Every finding on record at American River Center

Based on observation, interview, and record review, the facility failed to follow the professional standards of food service safety for a census of 98 residents, when: 1. Two thermometers, one manual and one digital, were not in good working condition; and 2. Weekly thermometer calibration was not done and not documented in the thermometer log binder. These failures had the potential for inaccurate thermometer readings and the time/temperature control for food safety not accurately monitored and increased the risks of food-borne illnesses. During a concurrent observation, interview, and record review on 4/8/26 at 9:30 a.m., the kitchen thermometers used for food preparation were inspected. [NAME] 1 (CK 1) demonstrated how to calibrate the thermometers. CK 1 indicated, two thermometers, one manual and one digital were not in good working conditions. The thermometer log binder did not indicate the thermometers were calibrated weekly. During a concurrent observation, interview, and record review on 4/8/26 at 9:35 a.m. with the Certified Dietary Manager (CDM), the CDM confirmed thermometer calibration was not documented weekly, and two thermometers were not in good working conditions. The CDM stated thermometer calibration was important to ensure accurate temperature readings to prevent food borne illness caused by undercook food. The CDM confirmed regular or weekly calibration corrected errors caused by daily thermometer use, drop or extreme food temperature shifts, ensured consistent quality cooking and food safety compliance. During an interview on 4/8/26 at 9:40 a.m. with CK 1, CK 1 stated calibrating the thermometers were done to ensure the temperature of the food was correct. CK 1 stated accurate temperatures were essential to ensure food was cooked or stored at safe levels, and inaccurate readings allowed bacterial growth. During an interview on 4/10/26 at 10:28 a.m. with the Registered Dietician (RD), the RD stated her expectation was for the kitchen staff to calibrate the thermometers weekly and calibration readings were recorded. The RD stated not regularly calibrating the thermometers would not give the correct or accurate readings. The RD stated food temperature shifts, too high and too low, and not properly monitored temperatures increased safety risks primarily caused by rapid bacterial growth. The RD stated all thermometers should be in good working conditions. A review of the facility's policy and procedure (P&P) titled, Food Preparation, revised 2/25, the P&P indicated, Thermometers in use should be tested and calibrated at least once a week for accuracy.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for two of 24 sampled residents (Residents 22 and 72), when: 1. Resident 72 was not observed during the entire medication pass to ensure medications were completely administered; and 2. Nursing staff did not use multiple strategies to administer Humalog KwikPen (a fast-acting insulin to treat diabetes) for Resident 22. These failures resulted in Resident 22 and Resident 72's not receiving their medications and had the potential to result in worsening of their clinical conditions.Findings: 1. During a medication pass observation on 4/7/26 at 8:41 a.m. with Licensed Nurse 2 (LN 2), LN 2 prepared eleven medications for Resident 72 including ClearLax (a medication used to treat constipation). LN 2 measured the ClearLax powder, poured it into a plastic cup, poured approximately 6 ounces lemonade into it and mixed until the powder dissolved. During the same medication pass observation on 4/7/26 at 8:48 a.m. with LN 2, LN 2 entered Resident 72's room and handed her the prepared pills and the cup that contained the ClearLax lemonade mixture. Resident 72 took all the pills with sips of ClearLax in between. Once Resident 72 had finished taking all the pills, approximately half of the ClearLax mixture remained in the cup. LN 2 exited the room before Resident 72 had finished consuming the remaining half of the ClearLax solution, leaving her with the medication in hand. Resident 72 did not consume the rest of the medication During an interview on 4/7/26 at 3 p.m. with LN 2, LN 2 stated he did not recall leaving Resident 72 with the ClearLax solution half drunk. During a review of the facility's policy and procedure (P&P) titled, Preparation and General Guidelines, dated 10/2017, the P&P indicated, Procedures.B. Administration.15) The resident is always observed after administration to ensure that the dose was completely ingested. 2. During a medication pass observation on 4/7/26 at 11:40 a.m. with LN 2, LN 2 prepared Humalog KwikPen for Resident 22. LN 2 entered Resident 22's room, measured the resident's blood sugar, and stated it was 177 milligrams per deciliter (mg/dL, a unit of measurement). During the same medication pass observation on 4/7/26 at 11:48 a.m. with LN 2, LN 2 prepared Humalog 10 units at the medication cart. While LN 2 prepared the medication, Resident 22 was heard yelling in her native tongue in an agitated tone. LN 2 entered the resident's room with the insulin and stated to her that he was going to administer it in her abdomen. Resident 22 was seated in a wheelchair when LN 2 bent over and reached down to lift Resident 22's sweater. Resident 22 pushed his hand away. LN 2 stood up and stated she had refused the medication and made no further attempts to administer Resident 22's insulin. He stated if the resident was wearing a short sleeve shirt he would have tried to inject it in the back of her arm. LN 2 stated he would take the resident to the dining room and wheeled her out of her room. During an interview on 4/7/26 at 2:45 p.m. with the Assistant Director of Nursing (ADON), the ADON stated nursing staff were expected to obtain a translation device that was available for staff to use with residents whenever there was a language barrier. The ADON stated a resident pushing the nurse's hand away was not considered a refusal of medication. The ADON stated the nurse should have made additional attempts to administer Resident 22's medication by getting another staff member to help calm the resident because it was a very important medication. During an interview on 4/7/26 at 3:05 p.m. with LN 2, LN 2 stated he was aware of the translation device but stated he did not choose to use it. He confirmed he did not make any additional attempts to administer Resident 22's insulin after the earlier observation. During an interview on 4/8/26 at 2:06 p.m. with LN 2, LN 2 stated when a resident resisted medication administration, other strategies such as trying a different environment or a different time or a familiar face could help a resident feel at ease to take their medications. During an interview on 4/8/26 at 2:44 p.m. with the ADON, the ADON stated nursing staff were expected to make more than one attempt to administer medication if a resident was resistant. She stated nursing staff were expected to explain the risks and benefits of a medication to a resident to help them be more compliant with medication administration. During a review of the facility's P&P titled, Preparation and General Guidelines IIA2: Medication Administration- General Guidelines, dated 10/2017, the P&P indicated, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. During a review of the facility's P&P titled, Requesting, Refusing, and/or Discontinuing Care or Treatment, revised 11/2025, the P&P indicated, Policy Interpretation and Implementation. 9. Documentation pertaining to a resident's request, discontinuation, or refusal of treatment includes at least the following. c. The resident's response and stated reason(s) for request, discontinuation, or refusal. e. That the resident was informed (to the extent of their ability to understand) of the purpose of the treatment and the potential outcome of not receiving the medication/or treatment f. The resident's condition and any adverse effects due to the request.

Based on observation, interview, and record review, the facility failed to ensure medications for disposal were not rendered unusable, irretrievable, and were not securely stored when red sharps containers with open lids were used to dispose of medication in 2 of 2 medication carts inspected; and medications with discontinued orders were not removed from facility drug supply and destroyed in a timely manner. These failures had the potential to result in medication errors and adverse events from residents receiving discontinued medications and the potential for diversion (the illegal transfer, theft, or misuse of medications) from medications not being disposed of timely.Findings: 1. During an inspection on 4/7/26 at 10:27 a.m. of Station 1 Medication Cart 2 alongside Licensed Nurse 1 (LN 1), a red sharps container with the lid open filled with whole tablets was observed. LN 1 stated nursing staff were to dispose of dropped or refused doses of non-narcotic medication in the sharps container. LN 1 agreed the medications could be easily removed from the container and were not irretrievable. During an inspection on 4/7/26 at 10:58 a.m. of Station 2 Medication Cart 2 alongside LN 2, a red sharps container (identical to the container in Station 1 Medication Cart 2) with the lid open filled with whole tablets was observed. LN 2 stated nursing staff were to dispose of dropped or refused doses of non-narcotic medication in that container. During an interview on 4/7/26 at 2:35 p.m. with the Assistant Director of Nursing (ADON), the ADON stated nursing staff disposed of dropped or refused doses of non-narcotic medication in the sharps containers stored in the medication carts. The ADON confirmed the medications were not non-retrievable using that method of disposal. During an interview on 4/8/26 at 11:33 a.m. with the Consultant Pharmacist (CP), the CP stated it was her understanding that nursing staff were to dispose of dropped or refused non-narcotic medications in a designated disposal container with a substance such as coffee grounds, hand sanitizer or soap in it to make it irretrievable. The CP acknowledged and confirmed the pills should have been disposed of in a manner that would have allowed staff or residents to have the ability to easily pour them out in their original form. During a review of the facility's policy and procedure (P&P) titled, Disposal of Medications and Medication-Related Supplies, revised 1/2025, the P&P indicated, Procedures A. All medications are placed in the proper waste container per facility policy.Date of first use to be recorded on the waste container.C. Non-controlled medication destruction occurs in the presence of two licensed nurses. 3. During an inspection on 4/7/26 at approximately 11 a.m. of Station 2 Cart 2 with LN 2, one bubble pack containing clonazepam (a medication to treat anxiety) for Resident 14 was identified in the separately locked narcotics compartment. A review of Resident 14's medical record indicated a physician's order for clonazepam 0.5 milligram (mg, a unit of measurement), give 1 tablet by mouth at bedtime for anxiety manifested by inability to sleep, discontinued December 2025. During a concurrent interview and record review on 4/7/26 at 2:31 p.m. with the ADON, Resident 14's clonazepam order was reviewed. The ADON confirmed the medication was discontinued in December 2025. The ADON stated the expectation was once medication was discontinued, it was to be given to the Director of Nursing (DON). The ADON stated discontinued medications should not have been in the medication cart. During an interview on 4/8/26 at 11:37 a.m. with the CP, the CP stated nursing staff were expected to give discontinued controlled (those with high potential for abuse or addiction) medications to the DON at end of their shift. The CP stated as soon as the medication was discontinued and nursing staff saw it in the Medication Administration Record, the medication should be set aside and given to the DON. During a review of the facility's P&P titled, Disposal of Medications and Medication-Related Supplies, dated 10/2017, the P&P indicated, Procedures.E. Medication is destroyed within 90 days from the date the medication was discontinued.

Based on observation, interview, and record review, the facility failed to ensure two of 24 sampled residents (Residents 50 and 76) were free of significant medication errors when: Resident 50 received dorzolamide (a medication to treat high eye pressure in glaucoma, a group of eye diseases that causes high fluid pressure inside the eye, leading to permanent vision loss or blindness if untreated) ophthalmic (eye) solution 18 times (doses) and latanoprost (a medication to treat high eye pressure) six times, past the expiration date; andResident 76 received fluticasone/salmeterol (a medication to chronic obstructive pulmonary disease (COPD), a progressive, long-term lung disease that makes it hard to breathe) 37 times, past the expiration date. These deficient practices had the potential for ineffective use of medications for Resident 50 and 76 resulting in complications and worsening of their clinical conditions such as permanent, irreversible vision loss leading to blindness and acute, life-threatening attacks and respiratory failure to long-term structural airway remodeling, chronic cough, and reduced lung function.Findings: 1. During an inspection on 4/7/26 at 10:09 a.m. of Station 1 Medication Cart 2 alongside Licensed Nurse 1 (LN 1), one bottle dorzolamide 2% ophthalmic solution and one bottle latanoprost 0.005% ophthalmic solution, both labeled discard 4/1/26, for Resident 50 were identified. LN 1 looked in the medication cart (med cart) to see if another vial of either eye drop was available for administration and stated, I don't see it. A review of Resident 50's medical record indicated the following physician's orders:Dorzolamide 2% ophthalmic solution: Instill 1 drop in both eyes three times a day for ocular hypertension, dated 3/2/26; and Latanoprost 0.005% ophthalmic solution: Instill 1 drop in both eyes at bedtime for glaucoma, dated 3/2/26. During a concurrent interview and record review on 4/7/26 at 10:30 a.m. with LN 1, Resident 50's Medication Administration Record (MAR) dated April 2026 was reviewed. LN 1 confirmed the MAR indicated Resident 50 received doses of expired dorzolamide eye drops on the following dates: 3 doses on 4/1/26, 2 doses on 4/2/26, 3 doses on 4/3/26, 3 doses on 4/4/26, 3 doses on 4/5/26, 3 doses on 4/6/26, and one dose on 4/7/26. This was a total of 18 doses of expired dorzolamide. LN 1 confirmed the MAR indicated Resident 50 received doses of expired latanoprost eye drops on the follow dates: 4/1/26, 4/2/26, 4/3/26, 4/4/26, 4/5/26, and 4/6/26. This was a total of six doses of expired latanoprost eye drops. LN 1 stated expired medications were potentially not as effective and the resident could have had complications from them not treating the conditions they were prescribed for. She stated nursing staff were expected to check the expiration date of a medication when preparing it. 2. During the same med cart inspection on 4/7/26 at 10:09 a.m. with LN 1, one fluticasone/salmeterol 250/50 microgram (mcg, a unit of measurement) inhaler opened 2/20/26, for Resident 76 was identified. LN 1 reviewed the manufacturer's labeling on the package and confirmed it indicated to discard the inhaler one month after opening the foil container. LN 1 confirmed the inhaler expired 3/20/26. She inspected the cart and identified a second identical inhaler for Resident 76, however it was unopened. LN 1 confirmed the opened inhaler was the one nursing staff used to administer the medication to Resident 76. A review of Resident 76's medical record indicated a physician's order for fluticasone/salmeterol 250/50 mcg inhaler, inhale 1 puff orally two times a day for COPD rinse mouth after use, ordered 2/19/26. During a concurrent interview and record review on 4/7/26 at 10:39 a.m. with LN 1, Resident 76's MAR dated March and April 2026 were reviewed. LN 1 confirmed the MAR indicated Resident 76 received doses of expired fluticasone/salmeterol twice daily since it expired on 3/20/26. This was a total of 37 doses of expired fluticasone/salmeterol. During an interview on 4/7/26 at 2:22 p.m. with the Assistant Director of Nursing (ADON), the ADON stated nursing staff were expected to check expiration dates of medications as part of the medication preparation process. During an interview on 4/7/26 at 11:20 a.m. with the Consultant Pharmacist (CP), the CP stated medications may not have been 100% efficacious beyond their expiration date and could potentially result in adverse effects if used after they (medications) were expired. During a review of the facility's policy and procedure (P&P) titled, Preparation and General Guidelines IIA2: Medication Administration- General Guidelines, dated 10/2017, the P&P indicated, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. During a review of the facility's P&P titled, Medication Storage in the Facility, dated 4/2028, the P&P indicated, Procedures.K. Medications requiring 'refrigeration'.are kept in a refrigerator with a thermometer to allow temperature monitoring.M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

Based on observation, interview, and record review, the facility failed to ensure opened multi-dose medications were dated with an open and discard date to ensure they were not used beyond the discard date, expired medications were not available for resident use, medications were stored according to manufacturer's labeling, and prescription medications were appropriately labeled with a pharmacy label. These deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, incorrect medications from inadequate labeling, and unsafe or ineffective medications from being stored outside of manufacturer's specifications.Findings: During a concurrent interview and inspection on 4/7/26 at 9:08 a.m. of Medication Storage room [ROOM NUMBER] with Licensed Nurse 3 (LN 3), six boxes hemorrhoidal suppositories (a small, torpedo-shaped medication designed to be inserted into the rectum to treat internal hemorrhoids) expired 11/2025 and one box expired 2/2025 were identified. Eight loose hemorrhoidal suppositories expired 11/2025, and four loose expired 2/2025 were also identified. LN 3 stated it was the unit manager's responsibility to check the medication storage room for expired medications, but the facility did not always have a unit manager. LN 3 confirmed the expired medications and stated they should have been removed from facility stock. During a concurrent interview and inspection on 4/7/26 at 9:50 a.m. of Medication Storage room [ROOM NUMBER] with LN 1, one vial Infuvite (an injectable multivitamin used to provide essential nutrients) with a pharmacy label that indicated Refrigerate was identified on the countertop. LN 1 confirmed the finding and stated the medication should have been stored inside the refrigerator. During a concurrent interview and inspection on 4/7/26 at 10:09 a.m. of Station 1 Medication Cart 2 with LN 1, one bottle Geritussin (a medication to treat cough) was identified with a pink crusty substance dried on the outside. LN 1 stated nursing staff were expected to wipe the outside of bottles, so they did not get dirty. LN 1 stated it was important to do so for the medication cart (med cart) to stay clean and prevent cross contamination. One bottle of dorzolamide (a medication to treat high eye pressure) 2% eye drop expired 4/1/26, one bottle latanoprost (a medication to treat high eye pressure) 0.005% eye drop expired 4/1/26, and one fluticasone/salmeterol (a medication to treat asthma) 250/50 microgram (mcg, a unit of measurement) inhaler expired 3/20/26 were also identified. LN 1 confirmed the finding and stated they should have been removed from the medication cart. One Trelegy Ellipta (a medication to treat asthma) 200 mcg/62.5 mcg/25 mcg inhaler labeled opened 2/13/26 was also identified. LN 1 reviewed the manufacturer's labeling on the package and confirmed it indicated to discard six weeks after opening. LN 1 stated the inhaler expired 3/27/26 and confirmed it should have been removed from med cart. Two Anoro Ellipta (a medication to treat chronic obstructive pulmonary disease (COPD), a progressive, long-term lung disease that causes obstructed airflow, making it difficult to breathe) 62.5/25 mcg inhalers and two Trelegy Ellipta 200/62.5/25 mcg inhalers opened and unlabeled with an open date were identified. LN 1 confirmed the finding and stated nursing staff were expected to put an open date on inhalers with shortened expiration after first use. One Humalog KwikPen (a fast-acting insulin to treat diabetes) was identified inside a clear plastic bag without a pharmacy label affixed. LN 1 confirmed prescription medications in the med cart needed a pharmacy label and she was not sure why the Humalog KwikPen did not have one. Four aformoterol (a medication to treat COPD) 15 mcg/2 milliliters (ml, a unit of measurement) vials for nebulization (a process that turns liquid into a mist for direct inhalation) were observed inside a clear plastic bag outside of the manufacturer's foil pouch. LN 1 stated the medication was usually stored in the refrigerator, not in the med cart, and confirmed there was no date on the label to indicate when it was brought to room temperature. LN 1 reviewed the manufacturer's labeling and confirmed the vials should have been stored inside the foil pouch. A review of the manufacturer's labeling for arformoterol, revised 12/2021, indicated, Store arformoterol tartrate inhalation solution in the protective foil pouch under refrigeration at 36 to 46 F (2 to 8 C). Protect from light and excessive heat. After opening the pouch, unused unit-dose vials should be returned to, and stored in, the pouch. Unopened foil pouches of arformoterol tartrate inhalation solution can also be stored at room temperature 68 to 77 F (20 to 25 C) for up to 6 weeks. If stored at room temperature, discard if not used after 6 weeks or if past the expiration date, whichever is sooner. During the same interview and inspection on 4/7/26 of Station1 Medication Cart 2 with LN 1, two vials ipratropium/albuterol (a medication to treat asthma) 0.5/3 milligram/3 ml for nebulization were observed inside clear plastic bags outside of the manufacturer's foil pouch. LN 1 reviewed the manufacturer's labeling and confirmed it indicated the vials were to be used within two weeks once removed from the pouch. LN 1 confirmed there was no date on the label to indicated when the vials were removed from the protective pouch. A box of single use dorzolamide/timolol (a medication to treat high eye pressure) opthalmic (eye) solution 2/0.5% vials was observed inside the med cart. In the box were multiple foil pouches that contained medication with one vial outside of the foil tucked behind the pouches. LN 1 reviewed the manufacturer's labeling on the box and confirmed it indicated to store the single use vials in the foil pouch to protect the medication from light. During a concurrent interview and inspection on 4/7/26 at approximately 11 a.m. of Station 2 Medication Cart 2 with LN 2, one opened Advair (a medication to treat asthma) 100/50 mcg Diskus inhaler was identified without an open date. LN 2 confirmed the inhaler did not have an open date. He reviewed the manufacturer's package labeling and confirmed it indicated to discard one month after opening or when the counter reached 0, whichever came first. During an interview on 4/7/26 at 2:22 p.m. with the Director of Nursing (DON), the DON stated nursing staff were expected to label inhalers with an open date and expiration date. She stated nursing staff were expected to keep medication bottles clean to prevent cross contamination in the med cart. DON stated nursing staff were expected to keep the nebulized solution vials in their foil pouch and to follow the manufacturer's instructions on storage for medications. The DON stated expired medications should have been discarded and not in the facility's stock and had the potential to not be as effective if used. During an interview on 4/8/26 at 11:20 a.m. with the Consultant Pharmacist (CP), the CP stated as soon as nursing staff opened a medication they were expected to label it with an open date. The CP stated nursing staff were expected to follow manufacturer labeling and any extra instructions from the manufacturer. The CP stated if they did not, the risk was having medications in the med cart that should not be there after a certain period. The CP stated expired medications may not be 100% efficacious beyond their expiration date. During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving From Pharmacy, dated 4/2014, the P&P indicated, Policy: Medications are labeled in accordance with facility requirements and state and federal laws.Procedures: A. Labels are permanently affixed to the outside of the prescription container.B. Each prescription medication label includes: 1. Resident's name 2. Specific directions for use, including route of administration.3. Medication name.4. Strength of medication.5. Prescriber's name 6. Date dispensed 7. Quantity of medication 8. Expiration date of medication 9. Name, address, and telephone number of dispensing pharmacy 10. Prescription number 11. Accessory labels.12. Container number and total number of containers.13. Initials of dispensing pharmacist 14. Lot number of medication dispensed. During a review of the facility's P&P titled, Medication Storage in the Facility, dated 4/2028, the P&P indicated, Procedures.K. Medications requiring 'refrigeration'.are kept in a refrigerator with a thermometer to allow temperature monitoring. M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. N. Medication storage areas are kept clean, well-lit, and free of clutter.

Based on interview, record review, the facility failed to ensure one out of 24 sampled residents (Resident 2) was free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behaviors), when Resident 2's fluoxetine (a medication to treat depression) dose was increased without adequate documented clinical rationale and without target behavior monitoring for efficacy. This failure had the potential to result in the unnecessary use of psychotropic medication and increased the risk of exposure to side effects such as nausea, headache, insomnia, diarrhea, dry mouth, and fatigue.Findings: A review of Resident 2's medical record indicated he was admitted to the facility in January 2021 with diagnosis which included bipolar disorder (a chronic mental health condition characterized by intense, unusual shifts in mood, energy, activity levels, and concentration), anxiety, and major depressive disorder. A review of Resident 2's physician's orders indicated the following:- Fluoxetine 40 mg (milligram, unit of weight measure): Give 1 capsule by mouth one time a day for depression manifested by verbalizations of sadness and anger, dated 2/19/24 to 2/13/25; and- Fluoxetine 60 mg: Give 1 tablet by mouth one time a day for depression manifested by verbalizations of sadness and anger, dated 2/13/25 to current. During a concurrent interview and record review on 4/8/26 at 11:24 a.m. with the Assistant Director of Nursing (ADON), Resident 2's Progress Notes (PN) and Medication Administration Record (MAR) were reviewed. The ADON stated she expected to an increase in target behaviors exhibited by a resident documented in the clinical record prior to increasing their dose of psychotherapeutic medication. The ADON reviewed Resident 2's PN dated 1/2025 to 2/13/25 (the 6 weeks leading up to Resident 2's dosage increase) and confirmed nursing staff had only two notes, both dated 1/25/25, which indicated Resident 2 was irritable and irate. The ADON reviewed Resident 2's MARs dated 1/2025 and 2/2025 and stated the order for behavior monitoring during those months was nonspecific and only directed nursing staff to document yes or no. The ADON stated this made it difficult for them to monitor Resident 2 and document the behavior. The ADON confirmed the MARs indicated Resident 2 exhibited behavior twice, during the evening shifts on 1/15/25 and 1/25/25. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, undated, the P&P indicated, Policy Interpretation and Implementation.3. Psychotropic medication management is an interdisciplinary process that involves the resident, family, and/or the representative and includes.c. adequate monitoring for efficacy and adverse consequences.Assessment and Evaluation of the Resident: 1. When determining whether to initiate, modify, or discontinue medication therapy the interdisciplinary team conducts and documents an evaluation of the resident. The evaluation includes the resident's: a. physical, behavioral, mental, and psychosocial status.c. expressions or indications of distress. e. resident complaints, behaviors, and symptoms.Dose, Duration and Duplicate Therapy: 1. The prescribed dose and duration are based on the resident's diagnoses, signs and symptoms, current condition. accepted standard of practice for dosing, and input from the IDT about the resident's goals and preferences.Monitoring and Adverse Consequences.2. Residents receiving psychotropic medication are monitored and the response to treatment is documented.

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 3) wound care treatment was followed as ordered, when the Treatment Nurse (TN) wrapped Resident 3's right lateral heel diabetic (chronic condition caused by increased blood sugar level and can delay wound healing) wound with a bandage (stretchable, reusable compression bandage made of cotton, polyester, and synthetic rubber, to support inured muscle and joint, reduce swelling) which was not ordered or indicated. This failure had the potential to delay the wound healing process and develop complications to Resident 3's right lateral heel diabetic wound. During a review of Resident 3's admission Record (AR), the AR indicated Resident 3 was admitted in early February 2026 with diagnoses which included peripheral vascular disease (PVD, a slow, progressive circulation disorder characterized by narrowed or blocked blood vessels outside the heart and brain, commonly affecting leg arteries) and chronic ulcer of right heel and midfoot. During a review of Resident 3's Physician's Order (PO) dated 3/13/26, the PO indicated, Right lateral heel eschar (a dry, dark scab or falling away of dead skin) diabetic ulcer, apply triad to peri wound, medi-honey to immediate wound, calcium alginate, cover with foam dressing. The PO did not indicate the use of any kind of bandage wrap to be applied on the wound. During a review of Resident 3's revised Care Plan (CP) dated 3/22/26, the CP indicated, At risk for skin breakdown related to PVD and right lateral heel diabetic ulcer. Provide wound treatment as ordered. During a review of Resident 3's Wound Surgical Consults (WSC) dated 3/13/26, 3/20/26, 3/27/26, and 4/3/26, the WSC indicated the goal was for the prevention of wound decline and creation of wound healing bed. The WSC indicated the wound fluctuates from increased to decreased in size with risk factors which included diabetes and limited mobility. The WSC indicated treatment included calcium alginate with honey and collagen and did not indicate to wrap the wound with bandage wrap. During a concurrent observation and interview on 4/9/26 at 9:38 a.m. with the TN, Resident 3 was in bed and her right lateral heel wound was wrapped with bandage wrap. The TN removed the wound bandage cleansed the wound with normal saline, wiped the wound dry and applied the triad to peri-wound, medi-honey to immediate wound, applied calcium alginate, covered with foam dressing and wrapped the wound with the same bandage wrap. During a concurrent interview and record review on 4/9/26 at 9:50 a.m., with the TN, Resident 3's PO for the wound was reviewed. The TN confirmed the treatment order did not indicate the wound should be wrapped with bandage wrap. The TN stated she did not clarify the order whether to use a bandage wrap after every treatment. The TN stated it was important to clarify every treatment order especially on wounds to ensure patient safety, prevent errors and treatment order was followed accurately. During a concurrent interview and record review on 4/10/26 at 9:44 a.m., with the Assistant Director of Nursing (ADON), Resident 3's clinical record was reviewed. The ADON stated LNs should always clarify PO to ensure the treatment was accurate including the use of bandage wrap. The ADON confirmed all orders should be followed and clarified when appropriate. During a review of the facility's Policy and Procedure (P&P), titled, General Policy Guidelines: Physicians order, dated 3/22/22, the P&P indicated, IV: A. Treatment orders will include the following: a description of the treatment, including the treatment site, if applicable, B. The frequency of treatment and duration of order, (when appropriate), and C. The condition / diagnoses for which the treatment is ordered.

Based on observation, interview and record review, the facility failed to store food in a safe and sanitary manner for 96 residents who received food from the kitchen when: 1. Opened and prepared foods stored without used by dates labeled; 2. foods with opened packages not covered tightly; and 3. spoiled food available to be served. These failures had the potential to result in foodborne illnesses among the vulnerable residents of the facility. Findings: 1. During a concurrent observation and interview on 1/7/25 beginning at 7:45 a.m. with the Certified Dietary Manager (CDM), while touring the kitchen, the CDM confirmed the presence of a pan of cinnamon brown sugar blondie dessert that had been prepared to serve to residents but had no label with dates. The CDM stated it was important to ensure food items were labeled with dates to know when the food was prepared and when it should be used by. During a concurrent observation and interview, on 1/8/25 beginning at 8 a.m., with the CDM, in the kitchen, the CDM confirmed the presence of two stacks of opened processed yellow cheese and an opened package of sliced [NAME] cheese, both cheeses had no labeled used by dates. 2. During a concurrent observation and interview on 1/7/25 beginning at 7:45 a.m. with the CDM, while touring the kitchen, the CDM confirmed the presence of a pan of prepared cinnamon brown sugar blondie dessert that was not covered and five prepared peanut butter and jelly sandwiches in unsealed bags. The CDM indicated foods should be covered and sealed to prevent residents getting sick with foodborne illness. During a concurrent observation and interview, on 1/8/25 beginning at 8 a.m., with the CDM, in the kitchen, the CDM confirmed the presence of a package of hot dogs that had been opened but not tightly wrapped or sealed. The CDM acknowledged the importance of wrapping foods to protect them from spoilage and the potential to cause foodborne illness. 3. During a concurrent observation and interview on 1/7/25 beginning at 7:45 a.m. with the CDM, while touring the kitchen, the CDM confirmed the presence of two tomatoes, in the walk-in refrigerator with other foods to be served to residents, that were mushy and rotten. The CDM stated spoiled foods had the potential to cause foodborne illness. A review of the facility's policy and procedure titled, Food Receiving and Storage, undated, indicated, .Food shall be received and stored in a manner that complies with safe food handling practices .When food is delivered to the facility it is inspected for .quality .All foods stored in the refrigerator or freezer are covered, labeled and dated .

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections when: 1. A visitor was observed accessing and obtaining ice from the nursing unit's ice chest unsupervised; 2. Ice scoop was stored uncovered; and 3. Certified Nursing Assistant (CNA) was observed not performing hand hygiene after handling garbage. These failures had the potential to result in the spread of infections for a facility census of 97 residents. Findings: 1. During a concurrent observation and interview on 1/7/25 at 9:28 a.m., with CNA 3, near ice chest by nursing station 2, CNA 3 confirmed a visitor was helping themselves to ice without staff assistance or supervision. An interview on 1/7/25 at 9:44 a.m., the Director of Staff Development (DSD) confirmed visitors and residents may not self-serve ice from the ice chest and added, staff must serve or fill up the resident's pitchers. An interview on 1/7/25 at 10:11 a.m., the Infection Preventionist (IP) stated only the facility staff may distribute the ice, and added, no resident or visitors may help themselves to the ice. During an interview on 1/7/25 at 11:23 a.m. the Administrator (ADM) confirmed there is no specific policy written for the usage and distribution of ice from the nursing station ice chest but stated he expected only facility staff may access and distribute the ice. 2. During a concurrent observation and interview on 1/7/25 at 9:28 a.m., with CNA 3, near ice chest by nursing station 2, CNA 3 confirmed there was an ice scoop which was stored uncovered on the cart. During a concurrent observation and interview on 1/7/25 at 9:50 a.m., with the DSD, near ice chest by nursing station 2, the DSD confirmed the ice scoop was stored uncovered. The DSD stated the ice scoop should be stored in a scoop container. An interview on 1/7/25 at 10:11 a.m., the IP stated the ice scoop must be stored covered to prevent exposure to dust or other contaminants in the environment. A review of facility Policy and Procedure titled, Ice, revised 9/2017 indicated: . Ice scoops will be cleaned and stored in a separate container that limits exposure to dust . 3. During a concurrent observation and interview on 1/8/25 at 10:00 a.m., in the 600 hallway, CNA 1 was observed handling resident garbage. CNA 1 was not observed performing hand hygiene before handling plastic straps. CNA 1 confirmed she had handled the garbage and then handled plastic wrist bands for the residents. CNA 1 stated she was supposed to perform hand hygiene after patient care activities such as handling garbage. An interview on 1/08/25 at 10:41 a.m., the ADM stated he expected staff to perform hand hygiene immediately before and after patient care activities. Review of policy and procedure Handwashing/Hand Hygiene effective date 9/18/23 indicated: .Purpose .This facility considers hand hygiene the primary means to prevent the spread of infections . All personnel shall be trained on the importance of hand hygiene preventing the transmission of healthcare - associated infections . All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections .Before and after contact with the resident . After contact with .visibly contaminated surface or after contact with objects in the resident room .

Based on interview and record review, the facility failed to ensure one of 23 sampled residents (Resident 71) urinary tract infection (UTI, an infection in the bladder/urinary tract) person-centered care plan was developed. This failure had the potential to negatively impact Resident 71's quality of treatment, care and services received. Findings: During a review of Resident 71's Admission Record (AR), the AR indicated, Resident 71 had diagnoses which included urinary tract infection and bacteremia (the presence of bacteria in the blood). During a review of Resident 71's Physician's Orders (PO) dated 1/6/25, the PO indicated, Nitrofurantoin Macrocystal (used to treat bladder infection) 50 mg (milligrams-metric unit of measurement, used for medication dosage and/or amount), give one tablet by mouth one time a day for UTI. During a review Resident 71's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for January 1 through 10, 2025, Nitrofurantoin Macrocystal 50 mg was administered daily. During a record review of Resident 71's plan of care, the record did not indicate a care plan for UTI was developed. During a concurrent interview and record review on 1/10/25 at 8:59 a.m., with the Director of Nursing (DON) together with the Assistant Director of Nursing (ADON), Resident 71's clinical record was reviewed. The DON and the ADON confirmed there was no UTI care plan developed for Resident 71. The DON stated nursing care could be compromised when care plan was not put in placed. During a review of the facility's policy and procedure (P/P) titled, Care Plan Comprehensive, dated 8/25/21, the P/P indicated, .an individualized comprehensive care plan that includes measureable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident .

Based on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents (Resident 51) had compression stocking (stockings that apply gentle pressure to the legs and ankles to improve blood flow) applied everyday to Resident 51's left lower extremity (LLE) as ordered. This failure had the potential to compromise Resident 51's blood circulation. Findings: A review of Resident 51's Admission Record (AR) indicated Residdent 51 had diagnoses which included hemiplegia (total paralysis of the arm, leg and trunk of the same side of the body) affecting the left dominant side and acute embolism (block in an artery caused by blood clots) and thrombosis (occurs when a blood clot forms either in an artery or vein) of unspecified deep [NAME] of LLE. A review of Resident 51's Physician's Order (PO), dated 9/22/23, the PO indicated, Compression stockings during day and off at night in the morning for edema [swelling] and remove per schedule. A review of Resident 51's Care Plan (CP) titled At risk for fluid volume excess as evidenced by edema, indicated, apply and remove compression stockings as ordered. If patient refuse, explain importance of compression stockings and risk of not wearing it. During observations on 1/7/25 at 11:35 a.m., on 1/8/25 at 10:43 a.m., and, on 1/10/25 at 8:09 a.m., Resident 51 was not wearing any compression stocking on his left leg, his LLE was observed to be bigger than his right lower extremity (RLE). During an interview on 1/10/25 at 8:09 a.m., Resident 51 stated he was not offered to wear the compression stockings. During a concurrent observation and interview on 1/10/25 at 8:09 a.m., with Certified Nurse Assistant 4 (CNA 4), CNA 4 confirmed Resident 51 was not wearing his compression stockings. CNA 4 stated she was supposed to put the stocking on today, but she did not. During an interview and record review on 1/10/25 at 9:40 a.m., with the Director of Nursing (DON) together with the Assistant Director of Nursing (ADON), Resident 51's clinical record was reviewed. The DON and ADON confirmed Resident 51 had a PO to wear the compression stocking everyday and nurses should follow that PO. The ADON stated the compression stocking would help control or reduce the leg edema. Both the DON and ADON validated if Resident 51 would not wear his stockings, his blood circulation could be compromised. During a review of the facility's policy and procedure (P/P) titled, Physician's Order, dated 3/22, the P/P indicated, .the Licensed Nurse . will be responsible for documenting and implementing the order .

Based on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents (Resident 1) had hearing aids (HA) applied everyday as ordered. This failure decreased the facility's ability to provide treatment and assistive devices to maintain Resident 1's hearing acuity. Findings: During a review of Resident 1's admission record (AR), dated 10/18/20, the AR indicated, Resident 1 had diagnoses which included need for assistance with personal care and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Physician's Order (PO), dated 2/9/22, the PO indicated, Apply both hearing aids in the morning and take off at night and put back in cart two times a day. During a review of Resident 1's Care Plan titled Resident has hearing impairment-adequate with bilateral hearing aids and The Resident has impaired communication as impaired hearing has x 2 hearing aids. Apply bilateral hearing aid every morning and remove every evening. During observations on 1/7/25 at 8:35 a.m., on 1/8/25 at 9:43 a.m., and, on 1/9/25 at 9:04 a.m., Resident 1 was not wearing her hearing aids. During a concurrent observation and interview on 1/9/25 at 9:43 a.m., with Certified Nursing Assistant 6 (CNA 6), CNA 6 confirmed Resident 1 had an order to wear the HA every morning but she was not wearing it today. During a concurrent observation and interview on 1/9/25 at 10 a.m., with Licensed Nurse 1 (LN 1), LN 1 confirmed she did not apply Resident 1's HA in the morning and the HA was not kept in the medication cart as ordered. During an interview and record review on 1/10/25 at 9:04 a.m., with the Director of Nursing (DON) together with the Assistant Director of Nursing (ADON), Resident 1's clinical record was reviewed. The ADON stated if there was an order to apply the HA, that order should be followed. The ADON stated it is important for Resident 1 to wear the HA to help with her communication and to avoid miscommuncation between the resident and the staff. During a review of the the facility's Policy and Procedure (P/P) titled, Hearing Aid, Care of, revised 2/2018, the P/P indicated, .The purpose is to maintain the resident's hearing at the highest attainable level

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 1), needs and preferences were accommodated, when Resident 1 was left on a patio outside of the facility and unable to contact staff. This failure reduced the facility's potential to provide services to Resident 1 with reasonable accommodation of her needs and preferences. Findings: A review of an ADMISSION RECORD indicated Resident 1 was admitted to the facility in August 2023, with multiple diagnoses which included multiple sclerosis (MS, a disease of the nervous system), quadriplegia (paralysis of legs and arms), and anxiety. A review of Resident 1's Minimum Data Set (MDS, a comprehensive assessment tool), dated 7/6/24, indicated, Resident 1 was dependent with self-care and mobility. During a review of Resident 1's Care Plan (CP), dated 8/14/23, the CP indicated, Resident 1 required assistance and was dependent for Activities of Daily Living (ADLs) including transfer and locomotion (the ability to move from one place to another). During a review of Resident 1's progress notes, dated, 7/11/24, the progress notes indicated, .MS has left her with the inability to care for herself and leading to functional quadriplegia .frequent visual checks .patient reminded .seek assistance. During a concurrent observation and interview on 8/1/24 at 10:20 a.m. with Certified Nursing Assistant 1 (CNA 1) in the dining room, Resident 1 was sitting outside the facility. CNA 1 stated, Resident 1 was brought outside by CNA 2 that morning and she did not know how long Resident 1 had been sitting outside. During a concurrent observation and interview on 8/1/24 at 10:23 a.m., Resident 1 was sitting in her wheelchair, outside the facility. Resident 1 was unable to move her wheelchair independently. Resident 1 stated, CNA 2 brought her outside that morning at 9:00 a.m. Resident 1 further stated, she had an arrangement with the CNAs to bring her outside from 9:00 a.m. to 11:00 a.m. daily. Resident 1 further stated, she was left outside past 11:00 a.m. yesterday. Resident 1 further stated, she tried calling the facility's front desk yesterday at 11:00 a.m., because the CNAs were busy, but no one answered the phone. Resident 1 further stated, the Recreations Assistant (RA), was walking outside at 11:10 a.m. and the RA was able to contact a CNA to assist Resident 1. Resident 1 further stated, yesterday was the second time she was left outside past her preferred time. Resident 1 further stated, she was left outside until 11:30 a.m. on Thursday, 7/25/24, and was unable to contact staff that day. Resident 1 further stated, she felt frightened when she was not able to contact staff. During an interview on 8/1/24 at 10:38 with CNA 2, CNA 2 confirmed that Resident 1 had an arrangement with staff to sit outside daily from 9:00 a.m. - 11:00 a.m. CNA 2 further stated, if staff was not outside to assist Resident 1, Resident 1 called the facility front desk. CNA 2 acknowledged; it is an issue when Resident 1 was unable to contact staff when she wanted to be brought back into the facility. During an interview on 8/1/24 at 10:48 a.m. with the RA, the RA stated, Resident 1 was sitting outside yesterday and requested the RA's assistance when the RA was walking outside. The RA confirmed that Resident 1 was alone yesterday, and Resident 1 was not able to contact a CNA. The RA acknowledged that Resident 1's needs may not be met if she is unable to contact staff when outside. During an interview on 8/1/24 at 12:06 p.m. with the Director of Nursing (DON), the DON stated, Resident 1 was able to communicate her needs and preferences with staff, including what time she wants to sit outside and come back into the facility. During a review of the facility's policy and procedure (P&P) titled, Resident's Rights, dated December 2021, the P&P indicated, .the rights include the resident's rights to .self-determination .communication with and access to people and services, both inside and outside the facility .be supported by the facility in exercising his or her rights .

Based on interview and record review, the facility failed to ensure a safe discharge home for one resident (Resident 1) of three sampled residents when Resident 1 was discharged home without verified home health service arrangements. This failure resulted in Resident 1 not receiving the necessary continuity of care for his wound. Findings: A review of Resident 1 ' s admission record indicated admission to the facility on [DATE] with diagnosis which included cellulitis (a deep infection of the skin caused by bacteria), disruption of external surgical wound (wound re-opening), and the necessity for change or removal of nonsurgical wound dressings. A review of Resident 1 ' s discharge plan documented by the Social Services Assistant (SSA) dated 6/5/24 at 12:21 p.m. indicated, Discharge Destination .Home alone .Will home Care be provided? .Yes .Estimated start date .6/11/24 .Home Care Services to be provided .PT- physical therapy .OT- occupational therapy .skilled nursing services . A review of a telephone order entered by the Social Service Director (SSD) dated 6/5/24 at 12:52 p.m. indicated, [Resident 1] to discharge home on 6/9/24 with home health RNx [nursing services for] medication/symptom management, PTx strengthening exercises/home safety, and OTx ADLs [activities of daily living such as toileting, eating, grooming, etc.] training and medication. Follow up with PCP [primary care physician] within 7-10 days of d/c [discharge]. Has wound vac to left groin s/p [status post] surgical debridement, to be changed every 72 hours. A review of Resident 1 ' s practitioner note written by the Nurse Practitioner dated 6/7/24 at 9:07 a.m. indicated, .[Resident 1] is to discharge home with home health .support .per SS [social service] [Resident 1] does have [PCP] and has a f/u [follow-up] appt [appointment] already set up .[Resident 1] has follow up appt with vascular surgeon .on 6/13/24. Hehas [sic] a f/u appt with his PCP on 6/17/24 .Examination .SKIN: left fem [femoral] site with wound vac [a machine which uses vacuum-assisted closure of wound to assist in wound healing] right fem site with moderate amt [amount] of slough .Home health nurse to evaluate within 1-2 days .Follow up with your Primary Care Provider in 5-7 days and your specialist as advised. A review of Resident 1 ' s Treatment Administration Record (TAR) dated June 2024 indicated, Change Wound Vac/Negative Pressure Wound Therapy; Negative Pressure 125 mmgHg [millimeters of mercury, a measurement of pressure] intermittent Cleanse with NS [normal saline, a solution used to clean wounds] or wound cleanser .Place black foam into wound. Apply skin prep to intact skin around the wound .Cover with occlusive dressing and secure tubing per manufacturer guide .every 72 hours for left groin s/p surgical debridement .Start Date 5/21/24 .D/C Date 6/9/24 . A review of Resident 1 ' s progress note dated 6/9/24 at 10 a.m. indicated, Wound Vac was beeping, re-enforced with extra dressing. Informed patient that he will be leaving with current wound vac and box placed by his bed would be the box he will be leaving with which was what the wound the [sic] vac came in. Wound Vac checked by this writer and RN [registered nurse]. A review of Resident 1 ' s progress note dated 6/9/24 at 4:43 p.m. indicated, resident DC home today, patient signed all paperwork, verbalized understanding of dc instructions . A review of all of Resident 1 ' s progress notes dated 6/5/24 to 6/9/24 showed no documented evidence social service or nursing staff called the home health agency to verify home health arrangements were set to be delivered within 72 hours of Resident 1 ' s discharge home. A review of Resident 1 ' s post discharge call back collection report dated 6/12/24 indicated, Home Health has not been in touch yet. [Resident 1] left several VM [voicemail messages] .educated pt [patient] that he should go to ER [emergency room ] if worse or appt on 6/13 . A review of Resident 1 ' s social service note dated 6/12/24 at 1:35 p.mn. indicated, Called and talked .with [Home Health agency]. Said it was being processed. They were trying to find PCP. HH did reach out .and ask about PCP but gave the information that was not currant [sic]. SSA was able to give them PCP. They will call SS back with confirmation and schedule appt with [Resident 1]. In an interview on 6/14/24 at 3 p.m. with the Director of Nursing (DON), the DON stated, .wound vac dressing should be changed [every] 72 hours. In an interview on 6/14/24 at 3:40 p.m. with the Assistant DON (ADON), the ADON stated social services was expected to follow up with the home health agency to ensure services were scheduled to start prior to discharge. In an interview on 6/14/24 at 4 p.m., the ADON confirmed the home health agency did not render services to Resident 1 and acknowledged the discharge order for wound care was not carried out. In an interview on 6/15/24 at 9:14 a.m., with the Unit Manager (UM), the UM confirmed the expectation was for staff to coordinate with other departments to make sure Resident 1 had everything he needed prior to discharge, and everything should have been verified with the home health agency. The UM further stated it was very important to ensure the continuity of care for all residents ' health. In an interview on 6/15/24 at 11:49 a.m., the Administrator (ADM) stated she expected continuity of care for all residents upon discharge was ensured for the residents ' well-being. A review of an undated facility ' s policy and procedures titled Transfer or Discharge, Preparing a Resident for, indicated, A post-discharge plan .will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident ' s discharge or transfer from the facility . A review of an undated facility ' s policy and procedures titled Referrals, Social Services, indicated, Social services personnel shall coordinate most resident referrals with outside agencies .Exceptions might include emergency or specialized services that are arranged directly by a physician or the nursing staff. Social services will collaborate with the nursing staff .to arrange for services that have been ordered by the physician.

Based on interview and record review, the facility failed to immediately report an injury of unknown origin for one resident (Resident 1) of three sampled residents. This failure decreased the facility's potential to protect Resident 1 from a possible allegation of abuse and ensure a safe environment during the investigation of the cause of the injury. Findings: Resident 1 was a [AGE] year-old female, readmitted to the facility on [DATE]. She had multiple diagnoses, which included Unspecified dementia (impaired ability to remember) without behavior disturbance, Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), unspecified site of disorders of bone density and structure (osteoporosis), history of falls, and muscle weakness. A review of Resident 1's Practitioner's Progress Notes (PPN), dated 5/14/24 at 4:05 p.m. indicated, [Resident 1] seen in [the] room after nursing report she is c/o [complaining of] left forearm pain. [Resident 1] with significant tenderness to palpation [touch]. She yelps and pulls [her] arm away during the exam. Will obtain xray of left forearm. A review of Resident 1's Radiology Results Report (x-ray), dated 5/15/24 at 3:52 a.m., indicated, .LEFT FOREARM .There is evidence of an acute [sudden onset] or possibly subacute fracture [break] of the distal radial diaphysis [both bones of the forearm] .There is [a] deformity of the distal ulna consistent with [a] distal diaphyseal fracture [wrist fracture] . A review of Resident 1's Daily Documentation (DD), dated 5/15/24 at 8:35 a.m., indicated at 5:29 a.m., Resident 1 was complaining of pain with a pain level of 6 over 10 (between moderate and severe level). A review of Resident 1's DD dated 5/16/24 at 2:50 a.m., indicated, Resident noted with pain [8/10] to left arm due to recent fracture . A review of Resident 1's Interdisiplinary Team (IDT) progress notes, dated 5/16/24 at 1:33 p.m. indicated, .IDT to review [Resident 1's] fx. [fracture] of [the] distal end of the L [left] radius. [Resident 1] c/o pain to left arm . was evaluated by NP [Nurse Practitioner] with rec. [recommendation] for [an] x-ray. X-ray ordered and results indicate fracture to left arm . A review of Resident 1's PPN dated 5/16/24 at 6:08 p.m. indicated, .[Resident 1] seen in [the] room after xray results come back showing a new fracture of left arm . A review of Resident 1's Minimum Data Set (MDS, a standardized comprehensive assessment tool) dated 6/3/24 indicated a score of seven out of 15, which indicated moderate cognitive impairment. On 6/11/24 at 10:30 a.m., the Department conducted an unannounced visit at the facility to investigate a complaint received by the Department on 5/29/24 involving an alleged injury to Resident 1 on 5/15/24. During an interview on 6/11/24 at 10:57 a.m., with the Director of Nursing (DON), the DON stated on 5/14/24, the NP saw Resident 1 due to a complaint of pain and the NP recommended obtaining x-ray. During an interview on 6/11/24 at 11:20 a.m., the DON confirmed she became aware of Resident 1's left arm fracture on 5/15/24. The DON acknowledged Resident 1's fracture was an injury of unknown origin because no one had reported Resident 1 had fallen. The DON verified the fracture could have been a pathological fracture (a fracture cause by disease of the bone) and stated she conducted an investigation to determine what the cause was. During an interview on 6/11/24, at 11:42 a.m., the DON confirmed and stated, .We didn't report it [Resident 1's fracture] . A review of the facility's policy and procedure titled Abuse Investigation and Reporting, revised July 2017 indicated, All reports of resident .injuries of unknown source .shall be promptly reported to .state .agencies .All .injuries of unknown source .will be reported immediately .The Administrator, or his/her designee, will provide the appropriate agencies .with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

Based on interview and record review, the facility failed to revise the care plan for one of four sampled residents (Resident 2) when Resident 2 had repeated falls. This failure resulted in Resident 2 to have unmet care needs for falls and could have contributed to the thigh bone fracture during her stay in the facility. Findings: Review of Resident 2's clinical record, ADMISSION RECORD, indicated the resident was admitted to the facility in March of 2024 for aftercare of right hip replacement surgery. Resident 2's diagnoses included diabetes and memory problems. Review of Resident 2's most recent MDS (Minimum Data Set, an assessment tool) indicated the resident had severely impaired cognitive function with a score 3/15 in the BIMS (Brief Interview for Mental Status) assessment. Review of Resident 2's clinical record, eINTERACT Change in Condition Evaluation-V 5.2 included the following 3 fall incidents in a month: a. 4/12/24-Staff member noted Patient sitting on the floor. Patient stated that she tried to get up to go outside. b. 4/25/24- .found resident sitting on the floor next to her w/c[wheelchair]. Per pt[patient] she tried to get up and sit on her w/c, but she fell .Pt c/o [complaint of] pain to right hip . c. 4/30/24- .to the activity room and found pt sitting on the floor, w/c is behind her, per pt she was trying to stand up and go to the other ladies to play with them. Review of Resident 2's clinical record included an x-ray taken on 4/25/24 and reviewed by the physician the next day with no new orders. No x-rays were not taken post 4/12/24 and 4/30/24 falls. Review of Resident 2's clinical record, Orthopedic Hospitalist Clinic Note, dated 5/14/24, indicated the resident sustained a new fracture to the right thigh bone after the admission to the facility. The Orthopedic Hospitalist Clinic Note documented, She [Resident 2] had x-rays done today .she has had a fracture in her greater trochanter [outside edge of the femur, near the hip joint] that is displaced about a cm[centimeter] .probably related to 1 of her postoperative falls. The immediate postoperative x-rays and once a month ago do not show that fracture. Review of Resident 2's clinical record, a care plan for at risk for falls, dated 3/20/24, identified the resident was at risk for falls due to diagnoses with dementia, with poor safety awareness, history of falls, disorientation and confusion, poor safety judgement, impaired balance, and unsteady gait. The care plan goal was, Resident will have no falls with injury x 90 days, including multiple interventions that were implemented 3/20/24; however, the care plan was not revised after the first two falls on 4/12/24 and 4/25/24. The care plan did not identify what caused the falls or what current resident needs to prevent future falls at the time of the falls. The care plan had no new goals or additional interventions implemented after each fall. Review of the facility's 8/25/21 policy and procedure, Care Plan Comprehensive, stipulated, Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident's condition change .The interdisciplinary Team is responsible for evaluation and updating of care plans: a. when there has been a significant change in the resident's condition. b. When the desired outcome is not met. In a concurrent interview and record review on 9/4/24 at 11:05 a.m. with the Director of Nursing (DON) in the conference room, the DON stated the facility did not create a fall care plan after the resident had an actual fall, instead the facility revised and updated the existing at risk for falls care plan to implement new interventions to prevent further falls. The DON reviewed Resident 2's care plan for at risk for falls and verified it was not revised after the falls on 4/12/24 and 4/25/24. The DON stated, We did not update the care plan and acknowledged residents' care needs could change quickly as well as interventions. The DON indicated the care plan should have been revised based on a change in conditions and in response to current interventions. The DON acknowledged Resident 2's care plan should have been revised after each of the resident's falls.

Based on observation, interview, and record review, the facility failed to maintain dignity for one of four sampled residents (Resident 1) when two Certified Nursing Assistants (CNA) had an argument regarding a staffing assignment while providing a shower to Resident 1. This failure resulted in Resident 1 crying and feeling afraid and decreased the facility's potential to protect residents' dignity. Findings: During a review of Resident 1's admission record, Resident 1 was admitted to the facility in May of 2024 with multiple diagnoses which included nontraumatic intracerebral hemorrhage (a condition in which a ruptured blood vessel causes bleeding inside the brain), hemiplegia and hemiparesis (weakness on one side of the body) affecting right dominant side, dysarthria (weakness in the muscle used for speech), aphasia (loss of ability to understand or express speech), muscle weakness, and major depressive disorder (persistently depressed mood or loss of interest in activities). Resident 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had moderate cognitive impairment. During a review of a document titled, Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 5/4/24, the document indicated, Resident 1 received a cold shower by CNA 1 and newly assigned CNA 2 took Resident 1 into the communal shower room and finished off with warm water. During a review of a document submitted to the Department titled, Investigative Summary Report, dated 5/8/24, the document indicated, [Resident 1] was in the shower room crying because he received a cold shower .On the morning of 5/4/23, [CNA 1] placed Resident 1 in the shower chair in the room and put on the water so it can start to warm up .While waiting for the water to warm up, she was approached by another CNA stating that the assignment was changed and that the patient is no longer in her assignment. CNA 1 went to see CNA 2 who was at the station and asked her to give the shower instead. After repeated calls, CNA 2 then went in .On 05/06/2024 at 9:40 AM [morning], [CNA 2] stated that since the assignment was changed, CNA 1 and the other CNA complained that there will be more people .While arguing about the assignment in the resident's room, [CNA 2] heard [Resident 1] crying and when [CNA2] checked in the bathroom, she saw [Resident 1] crying in the chair, hair was dry, but the body was wet .Conclusion: Whether or not a cold shower was intentionally or unintentionally given, the fact remains that the misunderstanding leading to an argument between [CNA 1] and [CNA 2] (because of the change in assignment), had unintended consequences that affected the resident . During a concurrent observation and interview on 5/16/24 at 11:30 a.m. with Resident 1 in his room, Resident 1 was observed awake, sitting on a wheelchair by the door of the bathroom. Resident 1 stated he cried when he was at the shower on the day of the incident and stated it was because the water was cold. Resident 1 further stated he was afraid it might happen again. Resident 1 was not able to clearly identify the staff involved in the incident. During an interview on 5/16/24 at 1:15 p.m. with the Director of Nursing (DON), the DON stated, There was nothing about abuse here, but because of the bickering, the resident didn't feel right that's why he cried .the problem is the interpersonal relationship of employees .the bickering was not appropriate during that time .they should have communicated separately where the [resident] cannot hear .they should professionally discuss the changes . During an interview on 5/16/24 at 2:02 p.m. with the Social Services Director (SSD), the SSD stated, It was more like drama between CNAs, but a resident was involved. During an interview on 5/16/24 at 2:29 p.m. with the Administrator, the Administrator stated, They [CNAs] feel they are overwhelmed. We've been telling staff and management to not discuss anything in front of the residents .As leaders, we are saddened with the situation because they [residents] might feel they are responsible for causing the argument. A review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 12/2021, the P&P indicated, Employees shall treat all residents with kindness, respect, and dignity .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . A review of the facility's P&P titled, Dignity, revised 2/2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .1. Residents are treated with dignity and respect at all times .10. Staff protect confidential clinical information. Examples include the following: a. Verbal staff-to-staff communication (e.g., change of shift reports) are conducted outside the hearing range of residents and the public.

Based on interview and record review the facility failed to follow its own policy for readmission when one of 3 sampled residents (Resident 1) was not permitted to return to the facility. This failure resulted in the violation of Resident 1's rights for readmission to resume residence at the facility. Finding: A review of an Admission Record for Resident 1 indicated he was originally admitted to the facility in April 2022 with diagnoses including vascular dementia (brain damage from impaired blood flow to the brain) and moderate protein-calorie malnutrition. A review of Resident 1's clinical record included the following documents: A Minimum Data Set (MDS, an assessment tool), dated 4/9/24, indicated a mental status assessment done for Resident 1 reflected memory problems and severe cognitive impairment. A facility Transfer Form note indicated Resident 1 was transferred to the General Acute Care Hospital (GACH) on 4/9/24 per daughter's request. A hospitalist admission notes, dated 4/10/24, indicated Resident 1 was admitted to GACH on 4/9/24, as requested by the daughter due to concerns of worsening oral candidiasis (also called oral thrush; white sore patches in the mouth and tongue) and poor care at the facility. A GACH Online Referral Note which was sent from 4/12/24-4/14/24 indicated a Case Manager (CM) contacted the facility multiple times to readmit Resident 1, all contacts resulted in facility response of unable to accept patient. In an interview on 4/16/24 at 12:19 p.m., the Admissions Director (AD) stated Resident 1 had Medicaid (a program that helps with healthcare costs for some people with limited income) as a primary payor for his last stay at the facility and also confirmed based on his transfer/discharge date Resident 1 was still eligible for a 7-day bed hold. In an interview on 4/16/24 at 1:08 p.m., with the Director of Nursing (DON) the DON agreed Resident 1 had the right to return to the facility, but the Interdisciplinary Team (IDT) decided not to readmit him due to unresolved conflict between the family and the facility staff. The DON further added that the IDT was aware of the consequence of refusing to readmit Resident 1, but they had to take care of their staff too. In an interview on 4/16/24 at 1:40 p.m. with the Administrator (ADM) the ADM stated she's aware that Resident 1 was eligible for a 7-day bed hold, but as part of the team she agrees with the IDT not to readmit Resident 1. A review of the facility's Policy and Procedure (P&P) titled, Readmission to the Facility, revised 3/2017, indicated, Residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility. A review of the facility's undated Bed Hold Policy and Authorization, stipulated, If your hospitalization or therapeutic leave exceeds the number of days indicated or is not covered you may still return to your previous room if available or be readmitted to the first available bed in a semi-private room if you still require the center's services .

Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. Ice machine was not clean, 2. The food storage racks were not well maintained in the walk-in refrigerator and walk-in freezer, and 3. The temperature of the freezer sections of the resident's food refrigerators located in nurse station one (1) and two (2) were not monitored. These failures had potential to cause food-borne illness in a highly susceptible population of 97 out of 98 residents who consumed meals or food in the facility. Findings: 1. During an initial kitchen tour on 3/19/24, at 9:30 a.m., a concurrent interview and observation of the ice machine was conducted. The Maintenance Supervisor (MS) stated he was responsible for the cleaning and sanitizing the ice machine. He stated he would take the parts out from the machinery part of the ice machine to clean and sanitize weekly. The MS stated he did the deep cleaning monthly and quarterly which included cleaning and sanitizing the machinery parts, running the chemical cycles, and the ice storage bin. Upon the ice machine dissemble, there were significant black and brown stains with scratches observed on the bottom of the evaporator unit (the part where conducts the heat exchange with water and freezes the water into ice cubes). The MS confirmed and he stated he scrubbed the bottom of the evaporator unit every time when he cleaned the machinery part of the ice machine, but the stains did not come off. He stated the scratches were old and the surface was not smooth, and the machinery part of the ice machine was old which might need to replace. During an interview with the Registered Dietitian (RD) on 3/21/24, at 9:10 a.m., she stated the scratches on the bottom of the evaporator unit surface could be easily harbor microorganisms which could contaminate the ice. The RD added the food contact surface should be smooth and could be cleaned easily. A review of departmental policy and procedure, titled, Equipment, dated 9/2017, it stated, .all foodservice equipment will be clean, sanitary, and in proper working order . A review of departmental policy and procedure, titled, Ice, dated 9/2017, it stated, .Ice will be prepared and distributed in a safe and sanitary manner . According to FDA (Food and Drug Administration) Food Code 2022, Section 4-202.11 Food-Contact Surfaces, it stated, .The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts . and .Multiuse Food-Contact Surfaces shall be: 1. Smooth; 2. Free of breaks, open seams, cracks, chips, inclusions, pits . 2. During an observation in the walk-in freezer and walk-in refrigerator on 3/19/24, at 9:12 a.m. and 9:16 a.m., observed there were two food storage metal racks in the walk-in freezer and two racks in walk-in refrigerator with brown substances. A concurrent interview with the Food and Nutrition Service Director (FNSD), she confirmed the brown substance was rust on the food storage metal racks. The FNSD stated she was aware of the rust and was working on the replacements. A review of departmental document, titled Kitchen Sanitation Checklist, completed on 1/2024 by the Regional Registered Dietitian (RRD), it indicated the RRD commented the walk-in refrigerator food storage metal racks showed signs of rust. A review of departmental policy and procedure, titled, Equipment, dated 9/2017, it showed, .all non-food contact equipment will be clean and free of debris . According to FDA Food Code 2022, on Section 4-101.19 Nonfood-Contact Surfaces, it showed, .Nonfood-Contact Surfaces of equipment .shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material . On Section 4-101.11 Characteristics, .Smooth means .a nonfood-contact surface of equipment having a surface equal to that of commercial grade hot-rolled steel free of visible scale . 3. During an observation of the resident's food refrigeration units (unit with combination of refrigerator and freezer) located at nurse station 1 and 2 on 3/19/24, at 12:29 p.m. and 12:42 p.m., there was a concurrent interview with the Assistance Director of Nurses (ADON) regarding the freezers' temperature monitor logs. She stated the refrigerators and freezers usually monitor temperature by the Director of Staff Developer (DSD). The ADON stated they did not have any monitor logs for both freezers when she reviewed the temperature monitor log folders for nurse station 1 and 2. During a follow up interview with the ADON on 3/19/24, at 2:29 p.m., she confirmed and stated she could not locate any records for the freezers' temperature monitor logs. The ADON stated the nurses did not monitor the temperature for both freezers of the resident's food refrigerators in nurse station 1 and 2. During an interview with the DSD on 3/20/24, at 9:45 a.m., she was aware that the policy and procedure said monitor refrigerator and freezer temperature for the resident's food refrigerator daily. The DSD stated she did not monitor the freezer temperatures and she would start to monitor as of now. A review of facility policy and procedure, titled, Safe Handling of Foods from Visitor, dated 8/25/21, it indicated, .b. have temperature monitored daily for refrigeration .and freezer .

Based on observation, interview, and record review, the facility failed to ensure that the menu was being followed for the therapeutic diet for lunch on 3/20/24 when: 1. Seven residents (Resident 2, 4, 6, 16, 20, 41, and 408) were on modified texture diets Dysphagia mechanical soft (a diet for people with mild to moderate chewing and/or swallowing difficulty) and Dysphagia advance (a diet for people with mild chewing and/or swallowing difficulty and usually more soft and moist for food tolerance) who received no gravy for the meat entree instead of receiving gravy as indicated on the menu; 2. Two residents (Resident 403 and 405) on TLC (Therapeutic Lifestyle Change, a diet for people who are trying to reduce blood cholesterol levels and risk of heart disease, diet with limited added sugar, saturated fat, and reduced sodium) diet who received gravy on the pork chop instead of no gravy as indicated on the menu; 3. Three residents (Resident 14, 303, and 553) who were on Renal diet (diet to treat chronic or acute kidney disease) and CCD (control carbohydrate diet - diet to treat diabetes and control blood sugar level)/Renal diet received cake instead of cookie for dessert, and received gravy on the pork chop instead of no gravy, and 4. Two residents (Resident 65 and 402) who were on CCD diet received sweet potato instead of mashed potato per the menu. These failures had the potential to result in compromising the medical and nutrition status of those 14 residents. Findings: During an observation of lunch meal service on 3/20/24 beginning at 12:10 p.m., it was noted as followed: 1. Residents 2, 4, 6, 16, 20, 41, and 408 were on dysphagia mechanical soft and dysphagia advance diets who did not received gravy for the meat entree. A concurrent review of the undated facility document titled, 2023-2024 Diet Guide Sheet, showed that dysphagia mechanical soft and dysphagia advance diet should receive two ounces (oz.) of gravy for the meat entree. 2. Residents 403 and 405 were on TLC diet wo received gravy on the pork chop. A concurrent review of the undated facility document titled, 2023-2024 Diet Guide Sheet, showed that TLC diet should not receive gravy for the pork chop. 3. Residents 14, 303, and 553 were on Renal diet and CCD/Renal diets who received cake for dessert. A concurrent review of the undated facility document titled, 2023-2024 Diet Guide Sheet, showed that Renal and CCD/Renal diets should receive cookie as dessert. 4. Residents 65 and 402 were on CCD diet who received sweet potato. A concurrent review of the undated facility document titled, 2023-2024 Diet Guide Sheet, show that CCD diet should receive mashed potato. During an interview with the Regional Registered Dietitian (RRD) on 3/20/24, at 1:33 p.m., she acknowledged and the residents who were on therapeutic and/or modified texture diets received the incorrect food items and stated the staff needed to pay attention and the staff needed to follow the menu/spreadsheet when they prepared meals for the residents. During an interview with the Registered Dietitian (RD) on 3/21/24, at 9:10 a.m., she stated the staff should have followed the menu or spreadsheet during preparing meals which may make the meal under- or over- nutrition and affect the nutrition needs for the residents. A review of facility document, titled Job Description: Cook, showed .The Cook prepares and serves food including texture modified and therapeutic diets according to the facility menu .adhere to menus and portion control stands, including those for special diets when preparing and serving meals .