Glendora Grand, Inc

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable, homelike environment by not ensuring the room temperature between 71 degrees Fahrenheit ( F, a temperature measurement unit) to 81 F for one of four sampled rooms and two of seven sampled residents (Resident 5 and Resident 6). This deficient practice violated Resident 5's and Resident 6's right to have a comfortable, homelike environment and placed Resident 5 and Resident 6 at risk for health complications due to increased room temperature.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed the facility's Infection Prevention and Control Program policy and procedure (P&P) for one of eight sampled residents (Resident 3) who was on Enhanced Barrier Precaution (EBP- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) when:1. Activity Assistant (AA) 1 came out of Resident 3's room, removed isolation gown and put the isolation gown in the trash outside Resident 3's room.2. Resident 3's used meal tray was taken outside Resident 3's room and placed on top of the cart used to store clean isolation supplies. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), received appropriate treatment to prevent further decrease in Resident 1's mobility (ability to move) when the facility failed to implement the physician order to have Resident 1 walk five times a week. This failure resulted in Resident 1 experiencing a decrease in the ability to walk. (Cross reference F627 and F842)

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record for one of two sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 documented inaccurate information in Resident 1's medical record, regarding the level of assistance Resident 1 needed from a caregiver for bed mobility (the ability to move around in bed, including rolling over, scooting, and moving from a lying to a sitting position) and transfers (move from one surface to another). This failure resulted in Resident 1's medical record containing incomplete information.(Cross reference F627 and F688)

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation and orientation to ensure a safe and orderly discharge for one of two sampled residents (Resident 1) when:a. The facility failed to arrange for Resident 1's formula for enteral feeding (a method of providing nutrition directly into the gastrointestinal [GI] tract through a tube) to be readily available upon Resident 1's return home.b. The facility failed to assess Resident 1's Caregiver's (RP 1) ability to safely transfer (move from one surface to another) and care for Resident 1. These failures had the potential for Resident 1 to experience an unsafe discharge and had the potential for Resident 1 to be hospitalized .(Cross reference F688 and F842)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for four of four sampled residents (Residents 50, 117, 148, and 197) in accordance with the facility's policy titled Call Light. These failures had the potential for Residents 50, 117, 148, and 197 not to receive necessary care or receive delayed services, placing the residents at risk for falls or injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure that ten of ten sampled residents, who attended the resident council meeting, were aware of the availability and location of the facility's latest survey results. This deficient practice had the potential for the residents not to be fully informed of the facility's deficient practices or how the facility corrected the deficient practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with indwelling catheter (also known as foley catheter, a thin flexible tube inserted into the body to drain urine or other fluids) were assessed and monitored for the presence of sediments (visible particles in the urine that may contain red or white blood cells, casts or bacteria) in the catheter tubing and bag consistent with the physician's order and the residents' care plan for two of two sampled residents (Residents 5 and 10). These failures had the potential for Residents 5 and 10 to receive delayed care and treatment to prevent urinary tract infection (UTI, an infection in the bladder or urinary tract).

Inspectors wroteBased on observation, interview, and record review, for two of two sampled residents, (Residents 304 and 18) the facility failed to:a. Ensure licensed nursing staff administered Resident 304's gastrostomy tube (GT- a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding as ordered by the physician and as indicated in the facility's Policy and Procedure (P&P) titled Enteral Nutrition.b. Ensure the Registered Dietitian's (RD) recommendation for Resident 18 to start multivitamins and minerals on 7/18/2025 was implemented/carried out and communicated to the physician. These deficient practices had the potential to result in adverse consequences for Residents 304 and 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents receiving oxygen therapy (treatment that provides supplemental, or extra oxygen) in accordance with professional standards of practice for three of the three sampled residents (Residents 17, 52, and 238) by failing to:a. Ensure residents with pro re nata (PRN, as needed, when necessary) oxygen order had an oxygen concentrator machine (medical device used to deliver oxygen) stand by (ready or available) set up in the room for Resident 52 to use.b. Ensure Resident 17's nasal cannula tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was stored appropriately when not in use.c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:A. Clarify a discrepancy between the physician's order for Resident 270's Olanzapine (treat mental disorders) and the prescription label prior to medication administration. B. Identify Resident 98 and Resident 270 prior to the administration of medication. C. Remove discontinued and inactive controlled medication ([CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) orders for Residents 47, 261, and 6. These failures increased the risk of medication errors for Residents 6, 47, 98, 261 and 270.

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to:A. Ensure Resident 5's inhalation medication DuoNeb (Ipratropium bromide and albuterol sulfate inhalation solution is a combination medication used to treat breathing problems associated with lung diseases like chronic obstructive pulmonary disease [COPD]) was stored appropriately in accordance with the manufacturer's specifications to maintain the medication's therapeutic effectiveness when needed. B. Remove non-controlled medications from the medication cart for a discharged resident, Resident 5C. Dispose of non-controlled medications in the presence of a witness in accordance with facility's policy titled, Disposal of Medications, Syringes and Needles - Disposal of Medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly cover six of 10 large trash bins with lids as indicated in the facility's Policy and Procedure (P&P) on garbage disposal. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects) and pests (any living thing that has a negative effect on humans) that could potentially enter the facility, affect the resident care areas, and expose the residents and staff to diseases.

Inspectors wroteBased on observation interview and record review the facility failed to ensure: A. Licensed Vocational Nurse (LVN) 1 performed hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) for one of five sampled resident (Resident 59) during medication administration observation. B. Resident 304's [NAME] valve (used to maintain a closed system, minimizing healthcare worker exposure to bodily fluids and reducing the risk of accidental contamination) used with a gastric or enteral feeding tube (GT or ENT, medical devices used to deliver nutrition, fluids, and medications directly into the stomach) was not observed crusty, dirty, or worn, and missing a coverage cap. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Resident 197 food choices that accommodated Resident 179's food preferences. This deficient practice has the potential to alter Resident 179's nutritional status and decrease meal intake that can potentially lead to weight loss and malnutrition (not having enough to eat or not eating enough).

Inspectors wroteBased on interview and record review, the facility failed to ensure its policies and procedures (P&P) were implemented for one of one sampled resident (Resident 11) by:1. Failing to obtain Resident 11's physician signature on the Acknowledgment of Receipt for Advance Directive (AD - a legal document indicating resident preference on end-of-life treatment decisions)/Medical Treatment Decisions (ARAD).2. Failing to maintain a full copy of the resident's POLST (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) in Resident 11's medical record with a physician signature. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy for one of one sampled resident (Resident 5) when Registered Nurse 2 (RN 2) did not close the privacy curtain while checking Resident 5's foley catheter's (thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) securement device. This deficient practice violated Resident 5's right to privacy and resulted in unnecessary exposure of Resident 5's lower extremities. This deficient practice had the potential to affect Resident 5's psychosocial (mental and emotional) well-being, self-esteem, and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to screen one of four randomly selected employees (Registered Nurse 1 [RN 1]) with the Office of Inspector General (OIG - investigates alleged violations of criminal and civil laws) data base for convictions of fraud and abuse prior to hire. This deficient practice had the potential for applicants with a history of abuse to be hired, which could lead to possible harm and abuse of the residents.

Inspectors wroteBased on interview and record review, the facility failed to complete the Minimum Data Set (MDS, a resident assessment tool) comprehensive assessment within federal time frames per Center of Medicare and Medicaid Services (CMS, a federal agency that manages healthcare programs like Medicare and Medicaid) requirement for two of two sampled residents (Residents 137 and 172). These failures had the potential to affect Residents 137 and 172's care by not providing CMS specific resident information and assessment timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 6) was kept clean on 8/5/2025. This failure had the potential to result in social decline, skin breakdown, and body odor to Resident 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the smoking policy and procedure (P&P) was implemented for one of two sampled residents (Resident 213) when Resident 213 was found with two cigarettes in Resident 213's possession. This failure had the potential to put the facility at risk of a fire hazard.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) received one-on-one supervision (1:1, one staff supervising 1 resident) to prevent fall (move downward, typically rapidly and freely without control, from a higher to a lower level) as indicated in Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals who collaborate to provide comprehensive care for Resident 1) Meeting/Care Conference, dated 5/1/2023. On 6/16/2025 at approximately 5:35 pm, Activity Assistant (AA) 1 left Resident 1 unsupervised in Resident 1's wheelchair inside Resident 1's room. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develope care plans (CPs) for two (2) of three (3) sampled residents (Resident 4 and Resident 6) in accordance with care and services to be provided to the residents according to the physician ' s order. Resident 4 ' s and Resident 6 ' s Diabetes Mellitus (DM, a disorder characterized by difficulty in blood glucose [sugar] control and poor wound healing) care plans (CPs) included a goal to maintain blood sugar levels between 70 milligrams per deciliter (mg/dl, a unit of measure) and 150 mg/dl. Resident 4 and Resident 6 did not have a physician ' s order for routine bedside blood sugar monitoring. These failure had the potential for Resident 4 and Resident 6 to receive inappropriate DM care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was provided with the necessary behavioral health care and services to address Resident 1's history of suicidal ideation (SI- a range of thoughts, fantasies, or contemplations about ending one's own life) by failing to: 1. Ensure the Social Services Director (SSD) and/or admitting licensed nurse accurately assessed and documented Resident 1's episode of suicidal ideation while Resident 1 was in the General Acute Care Hospital (GACH) 1 on 4/20/2025. 2. Develop a care plan for Resident 1's history of suicidal ideations. 3. Monitor Resident 1 for suicidal ideations. These deficient practices had the potential to worsen Resident 1's mental condition and increase Resident 1's risk for suicide and self-harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 assessed/checked one of two sampled residents (Resident 1) ' s body on 3/20/2025 and 3/21/2025 to prevent injury/wound (an injury to living tissue, specifically a break or disruption in the skin or other body tissues caused by an external force) from embedded (implanted, an object fixed firmly and deeply in a surrounding mass) bracelets (ornamental/decorative band, hoop, or chain worn on the wrist or arm). These failures resulted in Resident 1 developing an infected wound (a wound that harbors harmful bacteria, leading to symptoms like increased redness, pain, swelling, and pus) to Resident 1 ' s left wrist. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to implement one of two sampled residents (Resident 1)'s care plan, in accordance to the facility's policy and procedure titled, Comprehensive Care Plans by failing to perform daily body checks for Resident 1. This failure resulted in Resident 1 sustaining an infected wound (a wound where bacteria or other microorganisms have entered and are multiplying, causing an infection) to Resident 1's left wrist. Cross reference:

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 and Registered Nurse (RN) 1 assessed/checked one of two sampled residents (Resident 1) when foul (bad) smell was noticed on 3/20/2025 and 3/21/2025 from Resident 1. This failure resulted in unnoticed and untreated infected wound to Resident 1 ' s left wrist.

Inspectors wroteBased on interview and record review, the facility failed to provide foot care and treatment to one of eight sampled residents (Resident 4) according to Resident 4's Care Plan (CP) titled, Care Plan Report, and the facility's policies and procedures (P&P) titled, Podiatry Services, and Comprehensive Care Plans, by failing to ensure: 1. Licensed Nurses (all licensed nurses that assigned to care for Resident 4) notified Resident 4's physician(s) and Resident 4's family and/or responsible party (RP) when Resident 4 repeatedly refused to be treated by the podiatrist (medical doctor who specializes in the treatment of disorders of the foot, ankle, and the lower leg), for the year of 2024. 2. Licensed Nurses implemented Resident 4's CP when Resident 4 refused to receive podiatrist care and treatment for multiple times in one year. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one of eight sampled residents' (Resident 4's) physician(s) and responsible party according to the facility's policies and procedures (P&P) titled, Notification of Changes, and Change in a Resident's Condition or Status by failing to ensure: 1. Licensed Nurses (all licensed nurses that assigned to care for Resident 4) notified Resident 4's physician(s) and Resident 4's family and/or responsible party (RP) when Resident 4 repeatedly refused to be treated by the podiatrist (medical doctor who specializes in the treatment of disorders of the foot, ankle, and the lower leg), for the year of 2024. 2. Licensed Nurses notified Resident 4's physician regarding the condition of Resident 4's toenails. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the care plan for one of eight sampled residents (Resident 4) when licensed nurses did not notify Resident 4's physician regarding Resident 4's repeated refusals to be treated by the podiatrist as indicated in Resident 4's care plan (CP) titled, Care Plan Report. This failure had the potential for Resident 4 to not receive the necessary care and treatment for Resident 4's foot and result in discomfort, injury, and/or infections.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services to one of eight sampled residents (Resident 4) and failed to implement its policies and procedures (P&P) titled, Change in a Resident's Condition or Status, and Comprehensive Care Plans, when: 1. Resident 4's repeated refusal to be treated by the podiatrist (medical doctor who specializes in the treatment of disorders of the foot, ankle, and the lower leg) was not communicated to Resident 4's physician(s) and to Resident 4's family and/or responsible party (RP). 2. Resident 4's care plan regarding refusal of care and treatment was not implemented. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to prevent elopement (when an individual leaves the healthcare facility unsupervised and/or undetected) for one of three sampled residents (Resident 1) assessed as at risk for elopement as indicated in the facility's policy and procedure titled, Elopements and Wandering Residents, by failing to ensure Resident 1 was readmitted to the facility's secured unit (any area in the facility designed and operated to ensure that all its entrances and exits are locked to prevent residents from leaving the facility without permission and/or supervision). As a result, on 2/19/25 at 8:45 pm, facility staff (general) were unable to locate Resident 1 and filed a missing person report with the local police department on 2/19/25 at 10:10 pm. As of 2/26/25 at 5:37 pm, Resident 1 had not been found. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to prevent elopement (when an individual leaves the healthcare facility unsupervised and/or undetected) for one of five sampled residents (Resident 1) who was assessed as at risk for elopement as indicated in the facility's policy and procedure titled, Elopements and Wandering Residents, by failing to: 1. Ensure Janitor 1 ([DATE]) did not unlock the door of the facility's secured unit (any area in the facility designed and operated to ensure that all its entrances and exits are locked to prevent residents from leaving the facility without permission and/or supervision) to allow Resident 1 to leave the facility without a staff chaperone (a person who goes with and looks after another person or group of people) or helper. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for three of three sampled residents (Residents 228, 231 and 80 ) to prevent the development of a pressure ulcer (PU, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and failed to provide treatment to the PU. 1. For Resident 228 who was assessed as at risk for developing PU, the facility failed to: a. Ensure Treatment Nurses (TXN 1 and TXN 3) provided treatment to Resident 228's right hip opened scratches (areas of damage on the surface of the skin)/open wounds (injuries that involve a break in the skin and leave the internal tissue exposed) on 7/6/2024, 7/20/2024, 7/21/2024, 7/25/2024 as ordered by Resident 228's Medical Doctor (MD) 1. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for two of two sampled residents (Residents 81 and 25). These deficient practices had the potential to result in Residents 81 and 25 to not receive the necessary care or receive delayed services to meet the residents' needs that could result in a fall and accident.

Inspectors wroteb. During a review of Resident 80's AR, the AR indicated the facility initially admitted the resident on 4/4/2015 and readmitted the resident on 6/6/2024, with diagnoses that included dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning) and dysphagia (difficulty swallowing.) During a review of Resident 80's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition. The MDS indicated Resident 80 was dependent with all activities of daily living. During an observation on 8/1/2024 at 12:30 pm, Certified Nursing Assistant 5 (CNA 5) was assisting Resident 80 with lunch. Resident 80 coughed twice. Resident 80 was positioned slightly above 45 degrees and the neck was hyperextended (leaning backwards). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care to prevent Urinary Tract Infection ([UTI] an infection in any part of the urinary system [kidneys, bladders, ureters and urethral]) for two of two four residents (Residents 214 and 236) who had Foley catheter (a thin, sterile tube inserted into the bladder to drain urine), by failing to ensure: a. Licensed staff monitored Residents 214's urine output and notified the physician promptly for signs and symptoms of UTI. b. Licensed staff and/or Certified Nursing Assistant (CNA) positioned Resident 236's urine bag above the floor to prevent contamination of the urine. These deficient practices placed Residents 214 and 236 at risk for infection due to delayed treatment and contaminated urine when the urine bag was on the floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedures (P&P) titled, Oxygen Administration, and Oropharyngeal Suction, for two of two sampled residents (Resident 67 and 653) by failing to: 1. Remove and/or replace the suction canister after use for Resident 67 when the suction canister contained moderate amount of thick, yellow sputum (secretion, a mixture of saliva and mucus produced by the lungs). 2. Date (label with a date) Resident 653's humidifier (used to increase the level of moisture for supplemental oxygen) when Resident 653 had an oxygen machine at the bedside. These findings had the potential to result in the use of expired respiratory items for Resident 653 and result in inaccurate monitoring of sputum/secretion for Resident 67.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of five sampled residents (Residents 22,198 and 210) on psychotropic drugs (any drugs that affects brain activities associated with mood, emotions, and behavior) were free from unnecessary medication. a. For Resident 198, licensed staff failed to attempt a gradual dosage reduction ([GDR] a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) for Resident 198's Risperdal (antipsychotic drug) 1 milligram ([mg] unit of measurement) and Lexapro (antidepressant drug) 10 mg since ordered on 6/8/21. b. For Resident 210, licensed staff failed to attempt a GDR for Resident 210's Lexapro 10 mg since ordered on 3/27/23. c. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when: a. Two of two staff (Dietary Aide 1 [DA 1] and the Dietary Account Manager [DAM]) failed to follow the manufacturer's guidelines for chlorine paper (a type of test strip) testing when checking the chlorine (a chemical used to disinfect dishes) sanitizer concentration. b. Staff failed to follow manufacturer's guidelines of smartpower sink and surface cleaner sanitizer (a solution used to sanitize kitchen surfaces) in two of two kitchens (Kitchen 1 and 2) by not checking temperature for testing solution. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in two of two facility kitchen (Kitchen 1 and Kitchen 2) when: a. Freezer A bottom shelves had food debris, dust and gasket had dirt buildup. Freezer B vents had dust buildup. b. Reach-in refrigerator's vent had dust and dirt buildup in Kitchen 1. c. Stainless steel racks for kitchen utensil storage had rust. Stainless steel storage racks in the dry storage area had rust. Storage rack in Kitchen 2 had rust. d. Two (2) dented cans were stored with non-dented cans in Kitchen 1. One (1) dented can was stored with non-dented cans in Kitchen 2. e. The lids for the bulk container for oatmeal, thickener and flour had dirt buildup. f. Reach-in refrigerator in Kitchen 2 had ice buildup and dirt debris. g. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: 1. Four of four gray trash bins located outside of Kitchen 1 area and one of two black trash bin was not completely covered and closed located outside of Kitchen 3. 2. The facility did not maintain the trash area free from trash, soiled gloves, and other dirt debris in two of three kitchen (Kitchen 1 and Kitchen 3) dumpster areas. This deficient practice had a potential to attract birds, flies, insects, and pest and the potential to result in the spread of infections to residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Speech Therapy (ST, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) evaluations in accordance with physician's orders for three of nine sampled residents (Residents 147, 198, and 280) who had swallowing, communication, and cognitive (ability to think, understand, learn, and remember) concerns. This deficient practice prevented Residents 147, 198, and 280 from receiving ST services to potentially improve swallowing, cognitive, and communication abilities and maintain or achieve the highest practicable level of function.

Inspectors wroteBased on interview and record review, the facility failed to ensure its Resident-Facility Arbitration Agreement (AA, a Binding Arbitration Agreement requires the person who signed it resolve any dispute by binding arbitration, rather than in court) included selection of a venue convenient to both facility and residents and resident's responsible party for three of three sampled residents (Residents 250, 294 and 402). These deficient practices placed Residents 250, 294 and 402 at risk for unjust arbitration and delayed arbitration hearing in an event of an arbitration dispute.

Inspectors wroteBased on interview and record review for one of three sampled residents (Resident 80) on hospice care (medical service designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life), the facility failed to ensure: a. Documentation of services provided by the Hospice Health Aide (HHA) to Resident 80 during HHA visits. b. Accurate documentation of hospice Licensed Vocational Nurse visits. c. Hospice Licensed Nurse visits were implemented in accordance with the hospice physician's order.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Dispose soiled gauze in a safe and sanitary method in one of one resident's room (Resident 191's room). b. Ensure one of one Restorative Nursing Aide (RNA 1) removed an isolation gown (protective apparel used to protect the wearer from the transfer of microorganisms and body fluids) and gloves and performed hand hygiene after exiting Resident 147's room and entering the hallway during an Restorative Nursing Aide (RNA, nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) session with Resident 147 who was on Contact Isolation Precautions (procedures to reduce risk of spread of infections through direct or indirect contact). c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep three of three laundry dryers in a safe, operating, and sanitary condition for residents. This failure had the potential to result in spread of infection and pose as potential fire hazard.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided a homelike environment for one of one sampled resident's room (Resident 209) by failing to ensure the room did not have peeling paint on the walls and stain on the floor. This failure had the potential for unsafe and unclean resident's environment.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized/person- centered care plan for one of one sampled resident (Resident 22), who was on Ativan, (medication used to treat anxiety [group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear]) in accordance to the facility's policy titled Comprehensive Care Plans. This deficient practice had the potential to result in Resident 22 not receiving appropriate care treatment and/or services.

Inspectors wroteBased on interview and record review, the facility failed to revise one of one sampled resident (Resident 228) care plan (CP) when Resident 228's scratch (skin injury from something sharp or rough) on the right hip changed in color on 7/24/2024. This failure had the potential to delay the provision of care and treatment for Resident 228' injury and cause Resident 228's skin injury to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe administration of medications during a medication administration observation for one of three sampled residents (Resident 124) by failing to ensure Licensed Vocational Nurse (LVN) 6 did not administer medications that were dropped on the floor to Resident 124. This failure had the potential to result in infection for Resident 124 from consuming contaminated medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 42) received foot care in a timely manner. Resident 42's had unclean, yellow, and long toenails for both feet. This failure placed Resident 42 at risk for complications such as infection or injuries of the feet.

Inspectors wroteBased on observation and interview, the facility failed to post nursing staff data (the total number and actual hours worked by Registered Nurses, Licensed Vocational Nurses, and Certified Nurse Aides) on a daily basis at a place that was easy accessible for public review as required for one of six nursing stations (Station 1), at the beginning of each shift, which made the data unavailable to residents and visitors. This failure had the potential to give residents/visitors inaccurate staffing information and potentially affect the quality of care provided to the residents.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to provide necessary interventions for one of one sampled resident (Resident 80) who had dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). Resident 80 was calling out repeatedly from 8:30 am to 11:36 am on 8/1/24 without any help from staff. This deficient practice had the potential to not meet Resident 80's need such as pain, discomfort, hunger, thirst, or frustration.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of three sampled residents (Resident 250) who signed the Resident-Facility Arbitration Agreement (AA, a Binding Arbitration Agreement requires the person who signed it resolve any dispute by binding arbitration, rather than in court) on 1/1/2024 had the capacity to understand and make decisions. This failure had the potential risk to result in Resident 250 to not be able to make an informed decision and/or his rights to be denied.

Inspectors wroteBased on interview and record review, the facility failed to have a documented tracking process in place to ensure one of three sampled Certified Nursing Assistants (CNA 4) attended the required in-service trainings for nurse aides. This failure had the potential to result in CNA 4 to not receive the necessary training that could affect resident care and safety.

Inspectors wroteBased on interview and record review, the facility failed to provide information regarding an Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) for one of one sampled resident (Resident 252) in accordance to the facility's policy titled Advance Directives. This failure had the potential to result in the facility staffs to provide medical or surgical treatment against Resident 252's will.

Inspectors wroteBased on interview and record review, the facility failed to complete the Situation Background Assessment Recommendation (SBAR- tool used to communicate important often critical information that required immediate attention and action) and notify the physician of a change in condition (change in physical, mental, or functional abilities) in accordance with the facility's Policy and Procedure (P&P) on Change in a Resident's Condition or Status for one of two sampled residents (Resident 1), when Resident 1 had two vomiting episodes on 6/12/24 and 6/13/24. This deficient practice resulted to Resident 1 to continue to have vomiting episodes with no treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide immediate cardiopulmonary resuscitation (CPR emergency lifesaving procedure, consisting of a combination of chest compressions, mouth- to-mouth, or mechanical breathing [using a device to help someone breaths], performed when the heart stops beating or beats ineffectively and/or to restore breathing) to two of three sampled residents (Resident 1 and Resident 5) who had a full code status (when the resident's heart stopped beating and/or the resident stopped breathing, the resident or their representative wishes for all lifesaving procedures to be provided to keep them alive) by failing to ensure: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide supervision during meal time to prevent choking (a person who has severe difficulty in breathing because of a constricted or obstructed throat or a lack of air) accident (any unexpected or unintentional incident, which resulted or may result in injury or illness to a resident) for one of three sampled residents (Resident 1) who was at risk for choking by failing to: Ensure Certified Nursing Assistant (CNA) 1 did not leave Resident 1's dinner tray unattended in Resident 1's room with Resident 1 and supervised/monitored Resident 1 during mealtime as indicated in Resident 1's Care Plan (CP) titled, Resident Care Plan for Risk for Choking, and the facility's policy and procedure (P&P) titled, Meal Supervision and Assistance. [...]

Inspectors wroteBased on interview and record review, the facility failed to evaluate the competency (the capability to apply or use the knowledge, skills, and abilities required to successfully perform tasks in the work setting) of Registered Nurse Supervisor (RNS) 1, Licensed Vocational Nurse 1 (LVN) 1, LVN 6, Certified Nursing Assistant 1 (CNA) 1, CNA 2, and CNA 3 to prevent choking and to recognize when to provide cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of chest compressions and mouth-to-mouth or mechanical breaths, performed when the heart stops beating or beats ineffectively and/or to restore breathing) when: 1. CNA 1 failed to follow Resident 1's care plan by leaving Resident 1 unsupervised and unmonitored during dinner. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of eight sampled residents (Resident 3) from physical abuse (aggressive or violent behavior with the intention to cause physical harm) as indicated in the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation. As a result, on 4/24/2024 at 9 pm, Resident 4 threw a trash bin at Resident 3 (Resident 4's roommate) while Resident 3 was sleeping in Resident 3's bed. Resident 3 sustained corneal abrasion (scratch or cut on the white portion of the eye) and acute iritis (inflammation of the colored portion of the eye) to Resident 3's right eye. Resident 3 was transferred to General Acute Care Hospital (GACH) 1 on 4/25/2024 at 12:50 am for evaluation and treatment of injuries. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical record for three of three sampled residents (Resident 1, Resident 5, and Resident 6) was complete and accurate when: 1. The names of staff who provided Heimlich Maneuver (HM, a first aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) and cardiopulmonary resuscitation (CPR, emergency lifesaving procedure, consisting of chest compressions and mouth-to-mouth or mechanical breaths, performed when the heart stops beating or beats ineffectively and/or to restore breathing) to Resident 1 on 4/19/2024 were documented on Resident 1's clinical record. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee (responsible for identifying quality deficiencies [deviations in performance resulting in an actual or potential undesirable outcome, or an opportunity for improvement] throughout the facility, for developing and implementing corrective actions, for monitoring to ensure performance goals or targets are achieved, and for revising corrective actions when necessary) implemented the facility's Plan of Correction (POC, a plan developed by the facility and approved by the state survey agency that describes the actions the facility will take to correct deficiencies and specifies the date by which those deficiencies will be corrected) to prevent residents who were identified at risk for choking from choking. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one of five sampled residents (Resident 1) on 3/13/2024 when Resident 2 hit Resident 1 on the head. This failure resulted to a skin tear on Resident 1's left forehead and subjected Resident 1 to physical abuse by Resident 2 while under the care of the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of three sampled residents (Resident 4) who were not able to perform activities of daily living receive the necessary services to maintain good personal hygiene. Resident 4 did not receive his shower as scheduled. This failure had the potential to result in resident with poor hygiene causing dermatitis, bacteria buildup on skin, lost sense of well-being and satisfaction with life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to maintain Range of Motion [ROM, full movement potential of a joint (where two bones meet)] for one of six sampled residents (Resident 271) with mobility (ability to move) concerns, by failing to: a. Provide Resident 271 with ambulation (the act of walking) with handheld assistance (HHA, helper places their hands on the resident to perform the task) from two persons in accordance with the physician's order, dated 2/27/23. b. Provide Resident 271 ambulation with a front-wheeled walker (FWW, an assistive device with two front wheels used for stability when walking) in accordance with the physician's order, dated 3/2/23. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for two of two sampled residents (Residents 169 and 357): a. Certified Nursing Assistant 1 (CNA 1) stood over Resident 357 while assisting Resident 357 with eating his lunch. b. Certified Nursing Assistant 7 (CNA 7) stood over Resident 169 while assisting Resident 169 while feeding the resident. These deficient practices had the potential to negatively impact the resident's psychosocial well-being and/or make the resident feel rushed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the Long-Term Care Ombudsman (LTC Ombudsman, representatives who assist residents in long-term care facilities with issues related to day-to day care, health, safety, and personal preferences) information in two of five nursing stations in the facility. This failure had the potential to prevent residents, including three of six residents attending the resident group meeting, from communicating their concerns and obtaining resources from the Long-Term Care Ombudsman.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the most recent State and Federal inspection results (survey binder) were posted in a manner that was clear and visible for the residents and their families, including six of six residents who attended the resident group meeting. This failure had the potential to prevent the residents' and their families' right to view survey inspection results.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and/or implement the plan of care for four of four sampled residents (Residents 71, 557, 22 and 111), by failing to: a. For Resident 71, the facility failed to implement the resident's activities care plan. b. For Resident 557, the facility failed to implement the resident's activities care plan. These deficient practices resulted in Residents 71 and 557 not receiving activities as indicated in the care plan, inhibiting the residents' well-being, according to the facility's Policy and Procedures on Activity. c. For Resident 22, the facility failed to develop/ implement an individualized person-centered care plan for Resident 22 who had pitting edema (a type of swelling, often in the lower extremities, that causes enough fluid retention to leave a pit or indentation) on both lower extremities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide communication board and/or other functional communication system to five of nine non-English speaking sampled residents (Residents 71, 249, 259, 271 and 557), in accordance with the facility's Policy and Procedure on Communicating with Persons with limited English Proficiency. This deficient practice placed Residents 71, 249, 259, 271 and 557 at risk for miscommunication and delayed care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the resident activity preferences in accordance with activity assessment for five of nine sampled residents (Residents 71,182,188, 249 and 557). This deficient practice placed Residents 71,182, 188, 249, and 557 at risk for cognitive decline (a gradual loss of thinking abilities such as learning and remembering) and behavioral problem due to boredom (feeling disinterested in one's surroundings, having nothing to do, or feeling that life is dull).

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services for four of four sampled residents (Residents 22, 122, 658 and 71) by failing to: a. Notify Resident 22's physician regarding the resident's edema (excess fluid in tissues of the body) on both legs. b. Follow Resident 122's physician's order to follow up with a specific hospital regarding the resident's eye treatment. c. Ensure the Registered Dietician (RD) consult for Resident 658's needs was acted upon in a timely manner to meet the resident's dietary needs. These deficient practices placed the residents at risk for delay of necessary medical treatments and care services to improve the resident's quality of life and/or nutritional status d. Ensure Resident 71 received an accurate and comprehensive assessment of Resident 71's body rash by qualified licensed staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free from accident hazard and adequate assistive device and supervision for two of four sampled residents (Resident 286 and Resident 240) by failing to: a. Implement Resident 286's plan of care to provide low bed and two-person physical assistance during turning and bed mobility (moving to either side in bed and moving from lying in bed to the edge of bed) to prevent further fall incidents. b. Monitor Resident 240 for left over cigarette before leaving the designated smoking area. These deficient practices placed Residents 286 and 240 at risk for accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate alternatives prior to the use of bedrails for two of two sampled residents (Resident 286 and Resident 557.) These deficient practices had the potential for Residents 286 and 557 to sustain injuries due to the use of bedrails.

Inspectors wroteBased on observation, interview, and record review the facility failed to account for one dose of controlled medication ([CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 76 in one of six inspected medication carts (Medication Cart on the East Side of Station 3.) This deficient practice increased the opportunity for CM diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use,) placed Residents 76 at risk for receiving delayed medication treatment and continuity of care due to lack of availability of the CM, and had the potential to expose Resident 76 to harmful medications, possibly leading to physical and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review orders for accurate medication reconciliation (process of identifying most accurate list of all medications) and ensure that resident's drug regimen was free from unnecessary drugs (any drug in excess) for one of five sampled residents (Resident 282). Resident 282's duplicate medication orders remained as active drugs on the Medication Administration Record ([MAR]- a record of medications administered to a resident) since 6/1/23. This deficient practice had the potential to cause Residents 282 to receive suboptimal (less than the highest standard or quality) care, increase the risk of serious adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) and health complications, such as bleeding, likely resulting in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (%) due to six errors observed out of 25 total opportunities (error rate of 24%). The medication errors were as follows: a. Resident 264 received a dose of vitamin D3 (a medication used to help the body absorb calcium and build strong bones) that was different than the one ordered by Resident 264's physician. b. Resident 161 received five medications in a form that was not ordered by Resident 161's physician. These failures had the potential to result in Residents 264 and 161 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and had the potential to result in Residents 264's and 161's health and well-being to be negatively impacted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five licensed vocational nurses (LVNs) did not administer expired insulin (a medication used to treat high blood sugar) to one resident (Residents 208) in one of six inspected medication carts (Medication Cart [NAME] Side Station 3). This failure resulted in Residents 208 to receive a combined total of ten expired insulin doses from [DATE] to [DATE] and had the potential to result in Resident 208 to experience serious health complications, hospitalization, or death due to uncontrolled blood sugar (BS) levels.

Inspectors wroteBased on observation, interview, and record review the facility failed to: a. Label one Haldol (medication used to treat disorders that cause difficulty in telling the difference between things or ideas that are real and not real) vial for Resident 100, with an open date and discard the vial after one use, in accordance with the manufacturer's requirements, in one of six inspected medication carts (Medication Cart East Cart Station 1). b. Remove and discard one expired insulin (medication used to regulate blood sugar levels) vial for Resident 208, in accordance with manufacturer's requirements, in one of six inspected medication carts (Medication Cart [NAME] Side Station 3.) c. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure staff were competent in safe and effective food handling practices when: a. [NAME] 1 did not follow safe thawing (process of frozen substance becoming soft) procedure for thawing chicken under running water. The raw chicken temperature registered at 68 degrees Fahrenheit (normal range <41 Fahrenheit). b. Dietary aide DA1 did not know the acceptable range for dishwasher sanitizer concentration. DA1 documented sanitizer concentration at 200 Parts Per Million (PPM- measurement of the mass of the active ingredient chemical per volume of water), and supervisor was not notified.

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: a. Raw breakfast sausage and bacon were stored next to ready-to-eat ham and turkey, and the breakfast sausage and bacon did not have thaw (process of frozen substance becoming soft) dates. b. Expired burritos were stored in the refrigerator. c. Chicken was thawing in the sink under running water that is 73 degrees Fahrenheit (F) and the chicken temperature was over 41 degrees F (actual temperature of 68 degrees F) from 8:00AM until 10:40AM on 6/6/23. d. The food refrigerator for residents with outside foods in Unit Station 3 had freezer ice buildup, stored ice cream with did not have a label, and one ice cream belonged to a resident who had already been discharged . e. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide therapy services, including Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]), Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function), and Speech Therapy (ST or SLP, profession aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) to one of eight sampled residents (Resident 357) who had range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accuracy of medical records and altered restorative nursing aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) records for one of one sampled resident (Resident 286) who had range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns. For Resident 286, who received RNA services for ROM exercises and was on a feeding program, the facility initialed multiple RNA sessions as completed for 10/2022, 11/2022, and 12/2022 on 6/8/23 (six to eight months later). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed establish and maintain an infection control program, by failing to: a. Ensure two urinals in Resident 171's bathroom were labeled. b. Ensure facility staff perform hand hygiene after handling Resident 22's bed sheets/blankets and prior to pushing Resident 142's wheelchair. c. Ensure staff perform hand hygiene after replacing Resident 181's soiled mask d. Ensure to contain five large containers filled with soiled linen in the laundry room. e. Ensure not to use a cloth gait belt with Resident 271 and properly sanitize the cloth gait belt. f. Ensure Resident 263's foley catheter (F/C-flexible tube inserted into the bladder to drain urine) privacy bag and the F/C tubing were not touching the floor These deficient practices had the potential to result in cross contamination and spread of infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal need for assistance from staff) was within reach for one of four sampled residents (Resident 357). Resident 357's call light cord was hanging off the bed, out of reach of Resident 357. This deficient practice had the potential for the delay in meeting Resident 357's needs to get assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 22) was assessed for edema (swelling caused by fluid retention). Resident 22 was observed with edema to the left and right lower legs. This deficient practice had the potential for Resident 22 not to receive individualized care to meet the resident's medical needs in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess functional limitation (limited ability to move a joint that interferes with daily functioning) in range of motion [ROM, full movement potential of a joint (where two bones meet)] of both legs for one of 39 sampled residents (Resident 357). This failure had the potential to affect the provision of care to Resident 357 and provided inaccurate information to the Federal database.

Inspectors wroteBased on interview and record review, the facility failed to notify the state mental health authority for one of three sampled resident (Resident 150) who required Preadmission Screening and Resident Review (PASRR, a comprehensive assessment evaluation by the appropriate state-designed authority that determines the appropriate setting for individuals and recommends any specialized services and/or rehabilitative services the individual needs) Level II (a screening to determine whether placement or continued stay in a Nursing Facility is appropriate) as indicated in the facility's policy on Resident Assessment - Coordination with PASARR Program. This deficient practice had the potential for Resident 150 to not receive the necessary care and services needed in the appropriate setting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dialysis (treatment for kidney failure that removes unwanted toxins, waste products and excess fluids by filtering the blood) emergency kit was available at the bedside for one of three sampled residents (Resident 658). This deficient practice had the potential to result in the risk of prolonged bleeding and prevent emergency care and treatment to the dialysis access (a way to reach the blood for dialysis) site when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and document the side effects (unwanted effects of medication) of psychotropic medications (medications that affects brain actives associated with mental processes and behavior) for two of seven sampled resident (Residents 188 and 238) according to the facility's policy and procedure: a. For Resident 238, who is taking psychotropic medication, nursing staff did not accurately monitor and record Resident 238's hand tremors (involuntary shaking or movement) which a side effect (an effect that is unintended) of psychotropic medications. b. For Resident 188, who is taking psychotropic medication, nursing staff did not accurately monitor and record Resident 188's hours of sleep which is a side effect of psychotropic medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dental recommendation follow up was done, for one of two sampled residents (Resident 116). This failure resulted in Resident 116 to not receive necessary dental services and had the potential to result in an infection and a decline in Resident 116's physical health.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a comprehensive oversight (supervision) of the Food and Nutrition Services by the Registered Dietitian (RD-food and nutrition experts who can translate the science of nutrition into practical solutions for healthy living) for two (Residents 111 & 658) of three sampled residents, to ensure consults were followed, new admits were assessed, and annual assessments were completed, as evidenced by: a. Resident 111 was not assessed or followed up by a Registered Dietitian since October 2022 b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 182), or Resident 182's representatives were informed of the binding arbitration agreement (a private process where disputing parties agree that one or several other individuals can decide about the dispute) rights. Resident 182's agreement was signed by the Interdisciplinary Team (IDT, a group of professionals and direct care staff employed by the facility) and not by Resident 182 or Resident 182's representatives. This failure resulted in Resident 182 and Resident 182's representatives to not be informed about their right to make informed decisions and make important choices regarding aspects of the binding arbitration agreement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post a No Smoking sign in front of one of one sampled resident room (Resident 73's room), as indicated in the policy and procedure (P&P) titled, Resident Smoking Policy. Resident 73 was observed using oxygen in the room. This failure had the potential to result in a fire in Resident 73's room and result in harm and injury to the residents and the facility staff.