California Healthcare and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the environment remained as free of accident hazards as possible for one of three sampled residents (Resident 1) when Resident 1's bed was left unattended in the raised position. This failure had the potential to increase Resident 1's risk of falling or injury.

Inspectors wroteBased on interview and record review, the facility failed to respect personal privacy for one of three sampled residents (Residents 2) when a staff member entered the resident's room without permission. This deficient practice had the potential to result in negatively affecting the safety and security for this resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of a low air loss mattress (LALM- a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [ PU/PI-injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) for two of three sampled residents (Resident 2 and Resident 3) when on 6/8/2026 a cloth bed pad and a sheet were placed over the mattress surface while Resident 2 and Resident 3 were also wearing an incontinence (loss of bowel or bladder control) brief (diaper). This deficient practice had the potential to compromise the effectiveness of the LALM by reducing airflow and pressure redistribution, thereby increasing the risk of skin breakdown, development or worsening of PU/PI, excess moisture retention and delayed wound healing.

Inspectors wroteBased on interview and record review, the facility staff failed to notify the physician immediately when a resident had decreased meal intake (consumed less than 50 percent of his meal) for one of five sampled residents (Resident 5). This deficient practice had the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure History and Physical (H&P- contains relevant information about the resident's past medical history, current medical concerns, including review of any pre-existing medical conditions, past hospitalizations and surgeries, allergies, medications being taken, family medical history, physical examination and assessment of mental status) Examinations were completed by the physician for two of five sampled residents (Resident 4 and Resident 5). This deficient practice had the potential to result in incomplete clinical information, inconsistent care coordination, and compromised continuity of care, placing Resident 4 and Resident 5 at risk for unmet care needs and inadequate treatment planning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with a safe and comfortable environment when wheelchairs (a mobility device consisting of a chair mounted on wheels, designed for individuals who have difficulty or are unable to walk due to illness, injury, disability or age) and hospital beds were stored in the patio area. This deficient practice had the potential to place Resident 1 and other residents, staff, and visitors at risk for unsafe and/or uncomfortable environment.

Inspectors wroteBased on interview and record review, the facility's licensed nurses failed to conduct accurate fall risk assessments for two of four sampled residents (Resident 1 and Resident 2). These deficient practices had the potential to increase the residents' risk for falls and fall-related injuries. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (diet typer report) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the waste container. This failure had the potential to violate 125 of 125 residents' rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) by failing to:1. Develop a care plan that address monitoring of resident's behavior for three (Resident 1, Resident 8, Resident 14) of four sampled residents on physical restraints (any physical device attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of normal access to one's body) when the restraints were removed in accordance with the physician's order (called holidays). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to two of three sampled residents (Resident 90 and Resident 191) reviewed under the respiratory care area by failing to:1. Ensure Resident 90 and Resident 191's oxygen tubing (a flexible, clear hose that delivers oxygen to a patient during oxygen therapy) was labeled with the date it was last changed.2. Administer oxygen to Resident 191 as ordered by the physician. These deficient practices had the potential to negatively affect the provision of care and services related to oxygen therapy and placed the residents at increased risk for respiratory distress and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate and current daily nurse staffing postings for the Skilled Nursing Facility (SNF) and Subacute unit, in accordance with the facility's policy titled Posting Direct Care Daily Staffing Numbers. Specifically, the facility: 1. Failed to post the required daily staffing information for the SNF on 4/21/2026 and 4/22/2026. The form displayed on both dates was outdated and reflected 4/20/2026. 2. Failed to document and post the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care, per shift for 4/20/2026 on both the SNF and Subacute unit.3. Posted projected staffing hours labeled as Actual Hours Worked for the day, evening, and night shifts on 4/22/2026 in the Subacute unit.4. [...]

Inspectors wroteBased on interview and record review the facility failed to: 1. Have an available supply of oyster shell calcium (a medication used as a dietary supplement to provide support to bones) in the facility affecting 1 (one) of six (6) observed residents (Resident 87) for medication administration. As a result, Resident 87 did not receive oyster shell calcium on 4/21/2026 at 9:45 a.m. 2. Have an available supply of menthol-methyl salicylate cream (a medication used for pain) and glipizide (a medication used to lower blood sugar levels,) in the facility affecting 1 (one) of six (6) observed residents (Resident 201) for medication administration. As a result, Resident 201 did not receive menthol-methyl salicylate cream between 4/9/2026 and 4/20/2026 and did not received glipizide between 4/16/2026 and 4/20/2026. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Four (4) medication errors out of 26 total opportunities contributed to an overall medication error rate of 15.38% affecting three (3) of six (6) residents observed for medication administration (Resident 84, 87 and 201.) The medication errors were as follows: 1. Resident 84 did not receive sevelamer (a medication used for hyperphosphatemia [having high blood levels of phosphate, a mineral] for people on dialysis [treatment that removes waste and excess fluid from the blood,]) on 4/20/2026, as prescribed by Resident 84's physician. 2. Resident 87 did not receive oyster shell calcium (a medication used as a dietary supplement to provide support to bones), on 4/20/2026, as prescribed by Resident 87's physician. 3. [...]

Inspectors wroteFindings: During an observation on 4/20/2026 at 10:10 a.m. in Medication Cart Station 3, Licensed Vocational Nurse (LVN) 2 was observed administering gabapentin (a medication used for neuropathy [nerve damage,]) and metformin (a medication used for high blood sugar level) orally to Resident 201. Resident 201 was observed swallowing the gabapentin and metformin tablets with a glass of water. LVN 2 was observed not administering glipizide (a medication used for high blood sugar levels) to Resident 201. During a concurrent interview and record review on 4/20/2026 at 2:25 p.m. with LVN 2, LVN 2 reviewed Resident 201's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record]) for April 2026. LVN 2 stated that LVN 2 did not administer glipizide that day (4/20/2026) at 10:10 a.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Remove and discard from use one (1) expired latanoprost (a medication used for glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle for Resident 26, in accordance with manufacturers' requirements and facility policies, in one (1) of five (5) inspected medication carts (Medication Cart 2B). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance, flavor and temperature when: 1. Cold foods were not served cold and capri blend vegetables were squashed and brownish green in color for lunch meal on 4/20/2026.2. Foods not served at palatable temperatures for breakfast time on 4/22/2026. These failures had potential to result in 103 of 125 facility residents including Resident 76, Resident 130, and Resident 169 at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed capri blend vegetables looked flat and spread on the plate and puree spring fruit crip was watery and did not hold its shape. These failures had the potential to result in difficulty in swallowing, difficulty in eating, decrease in food and nutrient intake to 21 of 21 residents on puree diet (foods that are soft, pudding like consistency and hold its shape), resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 4/22/2026. This deficient practice had the potential to result in hunger and frustration for 124 to 125 residents receiving meals from the kitchen, including Resident 76 and Resident 88.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. A personal iced drink with a straw was stored in the pitcher storage area.2. Kitchen staff failed to perform handwashing when:a. Dietary Aide 1 (DA 1) sneezed and touched his hair, then proceeded to work on the trayline (an area where food is assembled from the steamtable [kitchen appliance that keeps food warm at a safe serving temperature] onto resident's plates) without washing his hands.b. DA 1 transitioned from handling dirty items to clean items in the pot sink area without washing his hands.c. [NAME] 2 touched the lid of the trash can and then handled a pan containing pureed sausages without washing her hands. 3. Refrigerator and freezer temperature monitoring was not consistently performed when: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: 1. A garbage container by the preparation area was not completely closed or covered when not actively in use. 2. The dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) surroundings had sticky black spills. These failures had potential to attract birds, flies, insects, pests and possibly spread infection to 125 of 125 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1). Accurately document on the medical diagnoses and on the Physician Orders for Life-Sustaining Treatment (POLST-a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life) for one of 35 sampled residents (Resident 211).2). Accurately document the form titled Supportive and Safety Device/Restraint - Physical. [...]

Inspectors wroteBased on interview and record review, the facility to offer the updated 2025/2026 influenza (flu, a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs) vaccine (medications used to prevent diseases usually given by injection or by mouth) at the start of the respiratory illness season (typically from October through April in the U.S., peaking between December and February, characterized by increased circulation of respiratory illnesses including the fly and COVID-19 [an infectious respiratory illness caused by the SARS-CoV-2 virus]) when the vaccine became available for four of five sampled residents (Residents 1, 2, 13, and 20) investigated for immunizations (the process where a person is made resistant to a disease). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident's dignity and respect for two of two sampled residents (Resident 212 and 94) reviewed under the dignity care area by: a. Failing to ensure the Infection Preventionist Nurse (IPN) knocked or requested permission before entering Resident 212's room. b. Failing to ensure Resident 94's indwelling urinary catheter (a flexible tube that is inserted into the bladder to help drain urine) collection bag (designed to collect urine drained from the bladder via catheter) was covered with a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible). These deficient practices violated the residents' rights to be treated with respect and dignity and had the potential to negatively affect resident's sense of self-worth and self-esteem.

Inspectors wroteBased on interview, and record review, the facility failed to implement its policy and procedure (P&P) titled Side Rails (adjustable metal or rigid plastic bars that attach to the bed ) for one of four residents (Resident 19) reviewed under the restraints care area by failing to obtain an informed consent (process in which the residents are given important information including possible risks and benefits, about a medical procedure or treatment) for the use of lower side rails. This deficient practice violated Resident 19's and/or the resident's representative the right to be informed of and to participate in the resident's treatment.

Inspectors wroteBased on interview and record review, the facility failed to clarify wishes written on Resident 211's advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) with the healthcare agent (a person legally authorized to make decisions on behalf of another individual when that person is unable to communicate r communicate their own decisions when one of four sampled resident's (Resident 211) orders did not match the advance directive. This failure had the potential to result in Resident 211 receiving unnecessary treatment and inappropriate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe homelike environment to two of two sampled residents (Resident 50 and Resident 13) investigated under environment task by failing to: a. Ensure Resident 50 had a trash bin to dispose of his trash in his room. This deficient practice caused Resident 50 to have to dispose his trash in the bin labeled urinal only and had the potential to affect the resident`s self-esteem and self- worth. b. Ensure Resident 13's floor mat (a cushioned floor pad designed to help prevent injury should a person fall) was in good condition and there was not trash on the floor and a dark red substance on the bottom of the bed frame. This deficient practice had the potential to violate the resident's right to living in a safe, comfortable, and homelike environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to remove one of five sampled residents' (Residents 8) restraints reviewed under the Restraints care area, in accordance with the physician's order. This failure to remove the restraints as ordered had the potential to increase the risk of harm including decreased circulation, skin breakdown, and decline in mobility.

Inspectors wroteBased on interview and record review, the facility failed to complete an admission comprehensive assessment within the required timeframe for when one of three sampled residents (Resident 211). This failure had the potential to result in Resident 211 not receiving the necessary treatment and appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS, a U.S. federal agency that administers major healthcare programs such as Medicare [a federal health insurance program in the U.S. for people aged 65 or older] and Medicaid [a program in the U.S. that provides low-cost health coverage to millions of Americans with limited income]) for two (Resident 22 and Resident 166) of two sampled residents. This deficient practice had the potential to result in delayed services for Resident 22 and Resident 166.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards that will meet each resident's physical, mental and psychosocial needs for one of one sampled residents (Resident 94) when the facility: 1. Failed to notify physician of Resident 60's refusal of dermatologist recommendation for skin biopsy of right temple 2. Failed to obtain treatment orders for ongoing care of right temple skin wound. This deficient practice had the potential for the wound to worsen, resulting in delayed healing and increased risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to to ensure the low air loss mattress (a specialized mattress that continuously circulates air) was used correctly for two of six sampled residents (Resident 155 and 60) reviewed under pressure ulcer/injury when:1. Resident 155's LALM was set to 499 pounds instead of 160 pounds. 2. Resident 60's LALM was turned off. These failures had the potential to result in development or worsening of pressure ulcers (localized pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), slower healing, and increased skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two out of five residents (Resident 105 and Resident 202) investigated for accidents by: a. Failing to ensure Resident 105's floor mat (a cushioned floor pad meant to prevent injury if a person falls) was placed next to Residents 105's bed. b. Failing to ensure medical equipment or waste container was not placed on top of Resident 105's floor mat. c. Failing to ensure a floor mat was placed on the right side of Resident 202's bed as ordered. These deficient practices placed the residents at increased risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the indwelling urinary catheter tubing (a hollow tube inserted into the bladder to drain or collect urine) did not have a dependent loop and urine did not backflow for one of two residents (Resident 212) investigated under urinary catheter. This deficient practice had the potential to negatively affect Resident 212 from receiving the proper care necessary to prevent urinary tract infection (UTI - an infection in the bladder/urinary tract).

Inspectors wroteBased on observation, interview, and record review, the facility failed to flush the gastrostomy tube ([GT] - a tube inserted through the belly that delivers nutrition and medications directly to the stomach) with water prior to medication administration, for one (1) of six (6) residents observed for medication administration (Resident 87.) This deficient practice had the potential to cause Resident 87 to receive suboptimal (less than the highest standard or quality) care and have complications of the GT, including aspiration (when food or liquid comes back up from the stomach and enters the lungs [pair of organs situated within the rib cage responsible for breathing,]) and clogging requiring replacement of the GT.

Inspectors wroteBased on interview and record review, the facility failed to ensure the hemodialysis (also known as dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center completed a pre and post-dialysis assessment (evaluation done after hemodialysis by the hemodialysis licensed nurses) by not ensuring the dialysis center recorded a resident's pre- and post-dialysis weights (the weight before and after fluid is removed during the dialysis treatment) on the Dialysis Communication Record (a record of a resident's vital signs and assessments the days he goes to a dialysis treatment) for one (Resident 18) of two residents in the facility investigated for dialysis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain consent and a physician's order for the use of four side rails for one of two sampled residents (Resident 116). This deficient practice had the potential to place the resident at risk for inappropriate use of bed rails and bed rail-related accidents, including the risk of a body part being caught between the rails which could lead to injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring and documentation of potential side effects for apixaban, an anticoagulant (blood thinner) used to prevent blood clots, for one of five sample residents (Resident 191) during review of unnecessary medications. This deficient practice had the potential to result in Resident 191 experiencing adverse effects, including signs and symptoms of bleeding. Without proper monitoring, staff may fail to recognize bruising or internal bleeding, resulting in delayed care, significant blood loss, and potentially life-threatening outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Binding Arbitration Agreement (a binding agreement in which parties agree to submit certain disputes to arbitration rather than court litigation) was explained in a manner understandable to the resident for one of three sampled residents (Resident 183), despite the resident having the capacity to make his own decisions. This deficient practice had the potential to result in the residents signing an agreement without fully understanding its terms and could compromise the resident's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control measures by failing to: 1. Ensure trash was not placed with a resident's urinal in the URINAL ONLY bin belonging to one of one sampled resident (Resident 50). This deficient practice placed residents and staff at risk of exposure and possibly contracting infectious microorganisms. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident specific care plan was developed for one of two sampled residents (Resident 1), when Resident 1 intermittently refused a physician order for Restorative Nursing Assistant (RNA - are Certified Nursing Assistants [CNAs] with specialized training in rehabilitation techniques, focusing on helping residents regain independence in daily activities) sit-to-stand treatment requiring a two-person assist, scheduled five times per week. This deficient practice had the potential to result in a decline in Resident 1's functional status, including reduced mobility, diminished strength and decreased ability to perform Activities of Daily Living (ADL - essential, routine self-care tasks such as bathing, dressing, eating, transferring, and toileting that residents perform daily). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 5) confidential personal information was protected by copying Resident 5's facility records onto an unencrypted (not converted into a code that would prevent unauthorized access) Universal Serial Bus drive (USB-also known as a flash drive, thumb drive, or memory stick - a small, portable, plug-and-play device used for storing and transferring files between computers) and mailing it to Family Member 1 (FM 1). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a facility policy and procedure (P&P) for sending Protected Health Information (PHI) via Universal Serial Bus (USB-also known as a flash drive, thumb drive, or memory stick - a small, portable, plug-and-play device used for storing and transferring files between computers) drive. This deficient practice resulted in an unencrypted (not converted into a code that would prevent unauthorized access) USB drive with a resident's PHI to be lost in the mail, potentially exposing a resident's confidential information. During a review of an email sent to the facility by FM 1 dated 1/26/2026, the email indicated FM 1 was Resident 5's authorized representative and was requesting copies of the complete medical records for Resident 5. [...]

Inspectors wroteBased on interview and record review the facility failed to provide referrals to local agencies and support services that can assist residents' representatives with discharge planning and failed to notify a resident's representative of a denial of admission by the facility preferred by the resident's representative for the resident's discharge, in accordance with the facility's policy titled, Discharge Summary and Plan, for one of four sampled residents (Resident 1). This deficient practice had the potential to delay Resident 1's return to the community and placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.

Inspectors wroteBased on interview and record review the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for one of four sampled residents (Resident 1) by failing to ensure the Activity Director (AD) or activity assistant document the activities provided to Resident 1 from 11/6/2025 to 1/5/2026. This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate medical documentation.

Inspectors wroteBased on interview and record review the facility failed to accurately identify and assess the stage of a pressure ulcer (PU - a localized injury to skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one of ten sampled residents (Resident 3) and did not implement appropriate interventions when on 9/15/2025 Licensed Vocational Nurse 1 (LVN 1) documented Resident 3's pressure ulcer located in the sacrum (a large, triangular bone located at the base of the spine) area as a Deep Tissue Injury (DTI- a pressure injury with damage to underlying soft tissue which may present as a purple or maroon area of discolored intact skin or a blood-filled blister [fluid-filled sac on the skin]) instead of Unstageable (a PU with full thickness tissue loss where the base is completely covered by slough [a type of [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed nurse documented on the resident's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) after administering an antibiotic (medication that kills or inhibits the growth of bacteria) for one of four sampled residents (Resident 1). This deficient practice had the potential to result in medication errors and Resident 1 to receive duplicate medication therapy, which could cause harm to the resident. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure the call light above the resident ' s door is functioning for one out of four sampled residents (Resident 3) to alert staff the call light is on. This deficient practice had the potential to result in a delay in care, and Resident 3`s inability to ask for assistance.

Inspectors wrote2. During a review of Resident 27's admission record, the admission record indicated the facility admitted the resident on 9/20/2023, with diagnoses including multiple sclerosis (a chronic disease that damaged the central nervous system), type two(2) diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly) and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 27's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/4/2024, the MDS indicated the resident was totally dependent on staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for two of three sampled residents (Resident 149 and Resident 183) by failing to: 1. Perform a bed rail/side rail (a safety device that can be installed on the side of a bed to help people get in and out of bed, turn in bed, and prevent falls) assessment prior to putting up the residents' lower side rails. 2. Obtain a physician's order on the use of bed rail/side rail. This deficient practicse had the potential to result in the restriction of residents' freedom of movement and physical harm from entrapment.

Inspectors wroteb. During a review of Resident 163's admission Record, the admission Record indicated that the facility admitted the resident on 7/20/2024 with a diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 163's MDS, dated [DATE], the MDS indicated that the resident was in a persistent vegetative state with no discernible consciousness and was dependent on staff for all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). On 5/7/2025 at 12:40 p.m., during a concurrent interview and record review, reviewed Resident 163's MDS records with the Minimum Data Set Coordinator (MDSC). A review of the admission MDS, dated [DATE], Section I - Active Diagnoses indicated that the resident did not have an active diagnosis of schizophrenia. [...]

Inspectors wroteb. During a review of Resident 59's admission Record, the admission Record indicated that the facility admitted the resident on 2/20/2025 with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness, and reduced mobility. During a review of Resident 59's Minimum Data Set (MDS - a resident assessment tool), dated 3/4/2025, the MDS indicated that the resident had moderately impaired cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated that the resident was at risk of developing pressure ulcers/injuries and had one or more unhealed pressure ulcers/injuries. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents receive treatment and assistive devices to maintain hearing abilities for one of one resident (Resident 5) reviewed under the communication/sensory care area when Resident 5 was not provided with an audiology consultation for his impaired hearing. This failure prevented Resident 5 from receiving the services and equipment needed to improve his hearing ability.

Inspectors wrote1.b. During a review of Resident 36's admission Record, the admission Record indicated that the facility originally admitted the resident on 7/6/2014 and readmitted the resident on 4/29/2025 with diagnoses including metabolic encephalopathy (a condition where brain dysfunction results from a problem with the body's metabolism, causing a change in brain function), legal blindness, and a history of falling. During a review of Resident 36's Minimum Data Set (MDS - a resident assessment tool), dated 3/3/2025, the MDS indicated that the resident had intact cognition (thought processes) and was dependent on staff for most activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 36's Fall Risk Assessment, dated 3/4/2025, the Fall Risk Assessment indicated that the resident was at high risk for falls. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) one (1) medication emergency kit (eKIT-contains certain medications that could be taken if needed immediately) containing controlled medications (CM- medications which have a potential for abuse and may also lead to physical or psychological dependence) for 5/2025, in one (1) of two (2) inspected medication rooms (Medication Room Station 1). 2. Reconcile one (1) medication eKIT containing CMs for 5/2025, in one (1) of five (5) inspected medication carts (Medication Cart Station 2B.) These deficient practices increased the opportunity for CM diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 34 total opportunities contributed to an overall medication error rate of 8.82% affecting two (2) of six (6) residents observed for medication administration (Resident 151 and 183.) The medication errors were as follows: 1. Resident 151 received carvedilol (a medication used to for hypertension [HTN - a condition in which the blood vessels have persistently raised pressure]) at a different time than ordered by Resident 151 ' s physician. 2. Resident 183: a. did not receive docusate (a medication used to soften stool) as ordered by Resident 183 ' s physician b. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Remove and discard from use one expired insulin (medication used to regulate blood sugar levels) Aspart (short-acting insulin) Flexpen (an injection device containing insulin) for Resident 6, in accordance with manufacturer ' s requirements and facility policy and procedures in one (1) of two (2) inspected medication rooms (Medication Room Station 1.) 2. Label one (1) insulin Humulin R (long-acting insulin) vial for Resident 12, in accordance with manufacturer's requirements and facility policy and procedures in one (1) of two (2) inspected medication rooms (Medication Room Subacute.) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature, flavor and appearance when the temperature of the food were as follows: -Zest spinach 121 degrees Fahrenheit (°F, a scale of temperature) -Chocolate cake 60°F, -Milk 47°F and 49°F -Puree chocolate cake 57°F. This deficient practice placed 138 of 199 facility residents on regular, therapeutic diets (a meal plan that controls the intake of certain food and nutrients) and puree diets (food with soft pudding like consistency) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree (foods that are smooth with pudding like consistency) when puree pasta was sticky pasta and not smooth pudding like consistency. These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 18 of 18 residents on puree diet, resulting in unintended (not planned) weight loss and chocking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Opened plastic bags of frozen pancakes and frozen pie crust in the freezer were not labeled and dated. 2. Kitchen equipment and kitchen areas were not cleaned and sanitized. a. The reach-in refrigerator's ceiling had dust and dirt debris. b. The two drawers by the preparation area were dirty to touch and had dust buildup. c. Plate warmer's internal part where the clean plates were stored had food and white dirt debris. d. The two push carts where clean resident's trays, bases and domes were stored had dirt, food and hair debris. e. Condiment containers contain loose sugar, pepper, sweetener particles and dirt residues. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when there were soiled gloves, empty plastic bottles, plastic and other trash on the floor and surrounding areas of the dumpster bin (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts). This failure had potential to attract birds, flies, insects, pests, and possibly spread infection to 138 of 199 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) records for one of seven sampled residents (Resident 690) with limitation in range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) indicated the provision of passive range of motion ([PROM] movement of a joint through the ROM with no effort from person) to both legs from 4/22/2025 to 5/5/2025 in accordance with the physician's order, dated 4/22/2025. This failure resulted in the inaccurate provision of care recorded in Resident 690's medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to: 1. Implement Enhanced Barrier Precautions ([EBP] an infection control intervention in nursing homes designed to reduce transmission of bacteria and other microorganisms that have developed resistance to antibiotics making infections hard to treat) with Resident 130 and 151 in the therapy gym during high contact activities. This deficient practice had the potential to increase the risk of spreading infection to other residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the therapy gym had adequate space and equipment to provide therapy services by failing to ensure: 1. One of two therapy mats functioned properly and was accessible for resident care. 2. One of eight hand weights was well-maintained for residents' use. 3. One of one oxygen concentrators (medical device used for delivering oxygen) was serviced. 4. One of one containers of ultrasound (imaging test that uses high-energy sound waves to look at tissues and organs inside the body) gel was not expired. These failures had the potential to place residents receiving therapy services from safe and optimal use of the therapy equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a comprehensive Minimum Data Set ([MDS] a federally mandated resident assessment tool) for one of 38 sampled residents (Resident 690) after admission on [DATE]. This failure had the potential to prevent Resident 690 from receiving services to achieve Resident 690's goal of walking with a single point cane ([SPC] walking device with a curved or bent handle at the top and long shaft that ends in a single tip used to provide support while walking) to return home.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one (1) out of one (1) sampled residents (Resident 35). This deficient practice had the potential to result in delayed services for Resident 35.

Inspectors wroteBased on interview and record review, the facility failed to develop a complete baseline care plan within 48 hours of a resident`s admission to the facility by failing to address the resident`s indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) for one of one sampled resident (Resident 99) reviewed under catheter care area. This deficient practice had the potential of Resident 99 to not receive appropriate care and treatment in the facility.

Inspectors wroteBased on interview and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident's restraint freedom splint (multipurpose soft splints that help restrict elbow and knee movement) was discontinued, for one of two sampled residents (Resident 63). This deficient practice had the potential to result in confusion in the delivery of care and service.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 156) was provided a communication device or board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) in her preferred language in order to effectively communicate with staff. This deficient practice prevented Resident 156 from communicating with the staff and receiving care in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 540) was provided a toileting program and/or bowel and bladder training (when facility staff assist a resident to the restroom at specific timed intervals) to restore as much bladder function as possible. This deficient practice had the potential to result in continued urinary incontinence (the involuntary leakage or loss of bladder control, resulting in unintended urination), development of urinary tract infection (UTI- an infection in any part of the urinary system), and potential to not achieve or restore normal bowel and bladder function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 15), who was receiving nutrition by gastrostomy tube (GT-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), received appropriate care and services to prevent complications of enteral feeding (tube feeding, a way of delivering nutrition directly to your stomach or small intestine). This deficient practice had the potential to lead to the inadequate care of Resident 15 and place the resident at an increased risk for complications such as infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1. Ensure that a resident received oxygen as ordered by the physician for one of two sampled residents (Resident 107) reviewed under Respiratory Care area. 2. Ensure that Resident 107`s oxygen tubing had a label indicating the date and time of when it was last changed. 3. Ensure that Resident 107`s oxygen humidifier (a medical device used to add moisture to supplemental oxygen, making it easier and more comfortable to breathe, especially for patients using oxygen therapy for extended periods ) was full. These deficient practices had the potential to place Resident 107 at an increased risk of infection and cause complications associated with oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure non-pharmacological interventions (treatments or therapies that do not involve the use of medications) were attempted prior to administering as needed oxycodone (a drug used to treat moderate to severe pain) for one of two sampled residents (Resident 100). This deficient practice placed Resident 100 at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from oxycodone such as drowsiness, increased risk of falling, or loss of appetite.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who received dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) received treatment in accordance with standards of practice for one of four sampled residents reviewed under the dialysis care area (Resident 160) by: 1. Failing to assess the resident`s right upper chest quinton catheter (non-tunneled central line catheters, which are often used as temporary access for hemodialysis) dialysis access site. 2. Failing to implement the physician's order for fluid restriction (limiting the amount of liquid a person consumes daily, often prescribed to manage kidney disease) limited to no water pitcher at the resident`s bedside. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Patient Assessment, policy and procedure for one sampled resident (Resident 18) reviewed under dementia care by failing to conduct a quarterly social service assessment . This deficient practice had the potential for Resident 18 to not attain or maintain the highest practicable physical, mental and psychosocial health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation to one of seven sampled residents (Resident 690) with range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns in accordance with the physician's order, dated 5/1/2025. This deficient practice prevented Resident 690 from receiving a PT Evaluation to assess the possibility of receiving additional therapy to achieve Resident 690's goal of walking with a single point cane ([SPC] walking device with a curved or bent handle at the top and long shaft that ends in a single tip used to provide support while walking) to return home.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate hospice services (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) to one of one sampled resident (Resident 61) reviewed under Hospice and End of Life care area by failing to: 1. Designate a member of the facility's interdisciplinary team to coordinate care provided to the residents by the facility and the hospice company in their Hospice Program, policy. 2. Honor Resident 61`s Responsible Party 2`s (RP 2) wish to end the resident`s hospice services. These deficient practices had the potential to negatively affect Resident 61`s physical comfort and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when one (1) fly (a type of insect) was observed in the kitchen. This failure had the potential to result in 138 of 199 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents at risk for developing pressure ulcers localized damage to the skin and/or underlying tissue usually over a bony prominence) had their skin assessed and documented on a weekly basis per the facility policy and procedure (P&P) for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to delay necessary treatments and services and to increase the residents' risk of skin breakdown.

Inspectors wroteBased on interview, and record review the facility failed to review and update a care plan (a document outlining a detailed approach to care customized to an individual resident's need) after a resident`s Change of Condition (COC-an improvement or worsening of a patient`s condition which was not anticipated) for one of two sampled residents (Resident 1 ). This deficient practice had the potential to result in Resident 1 receiving inadequate care and supervision to prevent falls.

Inspectors wroteBased on interview, and record review, the facility failed to follow the facility's policy and procedure titled Assessing Falls and Their Causes, for one of two sampled residents (Resident 1) by failing to complete a fall risk assessment after the resident`s fall on 12/25/2024. This deficient practice placed Resident 1 at increased risk for recurrent falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was treated with dignity by not communicating with Resident 1 his (Resident 1's) preferred time to receive activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. This deficient practiced had the potential to decrease the resident's sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to permit one of four sampled residents (Resident 1) to return to the facility after hospitalization. This deficient practice subjected Resident 1 to an unnecessary prolonged hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that facility staff (Certified Nurse Assistant 2 [CNA2]) documented blisters (small bubble-like raised bumps [raised area of the skin] on the skin) on the left posterior hand for one of three sampled residents (Resident 2) on the resident's Daily Body Check Report form. This deficient practice had the potential for Resident 2 to not to receive the care and services needed to treat Resident 2's worsening bump on the left posterior hand.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 3) was provided with a left-hand splint (a device that supports and protects the hand and wrist, and keeps them positioned correctly) to reduce further contractures (a permanent tightening of the muscles, skin, and nearby tissues that causes the joints to shorten and become very stiff) of Resident 3 ' s left hand. This deficient practice placed Resident 3 at increased risk for worsening and further development of contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident`s fingernails of two of five sampled residents (Resident 2 and 3) were not dirty as evidence by black substances under the tip of the nails. This deficient practice resulted in Resident 2 and 3 having dirty fingernails that had the potential to result in a negative impact on the resident's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure two of 11 sampled staff (Certified Occupational Therapy Assistant 1 [COTA 1] and Physical Therapy Assistant 1 (PTA 1) wore isolation gowns (protective apparel, used to protect the wearer from the spread of infection or illness if the wearer comes in contact with potentially infectious liquid and solid material) while providing therapy services to Resident 4, in Resident 4 ' s room which was placed on enhanced standard precautions (ESP - a set of infection control measures that involve wearing gowns and gloves during high-contact resident care activities for residents at increased risk of Multidrug- Resistant Organisms [MDROs - bacteria that have become resistant to certain antibiotics [a medicine that fights bacterial infections] such as residents with [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of five sampled residents (Resident 1). This deficient practice had the potential to result in a delay with resident care, possible injury to residents when unable to obtain the needed care and services and residents not receiving assistance with activities of daily living (ADL- tasks of everyday life such as eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services to maintain good grooming and personal hygiene for one of five sampled residents (Resident 1). This deficient practice resulted in Resident 1 having dirty fingernails that had the potential to result in a negative impact on the resident's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Physician Progress Notes (record that documents the physician's role in the assessment, evaluation, and care of residents) were completed as required for one of five sampled residents (Resident 1). This deficient practice had the potential for inconsistent care coordination due to incomplete records and placed Resident 1 at risk for poor continuity of care and care needs.

Inspectors wrote2. A review of Resident 179's admission Record indicated the facility admitted the resident on 3/9/2024 and readmitted the resident on 4/1/2024 with diagnoses of fracture (broken bone) of right femur (thighbone), fracture of left tibia (two bones between the knee and ankle), and fracture of right lower leg. A review of Resident 179's History and Physical (H&P - a formal assessment of a patient and their problem), dated 4/1/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 179's Order Summary Report, dated 4/1/2024, indicated to give oxycodone hydrochloride (medication used to treat moderate to severe pain) tablet 7.5 milligram (mg- a unit of measurement) by mouth three times a day for severe pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed lorazepam (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) to two of 37 sampled residents (Residents 11 and 166). This deficient practice had the potential to place the residents at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the window screen was affixed to the frame and did not have gaps or openings from top to bottom for one of 18 resident's room (Room A) investigated under physical environment. This deficient practice had the potential to result in insect infestation that could pose harm to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had a comprehensive care plan (a written document that summarizes a patient's needs, goals, and care/treatment) addressing the use of insulin (a hormone that lowers the level of glucose [sugar] in the blood) for one of one sampled resident (Resident 57) investigated for insulin use. This deficient practice had the potential to result in failure to deliver the necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Controlled Drug Record form (CDR- accountability record of medications that are considered to have a strong potential for abuse) reflected what was on the Medication Administration Record (MAR - report that serves as a legal record of the drugs administered to a resident by a health care professional) for one of three sampled residents (Residents 492). These deficient practices resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 187) did not exceed more than 3,000 milligrams (mg, unit of measure) of acetaminophen (Tylenol, a medication used to treat pain and fever) per day per physician order. This deficient practice had the potential to cause toxic levels of acetaminophen to build up in the blood which can lead to nausea, vomiting, abdominal pain, and/or liver failure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store six boxes of Santyl ointment (medication used for removing damaged tissue or burned skin to allow for wound healing and growth of healthy skin) in the medication's room discontinued medication cabinet for one of three residents (Resident 57) when it was discontinued by the physician on 5/22/2024. The deficient practice had the potential to cause unintentional medication administration and a loss of control against drug loss, diversion, or theft.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an eight-ounce glass of milk was not left at the resident's bedside for more than four (4) hours for one of three sampled residents (Resident 94). This deficient practice had the potential to result in food borne illness (when contaminated food is consumed which causes an infection resulting illness) upon ingestion of a spoiled milk.

Inspectors wroteb. A review of Resident 179's admission Record indicated the facility admitted the resident on 3/9/2024 and readmitted the resident on 4/1/2024 with diagnoses of fracture (broken bone) of right femur (thighbone), fracture of left tibia (two bones between the knee and ankle), and fracture of right lower leg. A review of Resident 179's History and Physical (H&P - a formal assessment of a patient and their problem), dated 4/1/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 179's Order Summary Report, dated 4/25/2024, indicated an order for vancomycin (used to treat and prevent various bacterial infections) 1.25 gram (gm, a unit of measurement) intravenously (entering by way of a vein) every 12 hours for surgical infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a resident's admission Minimum Data Set (MDS - a standardized assessment and care screening tool) timely for one of 37 sampled residents (Resident 172). This deficient practice had the potential to delay care and services for the resident.

Inspectors wroteBased on interview and record review, the facility failed to create and transmit a Discharge Minimum Data Set (MDS - a standardized assessment and care screening tool) upon a resident's discharge on [DATE] for one of 37 sampled residents (Resident 172). This deficient practice had the potential to delay care and services for the resident.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of six sampled residents (Resident 1), who sustained a fall on 5/8/2024. This deficient practice placed Resident 1 at risk for further falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to update the Physician Order for Life- Sustaining Treatment (POLST - a written medical that helps give residents with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) for one of five sampled residents (Resident 1), when Resident 1 ' s code status (describes the type of resuscitation procedures [ the process of treating the lack of breathing or heartbeat of a seriously ill resident]), if any; [...]

Inspectors wroteBased on interview and record review, the facility failed to update a comprehensive person-centered care plan (a plan for an individual ' s specific health needs and desired health outcomes) for one of five sampled residents (Resident 1), who had their code status (describes the type of resuscitation procedures [ the process of treating the lack of breathing or heartbeat of a seriously ill resident]) changed from Do Not attempt Resuscitation (DNR-instructs health care providers to not to do cardiopulmonary resuscitation [CPR- an emergency lifesaving procedure performed when the heart stops beating] if a patient's breathing stops or if the patient's heart stops beating) to Full Code (if a resident ' s heart stopped beating and/or they stopped breathing, all resuscitation procedures including CPR will be provided to keep the resident alive). [...]