Broadway Manor Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and care in accordance with professional standards of practice (established guidelines or requirements for safe and accountable practice, protecting both the public and the profession's reputation) for one of three sampled residents (Resident 1) by failing to assess the resident and notify the physician when the resident had a change of condition on 5/9/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive resident specific care plan for three of eight sampled residents (Resident 4, 8 and 31) in accordance with the facility's policy and procedures. A care plan for Resident 4 and 31 was not developed for management of dementia ( a progressive brain disorder that affects memory and thought process). This failure had the potential to result in the resident not to receive the necessary care needs and psychosocial needs, increased behavioral escalation, resident distress, and risk of harm. 2. A care plan for Resident 8 was not developed for the management of self inflicted wound of both hands by picking at his nails and skin using fingers on both hands. This failure had the potential to result in worsened or delayed healing of Resident 8's wound.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) two medication emergency kitS ([eKIT] - kit containing medications needed to be used during emergencies) containing lorazepam (a controlled substance [CS - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication [CM] used for anxiety) for February 2026, in one of two Medication Rooms (Medication Room Station A) inspected. 2. Account for one dose of Modafinil (a CM used to sleep apnea [a disorder where breathing repeatedly stops and starts during sleep, preventing necessary oxygen flow and restful sleep]) for Resident 4 in one of two inspected medication carts (Medication Cart 1). 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label, discard medications and stored safely, following manufacturer's recommendations and in accordance with the facility's Policy and Procedure (P&P) titled Medications and biologicals by failing to: 1. Label one (1) open Lantus (type of long-acting insulin [medication that lowers blood sugar]) in a Solostar pen (a type of prefilled syringe containing insulin) stored in Medication Cart 2 at room temperature for one of three sampled residents (Resident 83). 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the facility's policy and procedure for Sanitation and Infection Control, to ensure the Dietary Aide (DA) followed infection control policies to ensure the department operated under sanitary condition to serve 70 of 70 residents. This deficient practice had the potential to cause food-borne illnesses caused by consuming contaminated foods or beverages.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide sufficient training program to ensure the continuing competence of certified nursing assistants. This deficient practice had the potential to negatively impact the competence and performance of certified nursing assistants in delivering safe and effective nursing care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 of 7 sampled residents (Resident 48) had a current and accessible copy of the Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) in the resident's electronic chart and physical clinical record. These failures had the potential to cause conflict with Resident 48's and their representative party's wishes regarding end-of-life treatment and care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards and facility policy and procedures (P&P) for one of six residents (Resident 55) observed for medication administration by failing to administer crushed medications separately. This deficient practice increased the risk that Residents 55 could experience medication adverse effects (unwanted, unintended result) such as drug (medication) - drug interactions and cross-contamination from combining and administering crushed medications together.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 7) with limited range of motion (ROM - the extent of movement of a joint) was assessed for refusal of care and provided alternative treatment and services when resident refused to receive ROM exercises, use of hand roll splints (rigid, or semi-rigid devices used to stabilize fractured bones, injured joints, or muscles) and no alternative measures provided to prevent decline in ROM. This deficient practice had the potential to place the resident at increased risk for ROM decline and development of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and hazard free environment in accordance with facility's policy and procedure titled Oxygen Administration by failing to display a Oxygen in Use precaution on the door for one of eight sample residents (Resident 5) who was receiving oxygen. This deficient practice had the potential to place residents at risk of injury due to accidental fire and hazard.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of three sample residents (Resident 2, a resident who had kidney failure (failure of the kidney to filter toxins and remove extra fluid in the body) and receives hemodialysis (dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) fluid intake restriction was monitored properly and followed the Registered Dietitian's (RD) fluid restriction recommendation of 750 to 1500 milliliters (mL, unit of measure) as indicated in the Nutritional Assessment on 1/26/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Certified Nurse Assistant (CNA) 6 had the competency skill to accurately monitor and document one of one sampled residents (Resident 2) food intake who was receiving a renal diet (a specialized diet prescribed by the physicians for residents with kidney disorder) as indicated in the facility's policy and procedures. This failure had the potential to place Resident 2 at risk for unintended weight loss and fluid deficit or excess that could further decline in her nutritional management.

Inspectors wroteBased on observation, interview, record review, the facility failed to provide care and services to one of one sampled resident (Resident 8) with loss of dentures in accordance with facility policy and procedure titled Dental Services. This deficient practice had resulted in the Resident 8's ability to chew his food that could lead to choking or pain with chewing potentially leading to weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure complete and accurate medical records were complete and accurate for 2 of 8 sampled residents (Resident 64 and 42) by failure to ensure: Advance Directive (document used to verify and record that the resident or legal representative was informed of their rights to accept or refuse treatment) for Resident 64 was dated. Physician Orders for Life -Sustaining Treatment form (POLST- a physician's order that includes level of medical intervention) for Resident 42 contained required signature. This failure had the potential to result in confusion regarding the validity of resident's treatment preferences and delay or delivery of care that may not have been consistent with the residents wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's infection control program for one of eight sample residents (Resident 62) by failing to assess and document signs and symptoms of respiratory infection as indicated in the facility's policy and procedure titled Infection Control. This deficient practice placed other residents at risk of repiratory infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident's bedrooms measured at least 80 square feet (sq. ft) per resident for 30 of 31 rooms (Rooms 1-4, 6-12, 4-32) in the facility in accordance with the facility's policies and procedures (P&P) titled, Bedrooms, dated May 2017. This deficient practice had the potential to negatively impact the care and services of the facility's staff and to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Licensed Vocational Nurse [LVN] 1 and Registered Nurse Supervisor (RNS) 1 consulted and notified the attending physician (Physician 1) and/or Physician Assistant (PA) 1 of a resident's significant change in condition (refers to a major decline in a resident's health status that requires a comprehensive reassessment that is not expected to resolve on its own or through standard medical interventions) for one of two sampled residents (Resident 1) in accordance with Resident 1's physician's order and care plan developed to monitor Resident 1 and notify the physician for adverse reaction (unwanted, unexpected, or harmful effect resulting from a medication or other treatment), while receiving Eliquis (a brand of anticoagulant [blood thinner] medication that prevents or reduces blood clots) from 9/3/2024 to 2/25/2025. [...]

Inspectors wroteAmended Copy - 4/1/25 Based on interview and record review the facility failed to assess, monitor for the signs and symptoms of Peripheral Arterial Disease (PAD- also known as peripheral vascular disease [PVD], a circulatory problem where narrowed arteries reduce blood flow to the legs, arms, or other parts of the body, often due to plaque buildup), and follow the general acute care hospital (GACH 1) physician and facility ' s attending physician ' s recommendations for one of three sampled residents (Resident 1), who was recently hospitalized for an acute cerebrovascular accident (CVA - a type of stroke [occurred when blood flow to the brain was interrupted], loss of blood flow to a part of the brain), right internal carotid artery stenosis ([NAME]- a condition that happens when the carotid artery, which is the large artery on either side of the neck, becomes blocked), and PAD, by [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for 11 of 13 sampled residents (Resident 2, 14, 24, 25, 26, 48, 49, 61, 71 55 and 67). This deficient practice had the potential to result in confusion regarding the care and services provided to the residents, and a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient-centered, equitable (fair), and timely care.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices in accordance with the facility ' s policy and procedure by failing to ensure the scoop was not left inside the thickener (products used to modify the consistency of drinks, helping people with dysphagia [difficulty swallowing to control the way they swallow]) container/bin after each use. This deficient practice had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated (transfer of disease-causing organism the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) food.

Inspectors wroteBased on interview, and record review the facility's Quality Assurance Performance Improvement (QAPI-a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve quality in nursing homes) committee failed to develop and evaluate a QAPI plan to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) were transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for 11 of 13 sampled residents (Resident 2, 14, 24, 25, 26, 48, 49, 61, 71 55 and 67) which was an identified care area concern from the last annual recertification survey conducted from 12/18/2023 to 12/21/2023. These deficient practices had resulted in the late MDS transmission to the CMS data system that affects the care planning, quality of care and quality of life of the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs of one of two sampled residents (Resident 14) in accordance with the facility's policy and procedure by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was within reach. This deficient practice had the potential for Resident 14 not able to call the facility staff to ask for help or assistance especially during emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed provide a safe and homelike environment for one of two sampled residents (Resident 50) with five plastic bags tied together and used as an extension to pull as a string to turn on and turn off the overhead light above the bed. This deficient practice had the potential to cause accident and created a non homelike environment and frustration to Resident 50 when pulling the string.

Inspectors wroteBased on interview, and closed record review, the facility failed to ensure that one of three sampled residents (Resident 58), indicated the reason of discharge or transfer in the Notice of Proposed Transfer/Discharge form (a written notification to the resident or responsible party that included the reason for the transfer or discharge, where the resident will be transferred or discharged to, how to contact the State Long Term Care Ombudsman, and how to appeal the transfer or discharge if necessary) was not completed in accordance with the facility's policy and procedure. This deficient practice violated the residents right and the facility's policy procudere that had the potential for Resident 38 not to be informed about the reasons of his transfer/discharge.

Inspectors wroteBased on interview and record review, the facility failed to complete the Notification of bed-hold and Return form (a form that indicates the resident's rights to return to the facility after hospitalization) in accordance with the facility's policy and procedures, for two of three sampled residents (Resident 38 and 58) who were transferred to the General Acute Care Hospital (GACH) as ordered by the physician. This deficient practice resulted in the violation of the resident's rights to be informed about the Notification of bed-hold and Return policy and to be aware that he/she can return to the facility after hospitalization as ordered by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow up a Preadmission Screening and Resident Review (PASRR - a federally required screening for mental health; PASRR Level I identify suspected mental illness, intellectual/developmental disability, or related condition; Level II screening determines if the individual would benefit from specialized mental health services) evaluation for two of two sampled residents (Residents 49 and 69): 1. For Resident 49 who assessed as having positive level 1 screening on 4/29/2022, indicated required a level II mental health screening. 2) for Resident 69 who assessed as having negative level 1 screening on 6/3/2024, indicated to resubmit a PASRR level 1 screening if the resident remained at the facility longer than 30 days. (Resident 69 remained in the facility for more than six months and still in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 20) who had a right heel blood filled blister, had an air loss mattress ( LAL- mattress designed to prevent and treat pressure sore [a skin breakdown due to unrelieved pressure and friction to the skin]) setting was not set according to residents weight, the manufacturer's guidelines was set based on the resident's weight to prevent and/or minimize skin pressure on the bony prominences of the body. This deficient practice had the potential to delay healing, worsened pressure sore and that negatively affect Resident 20's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sample residents (Resident 70) who was incontinent (no control) of bladder receives appropriate treatment and services for the urinary indwelling catheter (or Foley Catheter is a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) to prevent urinary tract infection (UTI - an infection that can occur in any area of the urinary tract, including the ureters, bladder, kidneys, or urethra) by failing to: 1. Assess and document presence of sediments (visible solid particles in the urine containing blood, crystals and bacteria, including sloughing of tissue (debris), or cells) in the urine which commonly due to urinary tract infection (UTI). 2. Notify the physician presence of sediments in Resident 70's urine. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a supply of Norco (a medication used to treat pain) was available pursuant to an active physician order for one of five residents (Resident 44) observed for medication administration. The deficient practice of failing to maintain an adequate supply of Resident 44 ' s pain medication increased the risk for the resident to experience pain at a higher level for longer than necessary due to the unavailability of his medication that could lead to a decline in his quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the entire dose of warfarin (a blood-thinning medication used to prevent life-threatening blood clots from forming) 2.5 milligrams (mg - a unit of measure for mass) was administered via gastrostomy tube (g-tube - a tube surgically implanted in the stomach for feeding and medication administration) in accordance with the physician ' s order on 12/17/24 for one of five residents (Resident 279) who observed during medication administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and served food and menus that meet resident choices including their nutritional needs by failing to: 1. Ensure [NAME] 1 and [NAME] Assistant uses and have access to preparation guides and recipes during food preparation or puree diet (blended until they reach a smooth consistency) and thickened liquids for 18 of 18 residents receiving puree diet. 2. Ensure one of three sampled residents ( Resident 17) received double portion of meat as specified in the physician's order. This had the potential for residents to not receive the nutrition they need that could lead to food dissatisfaction and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to post an accurate nurse staffing information of actual hours worked by Registered Nurses (RN), License Vocational Nurse (LVN)/ License Practical Nurse (LPN) per shift on 11/17/2024 up to 12/17/2024 (one month) accordance with the facility ' s policy and procedure titled Posting Direct Care Daily Staffing Numbers. This deficient practice of posting inaccurate nurse staffing information had the potential to cause misleading information to the residents and the visitors of the nursing care provided to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's bedroom measured at least 80 square feet (sq. ft.-a unit of measurement) per resident in multiple resident bedrooms for 30 out of 31 rooms. Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 ,26, 27, 28, 29, 30, 31, and 32 that measured less than 80 sq. ft. per resident. This deficient practice had the potential to affect the delivery of care and services of the staffs the residents which can affect the privacy to the residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure to administer the morning medications as ordered by the physician for one of three sampled residents (Resident 1), who receives dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. It often involves diverting blood to a machine to be cleaned) treatments three times a week outside the facility, at 7:45 AM as ordered by the physician. This deficient practice had the potential for worsening Resident 1 ' s medical condition such as fluid overload, high blood pressure, and heart complications.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from significant medication error by failing to administer insulin as ordered by the physician for one of three sampled residents (Resident 1), who receives dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly. It often involves diverting blood to a machine to be cleaned) treatments three times a week outside the facility. This deficient practice had the potential for Resident 1 to have high blood sugar and complication such as Diabetic ketoacidosis (condition develops when body does not have enough insulin and glucose can't enter cells for energy, blood sugar level rises, and body begins to break down fat for energy which produces toxic acids called ketones. Ketones accumulate in the blood and eventually spill into the urine. [...]

Inspectors wroteBased on interview and record review, the facility failed to treat one of four sampled residents (Resident 4) with respect and dignity by failing to ensure to maintain Resident 4 ' s bodily privacy during an inspection of her G-Tube (a tube inserted through the belly that brings nutrition directly to the stomach) by LVN 1, which resulted in the resident's gastrointestinal tube being exposed in the resident ' s common Dining Area. This deficient practice had the potential to negatively impact residents leading to shame, depression, and embarrassment, diminishing the importance of emotional and psychological health.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS - a standardized assessment and screening tool) were completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) data base within the required time frame for 5 of 14 sampled residents (Residents 26, 65, 58, 28, 40). This deficient practice had the potential to negatively affect the provision of necessary care and services and care planning to ensure they meet their highest potentials for Residents 26, 65, 58, 28, 40).

Inspectors wroteBased on observation and record reviews, the facility failed to ensure the medication error rate of less than five (5) percent, due to failure of the licensed staffs to follow the facility's policy and procedure on medication administration for three of four selected residents (Residents 26, 13 and 28) during medication administration observation. These deficient practices resulted in four (4) medication errors out of twenty-seven opportunities (medications observed administered or attempted to administer) which resulted in a medication administration error rate of fifteen percent (15%), that exceeded the five (5) percent threshold.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure its residents were free from significant medication error as indicated in the facility's policy and procedure related to medication administration by failing to: 1. For Resident 26, the licensed nurse attempted to administer Morphine Sulfate (MS-a medication used to relieve sever pain) solution via mouth instead of via the gastrostomy tube (G-tube, a tube that is surgically inserted into the resident's stomach to allow access for food fluids and medications) as ordered by the physician. 2. For Resident 13, the licensed nurse failed to check the resident's apical pulse (a pulse site on the left side of the chest over the pointed end of the heart) before administering Digoxin (a heart medication) as ordered by the physician. 3. [...]

Inspectors wroteBased on observation interview and record review the facility failed to follow professional standards for food service safety, in accordance with the facility's policy and procedure on Refrigerator / Freezer Storage, by failing to: 1. Label and date 31 covered glasses of milk in the refrigerator. 2. Label and date an open bag of hashbrown in the freezer. These deficient practices had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food.

Inspectors wroteBased on observation, interview, and record review, the facility did not dispose garbage and refuse properly by not covering two of two metal dumpsters (large trash container designed to be emptied into a truck) due to overflowing garbage bags, leaving 10 trash bags on the ground next to the dumpster, while waiting for trash to be picked up by the garbage truck. This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 70 of 70 facility residents and affect including staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed implement the facility's policy and procedure on infection control to prevent spread of infection by failing to 1. ensure the nasal cannula (NC-a device used to deliver supplemental oxygen to people) tubing was changed weekly for Resident 60 and Resident 61. 2. ensure to date the gastrostomy (a creation of an artificial external opening into the stomach for nutritional support) feeding tubing for Resident 28 and Resident 37. 3. ensure the facility staff to perform hand hygiene and wear proper personal protective equipment before providing care to Resident 26. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of one resident (Resident 2) with respect and dignity by ensuring the facility staff who assisted Resident 2 to eat was not standing next to the resident who was sitting, did not take the spoon from the resident without permission and, the staff had an eye contact with Resident 2 while assisting the resident to eat. These deficient practices had the potential for Resident 2 to have decreased feeling of self-worth, lower self-esteem and a decline in psychosocial (social and emotional being) wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility did not implement its policy and procedures titled, Theft and Loss Policy and Procedures and Abuse Prevention and Prohibition Program by not thoroughly investigating an alleged misappropriation of property (he deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent) for one of three sampled residents (Resident 45). Resident 45 reported missing $1500 on 12/11/23 to the Administrator (the Abuse Coordinator) and the ADM Designee (ADMD) that was not thoroughly investigated by the facility. This deficient practice had resulted in Resident 45's verbalization of feeling sadness for not being able to share money to his family, and a potential to negatively affect Resident 45s quality of life, such as sadness and mistrust to facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure titled Theft and Loss Policy and Procedures by not reporting to the California Department of Public Health, Ombudsman (state agency that advocates for the residents and the Police Department) within 24 hours, the allegation of misappropriation of property (he deliberate misplacement, exploitation, or wrongful, temporary, permanent use of a resident's belongings or money without the resident's consent) for one of three sampled residents (Resident 45) who reported missing $1500.00 to the Administrator (ADM) and Administrator Designee (ADMD) on 12/11/23. As a result of this deficient practice Resident 45 felt sad that he could not give money to his family during the Christmas time. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive Minimum Data Sets (MDS - a comprehensive standardized assessment and screening tool) were completed and submitted in the CMS (Centers for Medicare and Medicaid Services- Long-Term Care) data base within the required time frame for two of 14 selected residents (Resident 42 and Resident 62). This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 42 and Resident 62.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a resident assessment and care-screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one of 14 sampled residents (Resident 68). This deficient practice had the potential to result in confusion regarding the care and services provided to Resident 41, and a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient-centered, equitable (fair), and timely care.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a Preadmission Screening and Resident Review (PASRR - a federally required screening for mental health; PASRR Level I identify suspected mental illness, intellectual/developmental disability, or related condition; Level II screening determines if the individual would benefit from specialized mental health services) Level II evaluation for two of three sampled residents (Residents 9 and 66). This failure had the potential to result in Resident 9 and Resident 66 not to receive the necessary mental health services which can negatively affect their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services to one of one sampled resident (Resident 27) by ensuring the resident was assisted immediately when calling for help to change a soaking wet brief from urine incontinence (no control) and to ensure the call light was within reach to be used by the resident who needed assistance with ADL (Activities of Daily Living) as indicated in the residents plan of care and facility's policy and procedures. This failure resulted in Resident 27's developing skin damaged from prolonged sitting on a wet incontinent brief and a high risk for resident to fall and sustain injuries when unable to use a call light for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion (limited ROM-joint that has a reduction in its ability to move) to receive Restorative Nursing Assistant (RNA) assisted active range of motion (AAROM) exercises followed by application and removal of left elbow splint (a plastic device used to immobilize elbow to support healing and to prevent further damage) to increase, prevent, or maintain the ROM mobility as ordered by the physician's for one of two residents (Resident 15). Residents 15 did not receive RNA assisted exercises on 12/18/23, left elbow splint application and removal with wear time of at least four hours a day on 12/12/23, 12/13/23, 12/15/23, 12/19/23 was not placed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a hazard free environment by ensuring one of one sampled resident (Resident 47) who smokes did not possess a pack of cigarettes and a lighter in his pocket while in the facility as indicated in the resident's plan of care. This deficient practice had the potential to result in an accidental fire in the facility and can lead to injury to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 55), received the Jevity 1.5 (feeding formula) as ordered by the physician, and was not administered Glucerna 1.5 (a feeding formula). This failure had a potential to result in Resident 55's unplanned weight loss/weight gain and/or an allergic reaction to the formula.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimal Date Set (MDS- a comprehensive standardized assessment and screening tool) (MDS) Coordinator had necessary skill sets and competency to complete and transmit to CMS (Centers for Medicare and Medical Services) data base the MDS assessments for all the facility residents in accordance with the facility's policy and procedure. This failure had a potential to result in inaccurate MDS assessment, documentation, late or missed completion and submission of MDS assessment to the CMS data base, and a potential to affect the facility's quality of care monitoring system that measures the effective, safe, efficient, patient-centered, equitable (fair), and timely care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 54) who was assessed by the facility as allergic to fish, was not served fish with the meal as indicated in Resident 54's plan of care and the facility's policy and procedure. This deficient practice had the potential to result in Resident 54 to experience an allergic reaction and anaphylactic shock (a severe, potentially life-threatening allergic reaction that can develop rapidly) which could lead to death.

Inspectors wroteBased on interview, and record review the facility's Quality Assurance Performance Improvement ([QAPI] performed a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve quality in nursing homes) committee failed to identify facility and resident care issues, develop, and implement appropriate plans of action, in accordance with the facility's policy and procedures on Continuous Quality Improvement Program (QAPI), by failing to: 1a. Ensure the QAPI committee identified and developed measures to ensure the Minimum Data Set-a resident assessment and care planning tool (MDS) were completed and transmitted timely to the CMS data System timely by the MDS Coordinator after reviewed by the DON for eight of eight residents (Residents 42, 62, 26, 65, 58, 28, 40 and 41). 1b. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 62), was informed of the benefits and potential side effects (undesired effect) of Influenza (Flu- a type of respiratory infection due to virus) vaccine (a substance injected into the muscle with the use of a needle to stimulate immunity [defense against fight infection] to a particular infectious disease) prior to administration. As a result of this failure Resident 62 was not able to exercise his right to have informed consent prior to accepting to receive or not receive the annual influenza vaccine.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's bedroom measured at least 80 square feet (sq. ft.-a unit of measurement) per resident in multiple resident bedrooms for 33 out of 44 rooms. Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 ,26, 27, 28, 29, 30, 31, and 32 measured less than 80 sq. ft. per resident. This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.