood sugar. RP 2 stated about five or six hours had passed, and no one had come back to Resident 1 ' s room to check the resident ' s blood sugar or give any medications. RP 2 stated he looked for somebody and found LVN 2 and asked why LVN 1 had not administered Resident 1 ' s insulin, medications, or checked Resident 1 ' s blood sugar during that shift. RP 2 stated that LVN 2 told him that Physician 1 had ordered to hold all of Resident 1 ' s medications/treatments, except for the Oxygen. RP 2 stated no one in the facility had asked or discussed with either RP 1 or RP 2 that Physician 1 had ordered to hold all of Resident 1 ' s medications/treatments. During an interview with LVN 1 on [DATE] at 1:33 PM, LVN 1 stated that on [DATE], during the 7 AM to 3 PM shift (charge nurse for Resident 1), between 9:30 AM to 10 AM, Resident 1 was having trouble breathing, eyes were closed, and Resident 1 was not responsive to verbal or tactile (pertaining to the sense of touch) stimulation. LVN 1 stated she notified RN 1. LVN 1 stated that it was RN 1 who told her to hold everything for Resident 1. LVN 1 stated she could not remember why she put NA on Resident 1 ' s MAR for the resident ' s blood sugar check on [DATE] timed at 7 AM. LVN 1 stated she also put NAon Resident 1 ' s MAR at 12 PM blood sugar check because she thought that all the orders for Resident 1 were placed on hold. When LVN 1 was asked what the abbreviation NA means, LVN 1 stated I do not remember. During the same interview on [DATE] at 1:33 PM, LVN 1 stated that when she checked Resident 1 ' s blood sugar on [DATE] at 7 AM and 12 PM, the glucometer reading indicated HI, but she did not document the blood sugar results in Resident 1 ' s eMAR note. LVN 1 stated when she informed RN 1 of Resident 1 ' s blood sugar result of HI, LVN 1 stated RN 1 instructed her to hold Resident 1 ' s medications, including the insulin. LVN 1 stated LVN 1 did not know why RN 1 did not write the physician order in Resident 1 ' s physician order sheets to hold Resident 1 ' s medications. LVN 1 stated, She could not recall if she notified Physician 1 of Resident 1 ' s glucometer reading of HIon [DATE]. LVN 1 stated Resident 1 ' s family (RP 1 and RP 2) did not tell her they wanted to discontinue or hold Resident 1 ' s medications on [DATE]. During an interview with RN 1 on [DATE] at 4:25 PM, RN 1 stated that during the morning of [DATE], LVN 1 notified her Resident 1 was having respiratory distress (a serious lung condition that causes low blood oxygen). RN 1 stated she sent a text message to Physician 1 notifying him of Resident 1 ' s respiratory distress and asked, if Physician 1 wanted to hold Resident 1 ' s g-tube feeding and medications. RN 1 stated she instructed LVN 1 to hold Resident 1 ' s g-tube feeding. RN 1 stated she was not sure what she had instructed LVN 1 regarding holding Resident 1 ' s medications during the morning of [DATE]. During the same interview, on [DATE] at 4:25 PM, RN 1 stated that Physician 1 replied through text message but did not reply about holding Resident 1 ' s g-tube feeding or medications. RN 1 stated she sent another text message to Physician 1 to clarify, and she believed Physician 1 replied to hold all of Resident 1 ' s medications through text message using the facility cellphone. RN 1 could not recall what time Physician 1 replied through text message. When RN 1 was asked to clarify what I believe means, RN 1 could not reply. When RN 1 was asked if I believe means she was not sure, RN 1 stated I believe so. RN 1 stated that LVN 1 checked Resident 1 ' s blood sugar the morning of [DATE], before RN 1 went to Resident 1 ' s room and the glucometer reading indicated HI. RN 1 stated she did not know if LVN 1 administered the required insulin to Resident 1 that time, because she was more concerned with Resident 1 ' s respiratory distress. RN 1 stated she did not enter a physician order in Resident 1 ' s physician order sheets to hold Resident 1 ' s medications. RN 1 stated they (RN 1 and LVN 1) should have informed Physician 1 of Resident 1 ' s glucometer reading of HI on [DATE]. During a telephone interview on [DATE] at 4:47 PM, LVN 2 stated that during change of shift for the 7 AM to 3 PM and 3 PM to 11 PM shift, on [DATE], LVN 2 received a report from LVN 1 that all of Resident 1 ' s medications were on hold. LVN 2 stated she did not see an actual physician order from Physician 1 indicating to hold all of Resident 1 ' s medications. LVN 2 stated at around 4 PM, on [DATE], RP 2 asked when Resident 1 ' s medications would be given. LVN 2 stated that RP 2 verbalized that RP 1 and RP 2 were not asked or informed that Resident 1 ' s medications were put on hold. LVN 2 stated she told LVN 1 to inform Physician 1 that RP 1 and RP 2 did not agree to hold Resident 1 ' s medications. When LVN 2 was asked if insulin was administered to Resident 1 on [DATE] at 6 PM for a documented blood sugar of 410 mg/dL on the MAR, LVN 2 stated she could not answer because she needed to see her notes to recall that day. During another interview with LVN 1 on [DATE] at 12:34 PM, LVN 1 stated she documented Resident 1 was actively dying on [DATE] on her progress notes because Resident 1 ' s eyes were closed and non-responsive, breathing and orientation was not normal. LVN 1 stated that when Resident 1 was awake, his eyes used to be open. LVN 1 stated she could not recall what time she received Physician 1 ' s order to hold the medications and why she had put Resident 1 ' s medications hold for the duration of [DATE] timed from 3:27 PM to 5:12 PM. LVN 1 stated she did not write an actual physician order in the physician orders or document anything about Physician 1 ordering to hold Resident 1 ' s medications in the progress notes. During a follow up interview, on [DATE] at 7 PM, LVN 2 verified through concurrent record review why she did not indicate if she administered insulin to Resident 1 on [DATE] at 6:10 PM for a B/S result of 410 mg/dL. LVN 2 could not remember why she did not document if insulin was administered to Resident 1. LVN 2 stated since the order indicated to give 12 units of insulin per insulin sliding scale order, LVN 2 stated she must haveadministered 12 units of insulin. LVN 2 stated she rechecked Resident 1 ' s blood sugar and it read 402. LVN 2 stated she did not call Physician 1 to inform the physician of the blood sugar result as indicated in the insulin sliding scale order and ask if additional order was needed. During an interview and concurrent review of Nursing Station 1 and Nursing Station 2 ' s facility cellphones on [DATE] at 5 PM, the Director of Nurses (DON) stated she could not find text messages sent or received from Physician 1, regarding holding Resident 1 ' s medications on [DATE]. During an interview on [DATE] at 10:38 AM, Physician 1 stated he was notified by the licensed nurses of Resident 1 ' s change in condition on [DATE]. Physician 1 stated the licensed nurse informed him that the change of condition was about Resident 1 ' s desaturation and respiratory distress. Physician 1 stated he ordered oxygen supplement and a chest x-ray for Resident 1. Physician 1 stated he could not remember what time he had talked to the licensed nurse about Resident 1 ' s change in condition on [DATE]. Physician 1 stated he could not remember how many times the licensed nurses notified him of Resident 1 ' s high blood sugar results on [DATE] and [DATE]. Physician 1 stated he received a notification from the facility stating Resident 1 ' s blood sugar level was over 400 and he ordered to give more insulin. Physician 1 stated if the licensed nurses had notified him of Resident 1 ' s repeated occurrences of HI glucometer readings and above 400 mg/dL blood sugar results after giving insulin, he would have ordered more insulin and could have adjusted Resident 1 ' s current short acting and long-acting insulin orders. During the same interview on [DATE] at 10:38 AM, Physician 1 stated he did not remember sending a text message to the licensed nurses to hold Resident 1 ' s blood sugar checks and medications which included the insulin and anticoagulant. Physician 1 stated, I don ' t think I gave this kind of orders. Physician 1 stated he remembered the licensed nurses informing him that Resident 1 was currently on comfort-focused care per RP 2 ' s request. Physician 1 was asked if Resident 1 ' s responsible parties had anything changed with the resident ' s previously signed POLST dated [DATE], currently present in Resident 1 ' s medical records. Physician 1 stated he had not discussed or spoke to Resident 1 ' s responsible parties about revisions in Resident 1 ' s POLST. Physician 1 stated the POLST dated [DATE] should have been revised by the facility since Resident 1 had been in and out of the facility in the past few months. Physician 1 stated that missing blood sugar checks and insulin could be one of the contributing factors for Resident 1 ' s diabetic coma in the GACH. During an interview with the DON on [DATE] at 12:10 PM, the DON stated Resident 1 ' s POLST had been signed by RP 1 on [DATE] and was Resident 1 ' s current active POLST in the medical records, since admitted d [DATE]. The DON stated that the resident ' s POLST will only be changed or updated if there is a change in status or treatment requested by the resident or the resident ' s family/responsible party. The DON stated a resident ' s POLST does not need to be revised every time a resident is discharged or readmitted back to the facility unless there is a change or revision to the care as requested/discussed with the resident or responsible party. The DON stated, she could not find any other revised POLST documented or filed in Resident 1 ' s medical records but the POLST

Based on observation, interview and record review, the facility failed to implement interventions to prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance to the facility's infection control policies and the Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) for 32 of 32 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32) by failing to: 1. Screen Surveyor 1 (SA 1) for signs and symptoms of COVID-19, history of travel and contact with positive COVID-19 persons upon entering the facility. 2a. Separate COVID-19 area (Red Zone, area for residents who tested positive for COVID-19) from the suspected COVID-19 area (Yellow Zone, area where patients under investigation for COVID-19 are allocated). b. Dedicate a Licensed Vocational Nurse 1 (LVN 1) to care for confirmed COVID-19 residents (Residents 1 and 2) and at the same time, not to take care of non-confirmed COVID-19 residents (Residents 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29). c. Ensure Certified Nurse Assistant 1 (CNA 1) followed infection control practices while donning (put on) and doffing (take off) personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while providing care for Resident 31. d. Ensure CNA 2 assigned in the Red Zone had a designated restroom and break room. e. Ensure Registered Nurse 1 (RN 1) performed hand hygiene after direct contact with contaminated gown. These deficient practices had the potential to result in the spread of COVID-19 from Residents 1 and 2 placing Residents 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, and staff at risk for COVID-19 infection that could lead to severe respiratory illness, hospitalization and/or death. On 11/1/20 at 4:50 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm impairment or death to a resident) was identified in the presence of the Director of Nursing (DON) and Infection Control Nurse 1/Director of Staff Development (ICN 1/DSD- a nurse who helps prevent and identify the spread of infectious disease in the healthcare environment), and via telephone with the facility's Administrator (ADM). The IJ was called in the presence of the ADM (via telephone), DON and ICN 1/DSD regarding the facility's failure to implement interventions to prevent the spread of COVID-19 infection that threatened the health and safety of the residents and staff. On 11/3/20 at 1:37 p.m., the IJ was lifted after the facility submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices); the surveyor verified and confirmed the implementations of the POA while onsite by observation, interview and record review. The IJ was removed in the presence of the DON. The DON provided an acceptable POA as follows: 1. The DON in-serviced the facility receptionist on 11/1/20 regarding screening of visitors for signs/symptoms of respiratory illness, history of travel, etc. The receptionist/designee will be monitoring/screening prior to allowing entry to the facility. The IP/designee will review and monitor the screening log and process daily. 2a. The facility would group residents into three separate cohorts based on the recommendations in All Facilities Letter 20-74 (AFL 20-74, all residents on the unit or wing where a case was identified in a resident or healthcare personnel (HCP) are considered exposed and should remain in their current rooms unless sufficient private rooms are available. Avoid movement of residents that could lead to new exposures, for example, moving a resident into a room where one of the new roommates is subsequently found to have unidentified asymptomatic infection. As much as possible the facility will cohort staff for the yellow and green rooms in accordance with LA Public health guidance. Director of Staff Development (DSD) will monitor staffing daily of each cohort. The patients in room [ROOM NUMBER] were moved to room [ROOM NUMBER] outside of the plastic barrier. b. The facility dedicated an LVN to the Red Zone on all shifts. DON would monitor staffing daily. There were two CNAs and two licensed nurses on a 12 hr shift assigned to the COVID-19 unit. The in-service provided by DON. c. The staff was in-serviced by DSD/DON on 11/1/20 and ongoing, regarding PPE donning/doffing. RN Clinical resources in-service staff on PPE donning and doffing on 11/2/20. DSD/IP will monitor donning and doffing three times a week. d. The residents in room [ROOM NUMBER] (Resident 28 and Resident 29) were moved, and room [ROOM NUMBER] was designated as a break room and bathroom for the Red Zone staff. e. The nursing staff was in-serviced by DSD/DON on 11/1/20 and ongoing regarding hand hygiene. Registered Nurse (RN) clinical resources in-serviced staff on hand hygiene on 11/2/20. IP/DSD will monitor hand hygiene three times a week. Facility staff would use single washable gown after each episode of care and place each reusable washable gown into a laundry hamper after each use. The staff in-serviced by DSD on 11/1/20 and ongoing regarding washable gown use. The DSD will monitor the staff to assure the use of single use of gowns three times a week. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on 8/30/20 with [DIAGNOSES REDACTED]. A review of Resident 1's Clinical Laboratory result, with a date reported of 10/30/20, indicated the resident tested positive for COVID-19. A review of Resident 2's Admission Record indicated the facility admitted the resident on 11/13/20 with [DIAGNOSES REDACTED]. A review of Resident 2's Clinical Laboratory result, with a date reported of 11/2/20, indicated the resident tested positive for COVID-19. A review of the facility's Order List Report dated 11/2/20 and timed at 11:10 a.m., indicated the following residents were in the Yellow Zone: Residents 3, 4, 5, 6, 11, 12, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32. 1. During the entrance to the facility and observation on 11/1/20 at 11:55 a.m., the facility's Receptionist did not ask nor verify SA 1 for signs and symptoms of COVID-19, history of travel and contact with positive COVID-19 people and did not ask SA1 to perform hand hygiene. During an interview on 11/1/20 at 12:53 p.m., ICN1/DSD stated the screening process was self-screen, and the Receptionist was supposed to double check the answers. During an interview on 11/1/20 at 2:37 p.m., the DON stated the Receptionist was supposed to verify the questions in the questionnaire to ensure all the questions were answered. During a concurrent observation and interview on 11/3/20 at 10:47 a.m., with the Physician from Department of Public Health (MD 1), he recommended to the ADM, DON, ICN 1/DSD, and ICN 2, to have someone asked the screening questions instead of the self-screen process. MD 1 stated facility's staff need to ask the screening questions to avoid any missing information. A review of the facility's undated Mitigation Plan, titled Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities, indicated the facility screen and document every individual entering the facility (this includes staff/vendors/family for end of life) for COVID-19 symptoms. Proper screening includes temperature checks and screening questions. 2. During a telephone interview on 11/1/20 at 12:24 p.m., ICN 2 stated Resident 32 had COVID-19 signs and symptoms such as cough and was sharing a room with Residents 30 and 31 (who did not show any symptoms of COVID-19). ICN 2 also stated the facility was not short of staff and not short of PPEs. During an observation with RN 1 on 11/1/20 at 12:41 p.m., in Resident 30's, 31's, and 32's room, there was a poster that indicated this room was a Yellow Zone room. The room door was open, CNA 1 was observed wearing a washable gown while providing a personal care to Resident 31 (Bed B). There were three cloth gowns hanging on the wall (two without labels) inside these residents' room. CNA 1 removed the washable cloth gown that she was wearing, then hung it on a hook that was labeled as C (Bed C). During a concurrent interview, CNA 1 stated she made a mistake by using Resident 32's gown instead of Resident 31's gown. A concurrent interview was conducted with RN 1, RN 1 stated he did not know why CNA 1 was reusing the gowns when the facility was not short of gowns. RN 1 stated the gowns that were hanging were re-used throughout the shift. During the concurrent observation, RN 1 touched one of the gowns that was hung without a label and did not perform hand hygiene after touching the gown. During an observation of Residents' rooms with RN 1 on 11/1/20, at 1:20 p.m., rooms belong to Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29, were located in the same hallway designated as Green, Yellow, and Red Zones. There was plastic barrier (9 feet high and 8 feet wide) with a doorway that had three open strips (1 foot wide and 7.5 feet long) that was not sealed allowing air to flow between Red and Yellow Zones. During a concurrent interview, RN 1 stated Resident 1's and Resident 2's room were considered the Red Zone, this room was across from Resident 27's and Resident 29's who were in the Yellow Zone; and there was no physical barrier to separate the Red from Yellow Zone. RN 1 stated the Green and Yellow Zones were scattered throughout the facility. During an observation of the Green and Yellow Zones on 11/1/20, at 1:25 p.m., LVN 1 was sitting at the nursing station. During the concurrent interview, LVN 1 stated he was assigned to provide care for Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29. LVN 1 further stated he passed medications to Resident 1 and Resident 2 in the Red Zone around 10:30 a.m., and then proceeded to attend to the residents in Green and Yellow Zones. During an interview on 11/1/20 at 2:37 p.m., the DON stated the facility was notified on 10/31/20 of Resident 1's positive of COVID-19 test results. DON stated the facility was not short of staff but that it took a while (unspecified time) to move the schedule around to designate staff (license nurses) for the Red Zone. During an observation and interview on 11/1/20 at 2:50 p.m., in the Red Zone area, CNA 2 was sitting on a chair and stated Resident 1's and Resident 2's room was considered the Red Zone area and that Resident 28's and 29's room was across from Resident 1's and 2's room with no barrier. CNA 2 stated she used Resident 1's and Resident 2's restroom because she had no other restroom nor breakroom. During a concurrent observation and interview on 11/3/20 at 10:43 a.m., MD 1 recommended to the ADM, DON, ICN 1/DSD, and ICN 2, to have three different cohorts (Green, Yellow, and Red Zones) with designated staff, breakrooms and restrooms, and to not reuse washable gowns to prevent cross contamination. MD stated facility's administrative staff need to conduct more audits to ensure staff follow basic infection control practices such as donning and doffing and hand hygiene. A review of the facility's undated Mitigation Plan, titled Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities, indicated the facility had implemented a staffing plan to limit transmission, including: a. All residents with COVID-19 infection confirmed by testing, or those residents who are recovering from COVID-19 infection, have been separated from residents who were not infected or have unknown infection status were placed in dedicated COVID-19 positive wings. b. Residents who were COVID positive would be isolated and cohorted together in the Red unit with designated staff. Dedicated, consistent staffing teams who directly interacted with residents who were COVID-19 positive. Limiting clinical and other staff who had direct resident contact to specific floors or wings. There should be no rotation of staff between floors or wings during the period they were working each day. c. Staff have been trained on selecting, donning, and doffing appropriate PPE and demonstrated competency of such skills during resident care. d. The facility had policies in place for dedicated spaces within the facility to ensure separation of infected patients for eliminating movement of health care personnel (HCP) among those spaces to minimize transmission risk. e. Train staff to perform hand hygiene (using alcohol-based hand sanitizer (ABHS) or washing with soap and water for 20 seconds) before and after patient contact, contact with potentially infectious material, and before putting on and upon removal of PPE, including gloves. References According to the Centers for Disease Control and Prevention (CDC), indicated before caring for patients with confirmed or suspected COVID-19, healthcare personnel (HCP) must don PPE correctly before entering the patient area (e.g., isolation room, unit if cohorting). Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf According to the CDC, [MEDICATION NAME] hand hygiene is a simple yet effective way to prevent infections. Cleaning the hands can prevent the spread of germs. Retrieved from: https://www.cdc.gov/handhygiene/index.html According to the CDC, hand hygiene is an important part of the United States (U.S.) response to the international emergence of COVID-19. [MEDICATION NAME] hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html According to the CDC, for the facility to determine the location of the COVID-19 care unit and create a staffing plan before residents or HCP with COVID-19 are identified in the facility. Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19. Depending on facility capacity (e.g., staffing, supplies) to care for affected residents, the COVID-19 care unit could be a separate floor, wing, or cluster of rooms. Assign dedicated HCP to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html

Based on interview and record review, the facility failed to provide adequate care and services for 1 of 5 sampled residents (Resident 1) by failing to: 1. Provide necessary assessment and dressing changes to Resident 1's Perma Catheter (PC- a vascular access inserted into a vein for [MEDICAL TREATMENT], a treatment that performs some of the functions of healthy kidneys of filtering wastes and water from the blood). 2. Follow the facility's policy and procedure which stated, Vascular access devices shall be removed upon therapy discontinuation or if deemed unnecessary and daily assessment of the vascular access need and removal when no longer needed to decrease the risk of infection. 3. Notify the physician that Resident 1 was no longer receiving [MEDICAL TREATMENT] treatment as of 2/17/16 and to discuss the plan of care for the resident with PC in place. 4. Consult with the physician to obtain an appointment for the removal of Resident 1 ' s PC when the resident's laboratory results indicated her kidney function normalized. These deficient practices resulted in infection of the Perma Catheter (PC) and the resident's admission to the acute hospital for the treatment of [REDACTED]. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. A review of Resident 1 ' s Minimum Data Set (MDS), a resident assessment and care-screening tool, dated 1/9/16 indicated the resident was assessed with [REDACTED]. The resident's history and physical dated 1/22/16, indicated [DIAGNOSES REDACTED]. Resident 1's physician's orders [REDACTED]. 1. [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday. 2. Dressing on access site (right chest PC) to be changed at [MEDICAL TREATMENT] center and as needed (PRN) at the facility if soiled and dislodged. 3. Monitor [MEDICAL TREATMENT] for color, redness, warmth, [MEDICAL CONDITION], drainage, pain and bleeding. A review of Resident 1's progress note dated 1/26/16 indicated the resident had a PC on the right chest and was dependent on [MEDICAL TREATMENT]. During an interview on 3/21/16, Registered Nurse 1 (RN) stated that the [MEDICAL TREATMENT] nurse at the [MEDICAL TREATMENT] center was responsible for PC dressing changes. RN 1 stated the nurses at the facility were responsible for checking the PC site every shift and providing dressing changes only PRN when the site was soiled to prevent infection. During an interview on 3/22/16, the Director of Nursing (DON) stated that the RN's were responsible for the care of PCs that include: assessing the site every shift; providing dressing changes PRN when it had not been changed; and documenting these interventions on the Intravenous (IV) Medication Administration Record [REDACTED]. The DON stated when the PC had a gauze dressing, it needed to be changed every 24 hours, and when it had a transparent dressing, then it needed to be changed every 7 days. The DON also stated that the IV MAR for Resident 1 dated February 2016 and March 2016, did not indicate the facility staff changed the PC dressing from 2/16/16 to 3/7/16. The DON added if the PC dressing were not provided then there would be a risk for infection. A review of Resident 1's document dated 2/1/16 to 2/29/16, and titled IV MAR indicated an order for [REDACTED]. The above order was also reflected on the IV MAR dated 3/1/16 to 3/31/16. However, there were also no staff initials to indicate that PRN dressing changes were done at the facility from 3/1/16 to 3/31/16. A review of the facility's policy and procedures undated and titled, Peripherally Inserted Central Catheter (PICC) and Central Line Catheters, indicated that gauze dressing shall not be used unless ordered by a physician and all gauze under the transparent dressing shall be changed every 24 hours to observe the site. The vascular access devices shall be removed upon resolved complication, therapy discontinuation, or if deemed unnecessary and daily assessment of vascular access devices need and removal when no longer needed are components of the central line bundle known to decrease risk of infection. During an interview on 3/29/16, Resident 1 stated the facility staff did not clean nor changed the dressing on the PC site. It was not changed at the last [MEDICAL TREATMENT] treatment by the [MEDICAL TREATMENT] center staff on 2/17/16 and the site had the same gauze dressing for 2 weeks. Resident 1 also stated she told the facility staff that she had PC site pain and staff responded that they could not assess and touch the site, so she called and notified the physician. The resident stated she checked the PC site and there were lots of yellow pus on the site. In an interview on 3/29/16, RN 2 stated she does not provide routine dressing changes because it was typically done, along with [MEDICAL TREATMENT] treatment, at the [MEDICAL TREATMENT] center. RN 2 stated the [MEDICAL TREATMENT] center would apply a gauze dressing to the PC site, which would last until the next [MEDICAL TREATMENT] treatment. RN 2 also stated that if the dressing was soiled or wet, then she would be responsible for providing dressing changes and would document it in the resident's IV MAR. RN 2 also added that the physician should be notified of any issues relating to the resident. During an interview on 3/29/16, the resident's physician (Physician 1) explained that Resident 1 called her and complained of redness and pain to the PC site. The physician stated she made a visit to assess Resident 1's PC site and observed redness to the site and started the resident on Keflex, an antibiotic that should be used only to treat infections that are proven or strongly suspected to be caused by susceptible bacteria per drug literature. The physician explained that the facility should have a policy and procedure, based on standards of care, to direct the care and frequency of dressing change to the PC. She also stated the facility should have routinely assessed and provided dressing changes to the PC site to prevent infection. Review of a physician's History and Physical for the resident dated 3/11//16, stated, Patient directly admitted to hospital from the Nephrologist ' s ' (Physician 2-a physician specializing in disease of the kidneys) office due to Perm-A-Cath site infection. Patient completed [MEDICAL TREATMENT] about a month ago since blood urea nitrogen and creatinine (BUN and Creat) improved. Perm-A-Cath was left in place. The resident's [DIAGNOSES REDACTED]. During an interview on 3/29/16, Physician 2 stated Resident 1, whose laboratory results indicated her kidney function normalized, missed her follow up appointment due to transportation issues. Physician 2 stated that the facility should have followed up with her to obtain another appointment for the removal of the resident's PC; otherwise, the PC site could become a source of infection. Physician 2 also stated Resident 1's PC site was infected and progressed [MEDICAL CONDITIONS] (bacteria in the blood that often occurs with severe infections), and the resident was started on antibiotics (medications that fight bacterial infections) for six weeks. Physician 2 also stated Resident 1 would be followed up by a Cardiologist (a physician that specializes in the medical management of [MEDICAL CONDITION]) to assess for endocarditis (infection of the inner lining of the heart that generally occurs when bacteria from another part of the body spread through the bloodstream and attaches to damaged areas in the heart). Physician 2 added that the facility, knowing that Resident 1 was no longer receiving [MEDICAL TREATMENT], should have provided PC site assessment and dressing changes routinely. During an interview on 3/29/16, RN 2 stated Resident 1's PC had a white gauze dressing and that to prevent infection [MEDICAL CONDITION] (a life-threatening complication of and infection potentially causing organ damage and failure); PCs with gauze dressing should be changed every 24 hours per facility's policy and procedures. RN 2 also stated the physician should have been notified that Resident 1 was no longer receiving [MEDICAL TREATMENT] treatment and to discuss the plan of care for the resident with PC in place. On 3/29/16, at 1:00 p.m., in an interview, the Case Manager (CM) stated when Resident 1 missed her appointment on 2/29/16, at 1:00 p.m., to see the Nephrologist they should have arranged a follow up with the Nephrologist. In an interview and record review on 3/29/16, at 4:04 p.m., the Assistant Director of Nursing (ADON) explained that [MEDICAL TREATMENT] Communication Record (a communication between the facility and the [MEDICAL TREATMENT] center) was a form that included the facility's documentation of pre-assessment and post-assessment of the resident and [MEDICAL TREATMENT], and the [MEDICAL TREATMENT] center's documentation of [MEDICAL TREATMENT] site dressing change. The ADON confirmed that this record documented the facility's pre-and/or post-assessment of the resident's PC site and whether the PC dressing was changed at the [MEDICAL TREATMENT] center or not. Resident 1's acute hospital documentation dated 3/7/16 indicated the resident was admitted due to infection of the PC and failure to remove the PC after [MEDICAL TREATMENT] stopped. Resident 1's [MEDICAL TREATMENT] catheter was removed on 3/7/16, and the tip of the catheter was sent for culture. The culture dated 3/7/16, revealed Resident 1's PC tip and cuff (a ring material that is around the catheter under the skin) [MEDICAL CONDITION]. The resident remained in the hospital for two nights and was discharged with a PICC line for long-term administration of IV (intravenous) [MEDICATION NAME] (antibiotic) until 4/6/16. Failure of the facility to provide necessary assessment and dressing changes to Resident 1's PC; follow the facility's policy and procedure; notify the physician and discuss the plan of care when Resident 1 was no longer receiving [MEDICAL TREATMENT] and consult with the physician when Resident 1's kidney function normalized presented a substantial probability that death or serious physical harm to Resident 1 would result therefrom and did.

The Department received a complaint on [DATE], alleging a resident (Resident 1) was discharged in a very poor condition with [MEDICAL CONDITION] and severe dehydration. The complainant also alleged the resident was transferred to a general acute care hospital (GACH) "within six hours" after discharge from the skilled nursing facility (SNF). A complaint investigation was conducted on [DATE]. Based on interviews, a closed record review, and review of the GACH's record, the facility failed to ensure 1 of 1 residents (Resident 1) was not transferred or discharged after Resident 1's condition started deteriorating. Resident 1, who was non-ambulatory and required extensive assistance in all activities of daily life (ADLs), had a change of condition with a significant weight loss and abnormal life threatening labs, was transferred to a lower level of care facility (board and care (B/C)). These failures resulted in Resident 1 being transferred to a B/C and within eight hours of being transferred the resident had an altered level of consciousness (ALOC) and was transferred to a general acute care hospital (GACH), placed in the intensive care unit (ICU) and required many [MEDICAL TREATMENT] treatments (mechanical filtering of the blood). See F325 for additional information for Resident 1. Findings: On [DATE], a review of Resident 1's SNF medical record indicated the resident was admitted to the facility on [DATE]. The residents' [DIAGNOSES REDACTED]. On [DATE], a review of a care plan titled, "ADL/Self-care Deficit" dated February 25, 2012, indicated the resident required a two-person assist for all activities of daily living (ADLs). According to a history and physical (H/P), dated [DATE], the resident was described as confused, weak, and non-ambulatory. The H/P indicated the resident did not have the ability to understand or make decisions. On [DATE], a review of another care plan titled, "Alzheimer's or Dementia," dated [DATE], indicated the resident had altered thought processes, memory loss, and confusion. The care plan also indicated the resident was at risk for injury due to altered judgment and self-care deficit. On [DATE], a review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], indicated the resident was confused with poor memory and required total assistance from the staff for all ADLs. The MDS indicated the resident required a two-person assist for bed mobility, transferring, dressing, and personal hygiene. According to a registered dietitians (RD) note, dated [DATE], she recommended a complete metabolic panel ((CMP) lab work that is an indicator of a resident's health and nutritional status), due to the resident's significant weight loss. The lab work was drawn on [DATE], with the following results: blood-urea- nitrogen level (BUN) of 76 milligram per deciliter (mg/dl) with a normal reference range of 8 mg/dl-26 mg/dl), creatinine level of 2.5 mg/dl with a normal reference range of 0.70 mg /dl-1.20 mg/dl, sodium level of 167 mg/dl with a normal reference range of 135 mg/dl-145 mg/dl, and a chloride level of 130 mg/dl with a normal reference range of 101 mg/dl-111 mg/dl. According to GLOBALRPh: the Clinician's Ultimate Guide, an elevated BUN and creatinine levels are indicative of [MEDICAL CONDITION] (<http://www.globalrph.com/labinter.htm>). According to Brenner & Rector's, "The Kidney," 8th edition (2008), Chapter 21;Page 692, significant [MEDICAL CONDITION] (high sodium levels) can be lethal in some cases with mortality (death) as high as 46% to 70%. Acute increases in serum sodium concentrations more than 160mEq/l is associated with a 75% mortality rate. A review of the general acute care hospitals' (GACH) Admission History and Physical, dated February 21, 2012 (four days prior to the resident's admission to the SNF), indicated the resident's laboratory data was within normal range as following: sodium was 141, potassium 3.8 (normal reference range is 3XXX,[DATE].0), chloride 109, BUN 28, and a creatinine of 1. On [DATE], a review of a nurse's note, dated [DATE], and timed at 3:30 p.m., indicated the resident's physician was notified of the abnormal lab values and ordered a repeat CMP in one week ([DATE]). According to a telephone physician's orders [REDACTED]. There was no documented evidence in the resident's clinical record that the physician was notified that the pending lab ordered a week prior (for the abnormal lab results), to be done on [DATE], was not done. On [DATE], at 3:15 p.m., while in the facility, Resident 1's physician was called and a message was left for him to please return the call regarding the resident's discharge. The physician's call was not returned. During an interview on [DATE], at 3:20 p.m., the facility's social worker ((MSW) masters in social work) stated it was not appropriate to transfer or discharge a resident to a board and care facility that required two or more areas of maximum assist in care, such as eating, drinking, toileting, and personal hygiene. After reviewing the resident's records, the MSW stated the facility's case manager handled Resident 1's discharge. She stated if the case manager had concerns or problems she could have assisted her if she had asked, especially since there was an issue of verbal abuse against the resident's family toward the resident. The MSW stated she had to report and refer the case to adult protective services (APS). In an interview with the case manager, on [DATE] at 3:36 p.m., in the presence of the MSW, the case manager stated she thought it was okay for Resident 1 to transfer to the board and care. Both the case manager and the MSW indicated the resident's family initially wanted to keep the resident at the facility or transfer to another SNF, but there were financial concerns. The MSW stated she would not have recommended a board and care for this resident and if the family insisted she would have called an inter-disciplinary team (IDT) meeting. The case manager stated the last time an IDT meeting was conducted regarding Resident 1 was on [DATE], almost three weeks prior to the resident's discharge. According to CMS/Medicare, " a Board and Care Facility is defined as group living arrangement that provides help with activities of daily living such as eating, bathing, and using the bathroom for people who cannot live on their own, but do not need nursing home services." <http://www.medicare.gov/longtermcare/static/BoardCareHome.asp> During a telephone interview, on [DATE] at 8:30 a.m., the complainant stated the resident had fallen in 2011 and again in 2012 and the second fall resulted in a [MEDICAL CONDITION] and the resident was admitted to the facility for rehabilitation. She stated the resident had difficulties, and would try to get up from his wheelchair and was not eating or drinking well. The complainant stated after the resident was transferred to a B/C on [DATE], the resident was then transferred to a GACH, and almost died , requiring [MEDICAL TREATMENT] treatments. On [DATE], during a review of the GACH medical records, the paramedic run sheet, dated [DATE] and timed at 7:30 p.m., indicated the resident was observed at the B/C with an ALOC. According to the run sheet, the resident's Glasgow Coma Scale (GCS/a neurological scale of the eye, verbal, and motor activity, a score of three being the lowest and 15 the highest). Resident 1's score was three. According to the paramedic run sheet, "the resident was last known well on [DATE], after not eating or drinking in days." The resident's vital signs were as follows: blood pressure, ,[DATE] (normal blood pressure is ,[DATE], National Health Library, <http://www.nhlbi.nih.gov/hbp/detect/categ.htm>), pulse 100, respirations 16, and an oxygen saturation of 96%. The record indicated the paramedics were told by the B/C staff the resident had not eaten or drank anything since Friday, [DATE]. An intravenous line (a small tube or catheter is inserted into a vein for access to give medication or fluids) was started and the patient was transported to the GACH. The Admission Summary from the GACH indicated the resident was admitted to the ICU. Lab work done upon admission indicated the following: BUN of 198 mg/dl (normal range 8 mg/dl-26 mg/dl), sodium of 187 (normal range 135 mg/dl-145 mg/dl), and a creatinine level of 7.10 (normal range (0.70 mg/dl- 1.20 mg/dl). Resident 1's admitting [DIAGNOSES REDACTED]. The resident had a Quinton Catheter (a large bore venous access catheter) inserted in the right internal jugular vein and received [MEDICAL TREATMENT] treatments (mechanical filtration of the blood) on [DATE], [DATE], [DATE] and [DATE]. The resident was stabilized and after seven days, was transferred to another GACH on [DATE], due to insurance reasons. During an interview, on [DATE], at 9:40 a.m., the facility's director of nurses (DON) stated Resident 1's family wanted to transfer the resident to another SNF, but the cost made them decide on a B/C. The DON stated she was not aware the resident was not eating, had a significant weight loss (35 pounds in 32 days) and had abnormal labs with an order to repeat the lab work on [DATE] (the following day after the resident was discharged ). The DON stated if she had known she would have spoken to the resident's physician about the resident's change of condition. She stated she would have at least encouraged the physician and or family to wait to repeat the abnormal labs. The DON stated if the labs remained abnormal, the family would then have to sign the resident out against medical advice (AMA) with a follow-up with adult protective services (APS).The DON stated it was the facility's responsibility to ensure a resident's transfer or discharge was safe and the resident was in a stable condition. She stated it was not just the case managers' responsibility, but the whole facility as a whole to look at the residents' needs and level of care prior to discharge. The DON stated if she had known all the information regarding this resident she would have intervened to prevent the discharge. She stated the facility should have waited for the repeat labs ordered [DATE], prior to letting the resident leave and to ensure the results were normal, because the resident had lost weight and was not eating, the resident did not meet the criteria for a lower level of care. An interview on [DATE], at 3 p.m., RN 1 stated Resident 1 was confused, non-ambulatory and required total assistance in all care. RN 1 stated the resident was not a good transfer candidate. On [DATE], at 8:55 a.m., while in the facility, the resident's physician was called again regarding the resident's discharge and another message left. The DON stated she would assist and she also placed a call and requested if he could return the call. Resident 1's physician did not return the call. In a written declaration, dated [DATE], written by the case manager, who was not a nurse, indicated she was not aware the resident's condition was deteriorating with weight loss, not eating, and had life threatening abnormal labs. The declaration also indicated the nurses had not informed the case manager about the resident's condition. An interview on [DATE], at 10:05 a.m., a licensed vocational nurse (LVN 1) stated the resident did not eat well, but took fluids. On [DATE], a review of the resident's breakfast/Lunch/Dinner Record indicated the resident during the previous month had eaten only 45% of offered breakfasts, 32% of offered lunches, and 31% of offered dinners. From [DATE] to [DATE], the resident had refused four of five breakfasts, three of four lunches and two of four dinners. On [DATE], at 10:45 a.m., during a telephone interview, Resident 1's family member stated and documented in a written declaration, that she was not made aware of the resident ' s abnormal lab results, especially sodium being high, and that he had lost a substantial amount of weight. She stated, "If I had known, I would have called 911 and would not have transferred him." She stated she was not made aware of the seriousness of the resident's sodium level until he was at the GACH and almost died . A review of the facility's policy and procedures, revised [DATE], for resident discharge planning indicated, under Section 1, the social service designee with the interdisciplinary team shall complete an assessment and develop a planned program for a resident discharge to a lower level of care. Under Section 3, the policy indicated the planning included health status, and the current level of care needed for the resident to be transferred. Under Section 5, the policy indicated the discharge plan was to be reviewed and reevaluated when there was a change in the resident's condition. CLASS B CITATION-PROBLEM TRANSFER [DATE]-F The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;The safety of individuals in the facility is endangered;The health of individuals in the facility would otherwise be endangered;The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a nursing facility, the nursing facility may charge a resident only allowable charges under Medicaid; orThe facility ceases to operate.The Department received a complaint on [DATE], alleging a resident (Resident 1) was discharged in a very poor condition with [MEDICAL CONDITION] and severe dehydration. The complainant also alleged the resident was transferred to a general acute care hospital (GACH) " within six hours " after discharge from the skilled nursing facility (SNF).A complaint investigation was conducted on [DATE].Based on interviews, a closed record review, and review of the GACH ' s clinical record, the facility failed to ensure:Resident 1 ' s transfer and discharge was appropriate and the residents ' health had improved and no longer needed the services provided by the facility. These failures resulted in Resident 1 being transferred to a board and care (B/C) and within eight hours of being transferred the resident had an altered level of consciousness (ALOC) and was transferred to a general acute care hospital (GACH), placed in the intensive care unit (ICU) and required many [MEDICAL TREATMENT] treatments (mechanical filtering of the blood). On [DATE], a review of Resident 1 ' s SNF medical record indicated the resident was an [AGE] year-old male who was admitted to the facility on [DATE]. The residents' [DIAGNOSES REDACTED].On [DATE], a review of a care plan titled, "ADL/Self-care Deficit" dated February 25, 2012, indicated the resident required a two-person assist for all activities of daily living (ADLs). According to a history and physical (H/P), dated [DATE], the resident was described as confused, weak, and non-ambulatory. The H/P indicated the resident did not have the ability to understand or make decisions.On [DATE], a review of another care plan titled, "Alzheimer's or Dementia," dated [DATE], indicated the resident had altered thought processes, memory loss, and confusion. The care plan also indicated the resident was at risk for injury due to altered judgment and self-care deficit.On [DATE], a review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated [DATE], indicated the resident was confused with poor memory and required total assistance from the staff for all ADLs. The MDS indicated the resident required a two-person assist for bed mobility, transferring, dressing, and personal hygiene.According to a registered dietitians (RD) note, dated [DATE], she recommended a complete metabolic panel ((CMP) lab work that is an indicator of a resident's health and nutritional status), due to the resident's significant weight loss. The lab work was drawn on [DATE], with the following results: blood-urea- nitrogen level (BUN) of 76 milligram per deciliter (mg/dl) with a normal reference range of 8 mg/dl-26 mg/dl), creatinine level of 2.5 mg/dl with a normal reference range of 0.70 mg /dl-1.20 mg/dl, sodium level of 167 mg/dl with a normal reference range of 135 mg/dl-145 mg/dl, and a chloride level of 130 mg/dl with a normal reference range of 101 mg/dl-111 mg/dl. According to GLOBALRPh: the Clinician's Ultimate Guide, an elevated BUN and creatinine levels are indicative of [MEDICAL CONDITION] (). According to Brenner & Rector's, "The Kidney," 8th edition (2008), Chapter 21;Page 692, significant [MEDICAL CONDITION] (high sodium levels) can be lethal in some cases with mortality (death) as high as 46% to 70%. Acute increases in serum sodium concentrations more than 160mEq/l is associated with a 75% mortality rate.A review of the general acute care hospitals' (GACH) Admission History and Physical, dated February 21, 2012 (four days prior to the resident's admission to the SNF), indicated the resident's laboratory data was within normal range as following: sodium was 141, potassium 3.8 (normal reference range is 3XXX,[DATE].0), chloride 109, BUN 28, and a creatinine of 1.On [DATE], a review of a nurse's note, dated [DATE], and timed at 3:30 p.m., indicated the resident's physician was notified of the abnormal lab values and ordered a repeat CMP in one week ([DATE]).According to a telephone physician's order [REDACTED]. However, there was no documented evidence in the resident ' s clinical record that the physician was notified that the pending lab ordered a week prior (due to being abnormal), to be done on [DATE], was not done prior to the resident ' s discharge on [DATE].On [DATE] at 3:15 p.m., while in the facility, Resident 1 ' s physician was called and a message was left for him to please return the call regarding the resident ' s discharge. The physician ' s call was not returned.During an interview on [DATE], at 3:20 p.m., the facility's social worker ((MSW) masters in social work) stated it was not appropriate to transfer or discharge a resident to a board and care facility that required two or more areas of maximum assist in care, such as eating, drinking, toileting, and personal hygiene. After reviewing the resident's records, the MSW stated the facility's case manager handled Resident 1's discharge. She stated if the case manager had concerns or problems she could have assisted her if she had asked, especially since there was an issue of verbal abuse against the resident's family toward the resident. The MSW stated she had to report and refer the case to adult protective services (APS).In an interview with the case manager, on [DATE] at 3:36 p.m., in the presence of the MSW, the case manager stated she thought it was okay for Resident 1 to transfer to the board and care. Both the case manager and the MSW indicated the resident's family initially wanted to keep the resident at the facility or transfer to another SNF, but there were financial concerns. The MSW stated she would not have recommended a board and care for this resident and if the family insisted she would have called an inter-disciplinary team (IDT) meeting. The case manager stated the last time an IDT meeting was conducted regarding Resident 1 was on [DATE], almost three weeks prior to the resident's discharge.According to CMS/Medicare, " a Board and Care Facility is defined as group living arrangement that provides help with activities of daily living such as eating, bathing, and using the bathroom for people who cannot live on their own, but do not need nursing home services." During a telephone interview, on [DATE] at 8:30 a.m., the complainant stated the resident had fallen in 2011 and again in 2012 and the second fall resulted in a [MEDICAL CONDITION] and the resident was admitted to the facility for rehabilitation. She stated the resident had difficulties, and would try to get up from his wheelchair and was not eating or drinking well. The complainant stated after the resident was transferred to a B/C, the resident was then transferred to a GACH, and almost died , requiring [MEDICAL TREATMENT] treatments.On [DATE], during a review of the GACH medical records, the paramedic run sheet, dated [DATE] and timed at 7:30 p.m., indicated the resident was observed at the B/C with an ALOC. According to the run sheet, the resident's Glasgow Coma Scale (GCS/a neurological scale of the eye, verbal, and motor activity, a score of three being the lowest and 15 the highest). Resident 1's score was three. According to the paramedic run sheet, "the resident was last known well on [DATE], after not eating or drinking in days." The resident's vital signs were as follows: blood pressure, ,[DATE] (normal blood pressure is ,[DATE], National Health Library, ), pulse 100, respirations 16, and an oxygen saturation of 96%. The record indicated the paramedics were told by the B/C staff the resident had not eaten or drank anything since Friday, [DATE]. An intravenous line (a small tube or catheter is inserted into a vein for access to give medication or fluids) was started and the patient was transported to the GACH. The Admission Summary from the GACH indicated the resident was admitted to the ICU. Lab work done upon admission indicated the following: BUN of 198 mg/dl (normal range 8 mg/dl-26 mg/dl), sodium of 187 (normal range 135 mg/dl-145 mg/dl), and a creatinine level of 7.10 (normal range (0.70 mg/dl- 1.20 mg/dl). Resident 1's admitting [DIAGNOSES REDACTED]. The resident had a Quinton Catheter (a large bore venous access catheter) inserted in the right internal jugular vein and received [MEDICAL TREATMENT] treatments (mechanical filtration of the blood) on [DATE], [DATE], [DATE] and [DATE]. The resident was stabilized and after seven days, was transferred to another GACH on [DATE], due to insurance reasons.During an interview, on [DATE], at 9:40 a.m., the facility's director of nurses (DON) stated Resident 1's family wanted to transfer the resident to another SNF, but the cost made them decide on a B/C. The DON stated she was not aware the resident was not eating, had a significant weight loss (35 pounds in 32 days) and had abnormal labs with an order to repeat the lab work on [DATE] (the following day after the resident was discharged ). The DON stated if she had known she would have spoken to the resident's physician about the resident's change of condition. She stated she would have at least encouraged the physician and or family to wait to repeat the abnormal labs. The DON stated if the labs remained abnormal, the family would then have to sign the resident out against medical advice (AMA) with a follow-up with adult protective services (APS).The DON stated it was the facility's responsibility to ensure a resident's transfer or discharge was safe and the resident was in a stable condition. She stated it was not just the case managers' responsibility, but the whole facility as a whole to look at the residents' needs and level of care prior to discharge. The DON stated if she had known all the information regarding this resident she would have intervened to prevent the discharge. She stated the facility should have waited for the repeat labs ordered [DATE], prior to letting the resident leave and to ensure the results were normal, because the resident had lost weight and was not eating, the resident did not meet the criteria for a lower level of care.An interview on [DATE], at 3 p.m., RN 1 stated Resident 1 was confused, non-ambulatory and required total assistance in all care. RN 1 stated the resident was not a good transfer candidate. On [DATE] at 8:55 a.m., while in the facility, the resident ' s physician was called again regarding the resident ' s discharge and another message was left. The DON stated she would assist and she also placed a call to the physician requesting if he could return the call. Resident 1 ' s physician did not return the call.In a written declaration, dated [DATE], written by the case manager, who was not a nurse, indicated she was not aware the resident's condition was deteriorating with weight loss, not eating, and had life threatening abnormal labs. The declaration also indicated the nurses had not informed the case manager about the resident's condition.An interview on [DATE], at 10:05 a.m., a licensed vocational nurse (LVN 1) stated the resident did not eat well, but took fluids. On [DATE], a review of the resident ' s Breakfast/Lunch/Dinner Record indicated the resident during the previous month had eaten only 45% of offered breakfasts, 32% of offered lunches, and 31% of offered dinners. From [DATE] to [DATE], the resident had refused four of five breakfasts, three of four lunches and two of four dinners.A review of the facility's policy and procedures, revised [DATE], for resident discharge planning indicated, under Section 1, the social service designee with the interdisciplinary team shall complete an assessment and develop a planned program for a resident discharge to a lower level of care. Under Section 3, the policy indicated the planning included health status, and the current level of care needed for the resident to be transferred. Under Section 5, the policy indicated the discharge plan was to be reviewed and reevaluated when there was a change in the resident's condition. The facility failed by not ensuring:Resident 1 ' s transfer and discharge was appropriate and the residents ' health had improved and no longer needed the services provided by the facility. The above violation had a direct relationship to the health, safety, and security of Resident 1.

Based on interview, closed record review and the acute hospital record review, the facility failed to ensure 1 of 1 resident (Resident 1) maintained their body weight, by not addressing the resident's weight loss and revising the plan of care. Resident 1, who had dementia (a decline in reasoning, memory, and other mental abilities), required total assistance with all activities of daily living (ADLs), including eating. These failures of not revising a plan of care to address the resident's weight loss and providing adequate nutrients resulted in Resident 1 losing 35 pounds (lbs.) in 32 days and compromised Resident 1's nutritional status, while in the skilled nursing facility (SNF). Findings: On May 14, 2012, a review of Resident 1's Admission Record (face sheet) indicated the resident was admitted to the facility on [DATE]. Resident 1, who had a [DIAGNOSES REDACTED]. A review of a care plan dated February 25, 2012, titled, "Altered Nutrition and Hydration Status" related to the resident's [DIAGNOSES REDACTED]. The staff 's approaches included allowing sufficient time for the resident to chew, notify physician of weight loss, and the registered dietitian (RD) to assess the resident 's nutritional status. On May 14, 2012, a review of a Minimum Data Set (MDS), a standardized assessment and care screening tool, dated March 27, 2012, indicated the resident was confused with poor memory and required total assistance from the staff with all activities of daily living (ADLs). According to the MDS, the resident's admission weight was 157 lbs. The resident's Monthly Weight Record indicated the resident weighed 157 lbs. on February 27, 2012 and March 1, 2012. The facility's RD initial assessment note, dated February 27, 2012 indicated the resident weighed 157 lbs. and had a height of 65 inches upon admission. The assessment indicated the resident was confused and non-expressive. The resident was initially started on a no added salt (NAS), low fat/cholesterol diet. Then on March 1, 2012, per the RD recommendation, the resident's diet was changed to fortified NAS and with 2 Cal/HN 90 ml by mouth to be given three times a day during the medication pass. Another RD entry, dated March 1, 2012, indicated Resident 1's caloric requirement was estimated to be 1700 calories per day, 70-90 grams of protein per day, and approximately 2000 milliliter (ml) of fluid per day. The RD made a recommendation to add 90 ml. (three ounces) of 2 CAL HN (a dietary supplement), three times a day by mouth. The physician ordered the dietary supplement for the resident on March 1, 2012. Another RD note, dated March 7, 2012, indicated the resident weighed 147 lbs., a weight loss of 10 lbs. in 12 days. The RD recommended and the physician ordered the resident to receive a Magic Cup, (a frozen liquid supplement that provides 290 calories and 9 grams of protein) twice a day with lunch and dinner. A review of a history and physical (H/P), dated March 8, 2012, indicated the physician documented Resident 1 was confused with advanced dementia. The physician documented under WT: "As per chart." There was no further documentation of the resident weight on the H/P. On May 14, 2012, a review of another physician's note (Ortho), dated March 13, 2012, indicated the resident was two weeks post-op surgery and doing well. However, the resident had lost 12 lbs. in the last 17 days since admission and there was no mention of the resident's weight loss. According to the clinical record, on March 13, 2012, the RD assessed the resident again and documented that the resident continued to lose weight, weighing 145 lbs. and the RD recommended to continue with the current interventions. According to the "Weight Monitoring Record," Resident 1 was last weighed on March 19, 2012, weighing only 135 lbs. There were no further weights recorded prior to the resident being transferred to a board and care facility (B/C), on March 27, 2012. According to Resident 1's Weight Record the following was indicated: On February 27, 2012, the resident weighed 157 lbs. On March 7, 2012, the resident weighed 147 lbs. (10 lbs. and 6.4% weight loss over 9 days). On March 13, 2012, the resident weighed 145 lbs. (12 lbs. and 7.6% weight loss over 15 days). On March 28, 2012, the resident weighed 122 lbs. (according to the general acute record), which was 35 lbs. and 22% weight loss over 32 days. According to the State Operations Manual, a severe weight loss is considered to be greater than 5% in one month. The RD's note, dated March 20, 2012, indicated the resident weighed 135 lbs. with a total weight loss of 22 lbs. since admission and a 10 lb. weight loss in the past week. The RD documented the resident had a very poor intake and was unable to state food preferences. The RD recommended a complete metabolic panel ((CMP), lab work that is an indicator of health and nutritional status). According to the CMP drawn on March 21, 2012, the residents' blood-urea-nitrogen level (BUN) was 76 mg/dl. (normal reference range of 8 mg/dl-26 mg/dl), creatinine level of 2.5 mg/dl (normal reference range of 0.70 mg /dl-1.20 mg/dl), sodium level of 167 mg/dl (normal reference range of 135 mg/dl-145 mg/dl), and a chloride level of 130 mg/dl (normal reference range of 101 mg/dl-111 mg/dl). However, a review of the general acute care hospitals' (GACH) Admission History and Physical, dated February 21, 2012 (four days prior to the resident's admission to the SNF), indicated the resident's laboratory data was within a normal range as following: sodium was 141, potassium 3.8, chloride 109, BUN 28, and with a creatinine of 1. According to GLOBALRPh, the Clinician's Ultimate Guide, elevated BUN and creatinine levels are indicative of someone in [MEDICAL CONDITION] (<http://www,globalrph.com/labinter.htm>). There was no documented evidence any other interventions were recommended and/or ordered for the resident's poor nutritional intake and weight loss. On May 14, 2012, a review of a nurses' note, dated March 21, 2012, indicated the resident had a 10 lb. weight loss and the resident's physician was notified without any new orders. There was no further documentation related to the resident's weight loss or new interventions. A review of a Change of Condition Report, dated March 25, 2012, indicated Resident 1 continued to refuse to eat breakfast and lunch, with a food intake of 25% in the last 24 hours, the report indicated the resident does take fluids. On the report, under Objective/underlying illness/Dx: Weight Variance was one of the choices, but was not checked, indicating the facility failed to place the resident on a weight variance although he was losing so much weight. The record indicated the nurse explained to the resident the risks and benefits of not eating. The report indicated both the resident's physician and responsible party were notified of the resident's refusal to eat. However, the resident's weight loss was not documented on the report. A review of Resident 1's Breakfast/Lunch/Dinner Record, during the months of February and March 2012, indicated the resident had eaten 45% of offered breakfasts, 32% of offered lunches, and 31% of offered dinners. From March 23, 2012 to March 27, 2012 the resident had refused four of the five breakfasts, three of the four lunches, and two of the four dinners. The feeding record indicated the resident refused breakfast five of seven times during the last seven days he was in the facility and ate only 30 % of his offered breakfast meals the other two days. He refused lunch four of the last seven days he was in the facility and ate only 20% of his offered lunch the other three days. The last seven days Resident 1 was in the facility, he refused to eat dinner for two days and ate an average of 35% of his dinner the other five days, prior to being discharged to a board and care facility. On May 15, 2012, at 8:30 a.m., during a telephone interview, the resident's family member stated the resident did not eat or drink well while in the facility. On May 16, 2012, at 9:40 a.m., during an interview, the director of nurse (DON) stated she was not aware the resident was not eating and had a significant weight loss with abnormal labs. On May 18, 2012, at 8:10 a.m., while she read her March 20, 2012 note, the RD stated the family was difficult to work with. She stated multiple diets and snacks were tried. The RD stated the certified nursing assistant (CNAs) were directed to encourage and assist the resident to eat. The RD stated she ordered lab work on March 20, 2012, to assess the resident's nutritional status after the resident had loss so much weight in one week (10 lbs.) and considered a possible intervention of a feeding tube placement. The RD documented under her plan to clarify the resident/family's desires regarding enteral feeding (being fed by a feeding tube). However, there was no further follow-up regarding the enteral feedings. The RD was questioned about this and stated, "I thought the nurses would follow-up with the family about a placement of a [DEVICE], I don't know what happened." There was no further documentation in the resident's clinical record about the resident's significant weight loss. An interview on May 18, 2012, at 10:05 a.m., a licensed vocational nurse (LVN 1) stated the resident did not eat well, but took fluids. LVN 1 stated she explained the risks and benefits of not eating to the resident. When she was asked how she communicate that information to the resident she stated, "I know he does not understand, was non-verbal, and did not communicate." LVN 1 stated she did speak to the resident's family and the physician about the risks of the resident not eating. However, there was no documented evidence LVN 1 had spoken to the resident's family or the physician and there was no follow-up. According to a "Licensed Nurses Discharge Progress Note," dated March 27, 2012, at 11:30 a.m., Resident 1 was discharged to a board and care facility. On May 18, 2012, a review of a paramedic run sheet, dated March 27, 2012, and timed at 7:30 p.m., indicated the resident was observed at the board and care with an altered level of consciousness (ALOC). According to the paramedic run sheet, the paramedics were told the resident had not eaten or drank anything since Friday, March 23, 2102, a period of four days. According to the GACHs' record, dated March 28, 2012, at 12:45 a.m., Resident 1's admission weight was 55.5 kg (122 lbs.) which was an additional weight loss of 13 lbs. (from the last time the resident was weighed in the SNF on March 19, 2012) for a total weight loss of 35 lbs. in 33 days. According to GACH discharge summary, dated April 18, 2012, the resident's admitting [DIAGNOSES REDACTED]. The resident was fed in the GACH with enteral feedings with a [MEDICAL CONDITION] tube (NGT/ the insertion of a plastic tube placed through the nose, past the throat, and down into the stomach). A review of the facility's policy and procedure, titled, Care and Treatment/ Nutrition, revised May 5, 2012, indicated the facility would ensure all residents will maintain acceptable parameters of nutritional status, such as body weight and protein levels. It also indicated that significant weight loss (5% in one month) should be addressed in the care plan. Under Clinical Evaluation, it indicated any resident with a weight that varies from the previous period by 5% in 30 days will be evaluated by the inter-disciplinary team to determine the cause of the weight loss and interventions required. However, a review of the resident's two IDT meetings, conducted on March 9, 2012 and March 16, 2012, did not contain documentation regarding the resident's significant weight loss.