Every finding on record at Arbor Rehabilitation & Nursing Center

Based on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when:1. There was no air gap or back flow prevention device installed for the food prep sink or the three compartment sink (a commercial kitchen essential with three basins for washing, rinsing, and sanitizing dishes), 2. Dietary staff (DS) 1 and DS 2 did not wear hygienic hair gear/hair net in the food preparation area,3. Food items for residents were stored inside the utility room. These failures had the potential to affect the flavor and palatability of the food and to lead to food borne illness (nausea, vomiting, diarrhea) for the 123 residents receiving facility prepared food. Findings: 1.During a concurrent observation and interview on 1/6/26, at 8:11 a.m., with the Dietary Manager (DM), in the kitchen, there was no air gap back flow system in place at the three-way compartment sink. The DM stated the facility was aware there was no air gap and the facility was in the process of fixing it. The DM further stated one concern of not having an air gap was for sanitation purposes, if there was any pressure change in the system it could pull water the wrong direction and it would go back up into the line. During an interview on 1/6/26, at 12:05 p.m., with the Registered Dietitian (RD), the RD stated the air gap helped so the flooding/water did not backup into the sink, and it had the potential of reverse back flow. The RD further stated having an air gap would help with sanitation and cross contamination. 2. During an observation on 1/7/26, at 11:24 a.m., with the Dietary Staff (DS) 1, the DS 1 walked into the kitchen, went to the kitchen sink to wash her hands, near the kitchen stove, then she walked to the dishwashing area and began washing dishes without a hair net on. The DC was already cooking beef in the pot for the taco menu at lunch time. During a concurrent observation and interview on 1/7/26, at 11:28 a.m., with DS 1, DS 1 confirmed she did not have hairnet on when washing dishes. DS 1 stated she should have covered her hair when she is in the kitchen. The DS 1 further stated the hairnet was to keep her hair away from the food and for sanitation purposes. During an interview on 1/7/26, at 11:31 a.m., with the DM, the DM confirmed DS 1 did not have hairnet on while in the kitchen. The DM stated hair was to be covered while in the kitchen to prevent contamination. During an observation on 1/7/26, at 11:37 a.m., in the meal prep area, near the tray lines, DS 2 walked into the kitchen to the food prep area where tray lines were already being set up by the Dietary [NAME] (DC) without his hairnet on. During an interview on 1/7/26, at 11:40 a.m., with DS 2, DS 2 confirmed he did not have a hairnet on when he walked into the kitchen and stated he had just started his shift for the day. DS 2 stated he was required to wear his hairnet when in the food prep or in the kitchen. DS 2 further stated the hairnet should be worn at the doorway, upon entering the kitchen to keep the hair from getting into the food. During an interview on 1/7/26, at 11:44 a.m., with the DM, the DM confirmed DS 2 did not wear a hairnet when in the kitchen/food prep area. The DM stated hairnets must be worn by all staff at all times when in the kitchen to prevent contamination. During an interview on 1/8/26, at 1:18 p.m., with the RD, the RD stated the facility's policy was to wear hairnets for cleanliness and to prevent any type of contamination. During an interview on 1/9/26, at 11:33 a.m., with the Director of Nursing (DON), the DON confirmed she witnessed DS 2 who walked into the kitchen without his hairnet on, that she was at the kitchen door. The DON stated the reason hairnets were worn because the facility did not want hair in the food and to prevent cross contamination and infection control. A review of facility policy and procedure (P&P) titled, Healthcare Menus Direct, LLC dated 2023, indicated, . the Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. Backflow prevention air gaps. if a connection exits between the system and the source of contamination water during times of negatives pressure, contaminated water be drawn into and foul the entire system. An airgap is the most reliable backflow prevention device. It is the physical separation of the portable and non-potable water supply systems by an air space. All steam tables, ice machines and bins, food preparation sinks, display cases, soda fountains, espresso machines, and other equipment that discharge liquid waste or condensate shall be drained through an air gap into an open floor sink. am tables. An air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drained), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch A review of an undated facility provided document titled, Dress Code, indicated, . 6. Hats are acceptable if all hair is covered by a hat . 7. Hairnets must be worn if all hair cannot be covered by a hat . 8. All facial hair of nominal length must be covered . 3. During an interview on 1/8/26, at 3:10 PM with Certified Nurse Assistant (CNA) 5, inside South Utility room, CNA 5 stated that the bins inside the South utility room were for solid waste, trash, dirty diapers with urine and feces, soiled tissue papers, and paper towels. The janitor would eventually pick up these bins and take them to the dumpsters. CNA 5 stated that food items like applesauce, thickened liquids, pudding, and nutritional supplements intended for residents, even if sealed and with the refrigerator dedicated to residents' food were unacceptable to be stored and kept in the utility room, given their proximity to the dirty side. CNA 5 stated that the red line separating the clean and dirty areas cannot guarantee prevention of cross-contamination. During an interview on 1/8/26, at 3:21 PM, with licensed nurse (LN) 8, LN 8 stated that storing food items for residents and a refrigerator for resident food inside the utility room, in close proximity to bins for soiled trash and a refrigerator for biohazard materials with urine and stool samples, posed great potential risks for cross contamination and health safety risks for residents. During an interview on 1/8/26, at 4:33 PM with Janitor (J) 1, J1 stated he felt uneasy about seeing food items stored in the combined utility room, considering there was only about four feet separating the clean area from the dirty area. J1 stated that this setup posed a high risk for contamination and the potential spread of diseases. During an interview on 1/9/26, at 9:19 AM, with Janitor (J) 2, J2 stated that storing food items inside the utility room was not safe and did not create a homelike environment. J2 further stated that food storage should be handled in the same way as it would be at home. J2 stated that the bins with soiled trash sometimes emitted an odor resembling urine or stool inside the utility room, making it seem unsanitary to use the room for food storage. During a concurrent observation and interview on 1/9/26, at 11:28 AM, with the Infection Preventionist (IP), in the South Utility room. The IP stated the facility had three utility rooms, one each for the South station, North station, and East/Terrace stations. The IP confirmed that the South utility room had both clean and dirty areas. In the dirty area (right side of the room), found a sink for hand washing, a dirty nebulizer for Central Supply personnel to clean and disinfect, green-colored wedges from a discharged resident, two bins for soiled trash, and a refrigerator labeled biohazard (something that can make people sick because it contains germs or harmful biological material) dedicated to sample specimens. On the clean side (left hand side of the room), there were three pieces of laboratory equipment (one near the food items supplied by the kitchen) used by phlebotomists (a healthcare worker who draws blood from patients) when handling blood specimens, seven IV (intravenous – given directly into a vein) poles, five nebulizers (a machine that turns liquid medicine into a mist so you can breathe it into your lungs), briefs for residents' use, a toilet seat, suction machines (a device that removes mucus, saliva, or fluids to help a person breathe safely) , and a refrigerator labeled Resident Food Only. During a subsequent concurrent observation and interview on 1/9/26, at 11:37 AM, it was observed that food items (pudding, applesauce, thickened liquids and nutritional supplements) were kept in the East/Terrace combined utility room. The IP described the East/Terrace combined utility room. On the clean side (right side of the room), there was a refrigerator labeled Resident Food Only, briefs for residents, under pads, a toilet seat raiser, small and large plastic bags, two sinks, two boxes of isolation gowns, and three IV poles. The dirty side (left side of the room) contained two wedges from discharged residents, four plastic bags with residents' belongings labeled with their names and room numbers, and a dirty suction machine. During an observation and interview on 1/9/26, at 11:45 AM, observed food items, including pudding, applesauce, thickened liquids, and nutritional supplements, kept in the North combined utility room. The IP described the North combined utility room. The IP stated that on the clean side (left side of the room), stored IT (Information Technology) equipment with black and blue wires, washcloths or wet wipes for residents, plastic cups, suction machines, a nebulizer, and cabinet storage containing gait belts, blue-colored plastic bags, and a toilet seat raiser. On the dirty side (right side of the room), there were two rolls of paper towels, a sink for handwashing, one dirty suction machine, residents' personal belongings inside a blue-yellow bag, and three bins for soiled waste trash. The IP further stated that although the facility followed infection control practices, storing food items in combined utility rooms posed a potential risk for cross-contamination. During an interview on 1/9/26, at 12:18 PM, with the Director of Nursing (DON), the DON confirmed that food items for residents were stored in the combined utility rooms. The DON stated she did not think it was a problem to keep residents' food items in the combined utility room along equipment like GT (gastrostomy tube – a feeding tube placed directly into the stomach) pumps, nebulizers, fall mats, suction machines, IV poles, centrifuge machines (a machine that spins samples like blood very fast to separate their parts) used by phlebotomists, and a refrigerator for specimen samples such as urine, sputum, wound specimens, and feces. The DON confirmed that sinks used for hand washing were considered a drain. During a concurrent interview and record review on 1/9/26, at 2:06 PM with the Registered Dietitian (RD), presented to RD the facility policy for storage of food and supplies. RD acknowledged the presence of centrifuge machines near the food items stored in the South utility room, and the RD stated, I cannot dispute that about the equipment's proximity to the food items. Review of a facility policy and procedure titled, STORAGE OF FOOD AND SUPPLIES, dated 2023, indicated, . POLICY: Food and supplies will be stored properly and in a safe manner. The storeroom should be well-lighted, well-ventilated, cool, dry, and clean at all times. Storage areas should be free from exposed pipes, drains, and mechanical equipment. Review of Food and Drug Administration (FDA) Food Code 2022 titled, Preventing contamination from the premises under the section, Food Storage, Prohibited Areas, indicated, . FOOD shall be protected from contamination by storing the FOOD . in a clean, dry location . Where it is not exposed to splash, dust, or other contamination . Food may not be stored . in garbage rooms . or Under other sources of contamination.

Based on interview, and record review, the facility failed to provide the COVID-19 vaccine, for four out of five sampled residents (for immunization review) when Resident 58, Resident 36, Resident 29 and Resident 86's electronic health record (EHR) did not contain documented evidence that the COVID-19 vaccine was administered after obtaining consent.This deficient practice placed Resident 58, Resident 36, Resident 29 and Resident 86 at risk to be infected with COVID-19 virus that could lead to severe illness, hospitalization, and/or death.Findings:A review of Resident 58's admission RECORD, indicated Resident 58 was admitted early October 2025.A review of Resident 36's admission RECORD, indicated Resident 36 was admitted early December 2025.A review of Resident 29's admission RECORD, indicated Resident 29 was admitted on [DATE].A review of Resident 86's admission RECORD, indicated Resident 86 was admitted on [DATE].During a concurrent interview, and record review on 1/8/26, at 10:27 AM, with the Infection Preventionist (IP), Resident 58, Resident 36, Resident 29 and Resident 86's EHR were reviewed. The IP confirmed that Resident 58 signed a consent upon admission to receive COVID-19 vaccine. The IP stated that she had not provided COVID-19 vaccine to Resident 58. The IP confirmed there was no information on Resident 36's vaccine status for COVID-19. The IP further confirmed that the consent was not uploaded on the EHR for Resident 36. The IP stated she had not provided the COVID-19 vaccine to Resident 36. The IP stated the COVID-19 vaccine should have been given upon admission or shortly after admission. The IP confirmed that the COVID-19 immunization consent was signed by Resident 29. The IP stated that the facility did not have a COVID-19 vaccine yet, and last week or the week before, she ran out of COVID-19 vaccine and the pharmacy was out of stock of COVID-19 vaccine. The IP confirmed that Resident 86 consented to receive COVID-19 vaccine which he signed upon admission. The IP stated that Resident 86 was sent out to the hospital but the COVID-19 vaccine should have been given to Resident 86 prior to his hospitalization. The IP further stated that Resident 86 was on antibiotics due to osteomyelitis (bone infection) and that was the reason she did not provide Resident 86 the COVID-19 vaccine. The IP stated that she should have communicated with the doctor first before deciding not to give the COVID-19 vaccine. The IP stated that she ordered COVID-19 vaccine a few weeks ago and they have not received the COVID-19 vaccine yet. A review of the facility's policy and procedure (P&P) titled, Immunizations - Residents, dated 9/2017, revised 8/2025, indicated, .It is the policy of this facility to offer and administer influenza, pneumococcal, and COVID-19 immunization to eligible residents after providing education on the risks and potential side effects of the vaccine (s) and obtaining consent.Purpose To minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza, pneumococcal disease, or COVID-19 by ensuring that each resident is informed about the benefits and risks of immunizations; and has the opportunity to receive the influenza, pneumococcal, or COVID-19 vaccine (s), unless medically contraindicated, declined or already immunized.Residents will be screened at that time of admission to determine vaccine status and eligibility, using current CDC/ACIP guidelines, to receive the influenza, pneumococcal, and/or COVID-19 vaccine(s). Each resident is offered a COVID-19 immunization unless the immunization is medically contraindicated, or the resident has already been immunized.

Based on interview, and record review, the facility failed to follow their policy and procedure for the pneumococcal (a serious bacterial infection that can cause respiratory illness) immunization for two out of five sampled residents (for immunization review) when: 1. Resident 31's pneumonia vaccine was not documented; and,2. Resident 86's pneumococcal vaccine was not given after being admitted to the facility.These failures had the potential for Resident 31 and Resident 86 to be at risk to be infected with the pneumococcal virus that could lead to severe illness, hospitalization, and/or death.Findings:a. A review of Resident 31's admission RECORD, indicated Resident 31 was admitted on [DATE].b. A review of Resident 86's admission RECORD, indicated Resident 86 was admitted on [DATE].During a concurrent interview and record review on 1/8/26, at 10:27 AM, with the Infection Preventionist (IP), Resident 31 and Resident 86's electronic health record (EHR) were reviewed. The IP stated Resident 31 received pneumonia vaccine on 7/21/2020. The IP confirmed that pneumonia vaccine information was not documented on the electronic health record for Resident 31. The IP stated that the pneumonia vaccine information of Resident 31 should have been documented at the EHR. Resident 86's immunization record was reviewed with the IP, the record indicated Resident 86 consented to receive a pneumonia vaccine which he signed upon admission on [DATE]. The IP further stated that Resident 86 went to the hospital on 1/5/26 but the pneumonia vaccine should have been given to Resident 86 before he went to the hospital. The IP stated that Resident 86 was on antibiotics due to osteomyelitis (bone infection) and that was the reason she did not provide Resident 86 the pneumonia vaccine. The IP further stated that she should have communicated with the doctor first before deciding not to give the pneumonia vaccine to Resident 86. During an interview on 1/9/26, at 10:55 AM, with the Director Of Nursing (DON), the DON stated that the immunization information and consent were obtained during admission for new residents. The DON further stated that the IP would follow up on the next business day if the consents were signed or needed to be signed. The DON stated that a reasonable time to complete a resident's immunization record was within 7-10 days upon admission. A review of the facility's policy and procedure (P&P) titled, Immunizations - Residents, dated 9/2017, revised 8/2025, indicated, .It is the policy of this facility to offer and administer influenza, pneumococcal, and COVID-19 immunization to eligible residents after providing education on the risks and potential side effects of the vaccine (s) and obtaining consent.Purpose To minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza, pneumococcal disease, or COVID-19 by ensuring that each resident is informed about the benefits and risks of immunizations; and has the opportunity to receive the influenza, pneumococcal, or COVID-19 vaccine (s), unless medically contraindicated, declined or already immunized.Residents will be screened at that time of admission to determine vaccine status and eligibility, using current CDC/ACIP guidelines, to receive the influenza, pneumococcal, and/or COVID-19 vaccine(s).Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated, or the resident has already been immunized.

Based on observation, interview, and record review, the facility did not provide adequate supervision to protect one of forty-four sampled residents (Resident 112) from alleged physical abuse when a Licensed Nurse (LN) witnessed one unsampled resident (Resident 25) hit Resident 112 on the face on 12/12/25. This failure could potentially result in physical injury and emotional distress that could negatively affect Resident 112's physical and psychosocial well-being.Findings:On 12/12/25, the Department received a facility reported incident regarding an alleged resident to resident altercation. This reported incident was investigated during the facility's unannounced annual recertification survey on 1/6/26.During a record review of Resident 25's admission RECORD, indicated, Resident 25 was admitted to the facility with diagnoses including schizophrenia and depression.During a record review of Resident 25's Order Summary Report, dated 12/17/25, indicated Resident 25 was discharged to another facility on 12/24/25. Resident 25 was not in the facility during the duration of their annual recertification survey.During a record review of Resident 112's admission RECORD, indicated, Resident 112 was admitted to the facility with diagnoses including depressive disorder.During a record review of Resident 112's Minimum Data Set, (an assessment tool) dated 11/4/25, indicated Resident 112's BIMS (Brief Interview for Mental Status) score was 14 out of 15 suggesting an intact mental functioning.During a concurrent observation and interview on 1/7/26, at 10:52 a.m. with Resident 112, Resident 112 was in the dining room playing table cards. When asked how he was doing, he responded in Spanish and motioned his hands indicating someone had hit him. When asked if the person who had hit him was still in the building and he motioned his hands that the other resident was no longer in the facility.During an interview on 1/7/26, at 10:52 a.m. with Resident 112, in the presence of Licensed Nurse (LN) 3 who interpreted Resident 112's responses from Spanish to English language, Resident 112 explained that he was minding his own business and was sitting out in the hallway when Resident 25 came out of nowhere and hit him on both sides of his head and he did not have the time to react. Resident 112 stated the other resident was his previous roommate. Resident 112 stated the other resident was no longer in the facility and had not seen him and went somewhere else. Resident 112 also explained that the nurse saw what happened and the nurse intervened and separated them.During an interview on 1/8/26, at 2:31 p.m. with Resident 112 in the presence of LN 3 who interpreted for Resident 112, Resident 112 stated he felt that what had happened to him was a physical abuse because the other resident had hit him out of nowhere and hitting was an abuse.During an interview on 1/8/26, at 4:23 p.m. with the Social Service Director (SSD), the SSD explained LN 5 had witnessed Resident 25 hit Resident 112 on the right cheek and sustained a scratch and some redness. The SSD stated this incident happened quickly and it was a spur of the moment. The SSD stated Resident 25 had a verbal outburst calling out staff devils and talking about snakes. The SSD also stated Resident 25 had visual hallucinations such as seeing snakes. The SSD added at times Resident 25 stood up and lunged at staff. The SSD stated Resident 25's family had reported he had cycles of episodes every few years.During an interview on 1/9/26, at 7:40 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 25 had behaviors of shouting at staff at times. CNA 1 also stated she had seen Resident 25 and Resident 112 exchanging words and at times could be verbally aggressive with each other.During an interview on 1/9/26, at 7:55 a.m. with CNA 2, CNA 2 explained that about two weeks prior to this incident she overheard Resident 25 saying things about faith, talking about God, and saying that he was being taken away from the place where he wanted to stay. CNA 2 also explained that she noticed Resident 25 did not want to go back to his room because Resident 112 had guns and he was a bad person. CNA 2 stated she also noticed Resident 25 who was previously quiet was now very talkative and talked a lot. CNA 2 also stated she observed Resident 25 getting mad and becoming aggressive. CNA 2 further explained before the incident happened that day Resident 25 went out to the patio and she followed him to calm him down and to encourage him to go back inside the building. CNA 2 stated Resident 25 entered the building and Resident 112 was sitting in front of the North Nurses Station while CNA 2 was in the North Nurses Station when she heard a commotion and saw Resident 25 walking with a walker approaching Resident 112 and hit him.During an interview on 1/9/26, at 9:34 a.m. with LN 5, LN 5 stated she witnessed Resident 25 hit Resident 112 on the face. LN 5 explained the morning of the incident Resident 25 and Resident 112 were sitting next to each other in the hallway near the North Nurses Station when suddenly, she heard yelling from Resident 25 and stood up from his chair and walked towards Resident 112. LN 5 further explained as she was going to assist and stop the altercation, Resident 25 was already standing and had hit Resident 112 twice on the face before she could intervene.During a record review of Resident 25's Care Plan Report, dated 8/14/25, indicated, .auditory hallucinations AEB [as evidenced by] hearing voices telling pt. [patient] Be careful [and] visual hallucinations AEB seeing snakes and the devil.During a record review of Resident 25's Care plan Report, dated 10/2/25, indicated, .Potential for mood problem.Observe for signs and symptoms of.racing thoughts.increased irritability.flight of ideas.agitation or hyperactivity.During an interview on 1/9/26, at 10:45 p.m. with the Administrator (ADM), the ADM stated that Resident 25 was transferred to another facility due to hallucinations. The ADM stated Resident 25 had a psychiatric diagnosis. The ADM also stated that things happen in an instance and do not guarantee nothing is going to happen. The ADM added that staff could not anticipate every resident's move every day.During a record review, Resident 25's Preadmission Screening and Resident Review (PASRR) Level 1 Screening, dated 7/18/25, indicated Resident 25 was positive for Serious Mental Illness (SMI) and a Level 2 Mental Health Evaluation was required.During a record review, Resident 25's Level 2 PASSR INDIVIDUALIZED DETERMINATION REPORT, dated 7/22/25, indicated a list of services and supports that supplement the facility's care to address mental health needs. During an interview on 1/9/26, at 12:29 p.m. with the Director of Nursing (DON), the DON stated Resident 25 was transferred to another facility due to escalated behavior and needed to be evaluated. The DON also stated that she was aware of Resident 25's diagnosis on admission. The DON stated that the goal for every resident staying in the building was their safety and any altercations would make the residents feel unsafe, fearful, or scared.During a record review of the facility's policy and procedure (P&P) titled, Abuse: Prevention of and Prohibition Against, revised date 8/25, indicated, .It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment.The Facility will act to protect and prevent abuse and neglect from occurring within the Facility by.identifying, correcting, and intervening in situations in which abuse.is more likely to occur.identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict.

Based on observation, interview, and record review, the facility failed to ensure infection control measures were used to prevent the spread of germs for a census of 128 when the oxygen nasal cannula (a flexible plastic tube connected to an oxygen source with two prongs that fit in the nostrils used to provide extra oxygen through the nose) was not placed in an antimicrobial bag (a bag that reduces the growth of germs on the nasal cannula) as ordered for Resident 134.This failure had the potential to result in the spread of germs and the need for additional medical interventions (medications and/or treatments).Findings: A review of Resident 134's admission Record indicated that Resident 134 was admitted to the facility in 2019 with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, a long-term disease that cause airflow blockage, breathing related problems, shortness of breath and cough).During an observation and concurrent interview with Resident 134 in her room on 1/8/26 at 9:12 a.m., Resident 134 pointed to her walker and stated that she asked facility staff for a plastic bag to protect her nasal cannula attached to the oxygen tank on Monday 1/5/26, and they still have not brought it to her. Resident 134 stated that she felt that it was unsanitary (not clean) to have the nasal cannula drag on the floor when she walked, so she put the nasal cannula in the compartment under the seat of her walker. The nasal cannula was observed coiling under the seat of Resident 134's walker and was not in a protective bag.A review of Resident 134's Physician Order Summary Report on 1/8/26 at 10:00 a.m. indicated, .Oxygen at_3_LPM (liters per minute, unit of measure) via_nasal cannula_ continuous every shift.Order Status.Active.Order Date.08/05/2025.A review of Resident 134's Physician Order Summary Report on 1/8/26 at 10:00 a.m. indicated, .Change Oxygen tubing as needed for when visibly soiled (dirty). Please place tubing in antimicrobial bag.Order Status.Active.Order Date.04/10/2025.Start Date.04/10/2025.A review of Resident 134's Physician Order Summary Report on 1/8/26 at 10:00 a.m. indicated, .Change Oxygen tubing every night shift starting on the 10th and ending on the 11th every month Please place tubing in antimicrobial bag.Order Status.Active.Order Date.04/10/2025.A review of Resident 134's Care Plan Report on 1/8/26 at 10:00 a.m. indicated, .Focus.Has Oxygen Therapy r/t (related to) COPD.Goal.Will have no s/sx (signs/symptoms) of poor oxygen absorption through the renew date.Date Initiated.09/25/2025.Target Date.01/31/2026.Interventions/Tasks.Oxygen per MD (physician) orders.A review of Resident 134's Medication Administration Record (MAR, a document listing medications and monitoring parameters) January 2026 on 1/8/26 at 10:00 a.m. indicated no documented oxygen tubing changes.During an observation and interview with the facility Director of Nursing (DON) on 1/8/26 at 11:08 a.m., the DON stated that her expectation was that oxygen tubing, nasal cannulas, masks for breathing treatments and CPAP (Continuous Positive Airway Pressure, a machine that uses mild air pressure to keep breathing airways open during sleep) masks needed to be stored in black bags or clear plastic bags off the floor when not in use. The DON stated that the black bags were antimicrobial and were good for thirty days. The DON stated that the nasal cannulas should be in a bag when placed in the resident walker seat compartment. The DON acknowledged that the facility policy was not followed.A review of a facility policy and procedure (P&P) titled, Oxygen Administration, dated 8/1/2025, the P&P indicated, .Policy.Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.Policy Explanation and Compliance Guidelines.1. Oxygen is administered under orders of a physician.5. Staff shall perform hand hygiene and don gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include.b. Change oxygen tubing and mask/cannula monthly and as needed if it becomes soiled or contaminated (in contact with germs). Documentation of this is made on the MAR.d. Keep delivery devices covered in.bag when not in use.

Based on interview, and record review, the facility failed to ensure an appointment was scheduled within 1 to 2 weeks after a hospitalization for 1 out of 44 sampled residents (Resident 161), when Resident 161's cardiology appointment was not scheduled as ordered. This failure resulted in Resident 161 missing a physician's appointment and a potential risk for causing a delay in care and treatment.Findings:A review of Resident 161's admission RECORD, indicated Resident 161 had diagnoses including disorder of circulatory system (impaired blood supply in certain areas of the body), embolism and thrombosis of arteries of the lower extremities (a blood clot forming or traveling to block blood flow in leg arteries), cardiomyopathies (a disease that weakens or changes the heart muscle, making it harder for the heart to pump blood effectively to the body), acute on chronic combined systolic congestive and diastolic congestive heart failure (a severe, sudden worsening of a long-term heart problem where the heart struggles with both its pumping and relaxing/filling functions, leading to fluid backup in the lungs and body), hypertensive heart disease with heart failure (long-term high blood pressure has damaged the heart, forcing it to work harder, thicken, and eventually weaken, making it unable to pump blood effectively).A review of Resident 161's [Hospital] Discharge summary, dated [DATE], indicated, Resident 161 had a follow-up appointment with cardiology within 1 to 2 weeks. Further review of the record indicated, .Call for outpatient follow up appointment with cardiology for further management of cardiomyopathy and heart failure.During an interview on 1/6/26, at 10:48 AM, with Resident 161, Resident 161 stated she was supposed to have an appointment with a cardiologist (heart doctor) but it was not scheduled yet. Resident 161 further stated she was admitted to the facility because she had a blood clot in her heart.During an interview on 1/6/26, at 8:28 AM, with the Social Service Director (SSD), the SSD stated that when a new admission came in, the case manager would schedule the appointments for the residents depending on their insurance. The SSD further stated that the MDS Manager (Minimum Data Set - A comprehensive, standardized assessment of a resident's health status, functional capabilities, and needs ) scheduled the appointments for Medicare residents, made the referrals and sometimes the nurses and the ADON would help with the scheduling. The SSD stated that the Social Services department arranged the transportation and she would oversee the transportation schedule for the residents' appointments. During a concurrent interview and record review on 1/8/26, at 8:52 AM, with the MDS Manager (MDS), Resident 161's electronic health record (EHR) was reviewed. The MDS stated that she and the case manager were responsible for scheduling the appointments for the residents. The MDS confirmed that Resident 161's hospital discharge records indicated there was an order for a consultation with cardiology within 1 to 2 weeks. The MDS further confirmed that the cardiology appointment was not in the active order list of Resident 161's EHR. The MDS stated that the risk of missing the appointment especially if it was a cardiology appointment, could potentially worsen Resident 161's condition. The MDS further stated that the cardiology appointment was important because Resident 161 was admitted for cardiac issues.During a concurrent interview and record review on 1/8/26, at 9:04 AM, with the Case Manager (CM), Resident 161's EHR was reviewed. The CM stated that when the nurses would admit the residents, they placed the order from the hospital discharge summary. The CM further stated that if the admission nurse missed placing the appointment order in the EHR, she would double check the uploaded documents in the resident's EHR. The CM stated that when they completed the meet and greet with the newly admitted resident, she would often ask the resident or the RP (responsible party) if they were aware of any scheduled appointments. The CM confirmed that the cardiology appointment should have been ordered upon admission or shortly after Resident 161 was admitted to the facility. The CM stated missing a cardiology appointment could lead to a health risk and it could complicate Resident 161's health condition. During a concurrent interview and record review on 1/9/26, at 10:55 AM, with the Director Of Nursing (DON), Resident 161's hospital discharge summary was reviewed. The DON stated that the nurses that were admitting the resident were responsible to place the order in the EHR. The DON further stated that the doctor would then review the orders. The DON confirmed that the appointment should have been discussed with the doctor and documented that discussion with the doctor. The DON stated that the appointment should have been discussed with Resident 161. The DON further stated that the nurse who admitted Resident 161 did not see the appointment and failed to input the order in the EHR.A review of the facility's policy and procedure (P&P) titled, Resident Appointments, revised December 2008, indicated, .The facility will assist residents with scheduling, transportation, and coordination of medically necessary and requested appointments.Appointments will be documented in the resident record, and appropriate clinical information will be communicated to the provider as needed.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage for a census of 128 when prescribed medications found in the pharmaceutical waste container (where unused and/or discontinued prescribed medications were held for ultimate safe disposal) in the South Station medication room were not disposed of properly where pills, medication bottles, and inhalers (used to deliver medication directly to the lungs) were still recognizable and retrievable by hand.This failure had the potential for misuse of prescribed medications due to unsafe disposal practices.During a medication storage observation and interview on 1/7/26, at 2:41p.m. with Licensed Nurse (LN) 7, the medication room at South Station was inspected. A pharmaceutical waste container inside the cabinet contained discarded prescribed pills, inhalers, and medication bottles that were still recognizable and retrievable by hand. LN 7 could not explain when asked what the process was of discarding prescribed pills into a pharmaceutical waste container.During an interview on 1/7/26, at 2:54 p.m. with the Assistant Director of Nursing (ADON), the ADON confirmed the discarded prescribed pills found in the pharmaceutical waste containers were still recognizable and retrievable by hand. The ADON explained the discarded pills should have been mixed with a drug buster (drug disposal product used to safely and effectively dispose of unwanted or expired medications) such as used coffee grounds, cat litter, or covered with fluid to prevent the risk of drug misuse and/or drug diversion.During an interview on 1/8/26, at 2:55 p.m. with the Director of Nursing (DON) in the presence of the Clinical Nurse Consultant (CNC), the DON stated she expected the discarded prescribed medications in the pharmaceutical waste containers should have been unrecognizable and unretrievable by hand. The DON also stated the discarded medications should have been mixed with drug buster, cat litter, or used coffee grounds to prevent the risk for misuse and potentially be pulled out from the waste container and be used by unauthorized individuals.During a record review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 8/1/25, the P&P indicated, .Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications.These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.During a record review of the facility's P&P titled, Destruction of Unused Drugs, dated 8/1/25, the P&P indicated, .All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations.Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with current and applicable state and federal requirements.

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for one of five sampled residents (Resident 109) during medication administration by failing to follow a physician order when, Resident 109's insulin (medication used to manage blood sugar levels in people with diabetes, a chronic condition where the body does not produce or use insulin properly leading to high blood sugar levels) order indicated to administer the medication on an empty stomach and Resident 109's insulin was administered during the breakfast meal on 1/8/26.This failure had the potential for Resident 109 to experience blood sugar fluctuations of hypoglycemia (when blood sugars are too low) and hyperglycemia (when blood sugars are too high) and increased the risk for unsafe medication administration. Findings:During a review of Resident 109's admission RECORD, indicated Resident 109 was admitted to the facility with diagnoses including diabetes.During a medication administration observation on 1/8/26, at 7:59 a.m. with Licensed Nurse (LN) 6 at the hallway in front of Resident 109's room, LN 6 was preparing her equipment to take Resident 109's fasting blood sugar (FBS) level. Resident 109 was seated by the doorway with her breakfast meal tray on top of the bedside table and in front of her. After LN 6 took her FBG, she had asked LN 6 to remove the plate cover. LN 6 walked back to her medication cart to administer resident 109's insulin. LN 6 read the order from the eMAR (electronic Medication Administration Record) and looked for the medication in the cart. LN 6 had indicated to Resident 109 that she did not see her insulin in the cart, and she was going to look for it in the refrigerator that was in the medication room. LN 6 then locked her cart and took the cart with her to the nurses' station without administering the insulin to Resident 109. In the meantime, Resident 109 had started eating her breakfast. In her meal tray, she had sausage patty, hard boiled eggs, banana, and hot cereal. Resident 109 had eaten her sausage patty and LN 6 had not been back to administer her insulin. Resident 109 had indicated that she ate her sausage patty.During a record review of Resident 109's Medication Administration Record, (MAR-a record that guides the nurses for medication administration) dated 11/10/25, indicated, .Insulin Lispro Injection solution 100 UNIT/ML (UNIT- strength of insulin in ML-milliliter, unit of measurement) (Insulin Lispro) Inject as per sliding scale.subcutaneously before meals for DM [diabetes mellitus].During an interview on 1/8/26, at 8:29 a.m. with LN 6, LN 6 explained that she did not find Resident 109's Insulin Lispro and there was none from the emergency kit, but Novolog (insulin aspart) injection 100 units/ml was available. LN 6 stated she had to call the physician to get an order to give Novolog insulin instead. By this time, LN 6 administered the insulin to Resident 109.During a record review of Resident 109's Medication Administration Record (MAR), dated 1/8/26, indicated, .Novolog Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale.subcutaneously before meals.for DM.During an interview on 1/8/26 at 11:32 a.m. with LN 6, LN 6 confirmed she administered Resident 109's insulin after Resident 109 had eaten some of her breakfast meal and stated it should have been given at least 15 minutes before meals. LN 6 explained she should have followed the physician order to administer before meals because it could have a potential risk for Resident 109's blood sugar level to spike once food was digested and her blood sugar level to drop later causing hypoglycemia.During a record review of Resident 109's Diabetes Care Plan, dated 1/27/23, indicated, .Diabetes medication as ordered by doctor.During a record review of Resident 109's Order summary Report, dated 1/8/26, indicated, .Novolog Injection Solution (Insulin Aspart) Inject as per sliding scale.subcutaneously before meals.for DM.During an interview on 1/8/26, at 2:46 p.m. with the Director of Nursing (DON), the DON stated she expected the physician order should be followed in order to keep the blood sugar at a stable level and prevent the potential spike in blood sugar if given too late and the insulin medication could bring the blood sugar level down too fast.During a record review of the facility's policy and procedure (P&P) titled, General Dose Preparation and Medication Administration, dated 11/15/24, the P&P indicated, .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.Administer medications within timeframes specified by facility policy or manufacturer's information.During a record review of the facility's undated P&P titled, Medication Administration, indicated, .Medications are administered by licensed nurses.as ordered by the physician.Medications requiring administration on an empty stomach.Insulin.

Based on observation, interview, and record review the facility failed to ensure safe pharmaceutical services with a census of 128 when:Medications were left at Resident 97's bedside, and;Narcotic (strictly regulated substances due to their high potential for abuse, addiction, or illegal use) sheets were not signed immediately after medication administration.These failures had the potential to negatively affect the health and well-being of Resident 97, the efficacy of the medications being administered, and had the increased risk of drug diversion. 1. A review of Resident 97's admission Record indicated that Resident 97 was admitted to the facility in 2025 with diagnoses which included Type II Diabetes Mellitus and Heart Failure (a chronic condition in which the heart does not pump blood as well as it should, causing fluid to back up into the lungs). During a concurrent observation and interview with Resident 97 in her room on 1/6/26 at 9:02 a.m., Resident 97 sat in her wheelchair at her bedside where a cup of medications on the bedside table was observed. When asked about the cup of medications at the bedside, Resident 97 quickly put the medications into her mouth and drank water. Resident 97 answered, Yes, when asked if the Licensed Nurse (LN) left the medications at the bedside for her to take. During an interview on 1/6/26 at 9:11 a.m. with LN 1 at the medication cart, LN 1 stated that he gave medications to Resident 97 to take earlier in the morning. LN 1 stated that Resident 97 was in the process of taking the medications when he left the room. LN 1 stated that Resident 97 put the medications in her mouth, so he left the room. LN 1 stated that the risk of leaving the medications at Resident 97's bedside was that Resident 97 could give the medications to another resident, or double dosing (taking the same medication twice). During an interview with the facility Director of Nursing (DON) on 1/8/26 at 11:08 a.m., the DON stated that her expectation was that licensed staff administered medications to residents per the physician orders, adhered to the five rights for medication administration, and that staff did not leave medications at the residents' bedside unless there was a physician order to do so. The DON stated that the risk of leaving medications at the residents' bedside was that a wandering resident could take someone else's medications, or the resident forgets to take the medications. The DON acknowledged that the facility policy was not followed. 2. During a concurrent medication cart observation, interview, and record review on 1/7/26, at 2:09 p.m. with LN 4 at the South Station, the medication cart #2 was inspected and the controlled drug (strictly regulated substances due to their high potential for abuse, addiction, or illegal use) binder was reviewed. There were 7 controlled drug count sheets (a tool used to track the inventory, administration, and disposal of controlled substances to ensure strict accountability and prevent theft or misuse) reviewed involving 3 sampled residents (Resident 27, Resident 120, Resident 15) and 3 unsampled residents (Resident 38, Resident 45, Resident 61). All 7 controlled count sheets reviewed did not match the number of pills documented on the count sheets with the number of pills that were available in the bubble packs (a medication management system where individual doses are pre-sorted into sealed, clear compartments). LN 4 stated she did not have the time to document on the count sheets immediately after removing the pills from the bubble packs and after administering the pills to the residents. The controlled count sheets reviewed were as follows: Resident 27's count sheet titled, Controlled Drug Record, dated 12/5/25, indicated, .CLONAZEPAM (used to treat anxiety or seizures ) 2MG (milligram, unit of measurement) TABLET, TAKE 1 TABLET BY MOUTH TWICE A DAY FOR ANXIETY. The pills remaining as documented was 9 and the pills available in the bubble pack was 8. Resident 120's count sheet titled, Controlled Drug Record, dated 12/9/25, indicated, .OXYCODONE IMMEDIATE (a strong pain medication) 10MG TABLET, GIVE 1 TABLET BY MOUTH TWO TIMES A DAY FOR PAIN . The pills remaining as documented was 9 and the pills available in the bubble pack was 8. Resident 15's count sheet titled, Controlled Drug Record, dated 12/23/25, indicated, .OXYCODONE IMMEDIATE 5MG TABLET, GIVE 1 TABLET BY MOUTH EVERY 6 HOURS FOR MODERATE TO SEVERE PAIN. The pills remaining as documented was 6 and the pills available in the bubble pack was 5. Resident 38's count sheets titled, Controlled Drug Record, dated 12/25/25 and 1/1/26, indicated, .MORPHINE SULFATE ER F/C (a strong pain medication) 60MG TABLET, GIVE 1 TABLET BY MOUTH EVERY 12 HOURS FOR PAIN (4-10). The pills remaining as documented was 5 and the pills available in the bubble pack was 4. And .OXYCODONE.10-325MG TABLET, GIVE 1 TABLET BY MOUTH EVERY 4 HOURS AS NEEDED FOR MODERATE TO SEVERE PAIN . The pills remaining as documented was 20 and the pills available in the bubble pack was 19. Resident 45's count sheet titled, Controlled Drug Record, dated 1/4/26, indicated, .HYDROCODONE (a strong pain medication).5MG-325MG TABLET, GIVE 2 TABLET [sic] BY MOUTH EVERY 6 HOURS AS NEEDED FOR SEVERE PAIN . The pills remaining as documented was 24 and the pills available in the bubble pack was 22. Resident 61's count sheet titled, controlled Drug record, dated 11/27/25, indicated, .LORAZEPAM (used to treat anxiety) 1MG TABLET, GIVE 1 TABLET BY MOUTH EVERY 12 HOURS FOR ANXIETY . The pills remaining as documented was 8 and the pills available in the bubble pack was 7. During an interview on 1/7/25, at 2:09 p.m. LN 4 confirmed that she did not sign off the controlled medications at the time the pills were popped out from the bubble pack and at the time the pills were given to the residents. LN 4 also stated she should have documented immediately on the count sheets at the time the pills were removed and administered, and it would be best practice to document immediately. LN 4 further stated there could be a high risk for medication errors when controlled count sheets were not signed off in a timely manner. During an interview on 1/7/26, at 2:54 p.m. with the Assistant Director of Nursing (ADON), the ADON stated it was not the facility practice to sign the controlled count sheets at a later time. The ADON explained it was best practice to sign off the controlled drugs in a timely manner to prevent the risk for medication errors. During an interview on 1/8/26, at 2:55 p.m. with the DON in the presence of the Clinical Nurse Consultant (CNC), the DON stated she expected the nurses to sign out the controlled drugs in the count sheets immediately after popping out the pills. She explained controlled drugs not accounted for could lead to further investigation due to possible drug diversion. During a record review of the facility's policy and procedure (P&P), titled, General Dose Preparation and Medication Administration, revised date 11/15/24, the P&P indicated, .Document the administration of controlled substances in accordance with applicable law. During a record review of the facility's undated policy and procedure (P&P), titled, Medication Administration, the P&P indicated, .If medication is a controlled substance, sign narcotic book.

Based on observation, interview, and record review, the facility failed to ensure residents received the care and services necessary to attain and maintain the highest practicable physical, mental, and psychosocial well-being, including preventing avoidable decline for 1 of 44 sampled residents (Resident 14) when Resident 14's Physician-ordered Range of Motion (ROM) exercises were not consistently provided as ordered. This deficient practice placed Resident 14 at risk for decline in mobility, development of contractures, muscle stiffness, decreased functional ability, and diminished quality of life.Findings:A review of Resident 14's, admission RECORD, indicated Resident 14 was admitted to the facility with diagnoses including hemiplegia (very little or no movement on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke - a part of the brain gets damaged because it did not receive enough blood and oxygen).During a review of Resident 14's clinical record titled, Care Plan Report, Resident 14's care plan, initiated on 10/7/25, in the section titled Focus, indicated, . [Resident 14] has limited physical mobility r/t [related to] Disease process, Stroke, Weakness AEB [as evidenced by] limited BUE [both upper extremities]/ BLE [both lower extremities] ROM [range of motion] .During a review of Resident 14's Electronic Health Record (EHR) titled, Care Plan Report, Resident 14's care plan, initiated on 11/3/25, in the section titled, Intervention/Tasks, indicated, . [Resident 14] . RNA [Restorative Nursing Assistance: helping residents maintain or improve their physical abilities so they don't lose strength or independence] Programs: Gentle PROM [Passive Range of Motion - moving person's joints for them when they cannot move on their own] to RUE [ right upper extremity] then apply R [right] WHFO [wrist, hand, forearm orthosis - a brace or splint that supports the wrist, hand, and forearm] for 4 hours, or as tolerated 6x/wk [6 times a week] and PROME [passive range of motion exercises - exercises where someone else gently moves your arms or legs for you] on B [both] [NAME] [lower extremities] all planes with end range stretching towards knee extension [straightening the knee] x 30 secs [seconds] hold x 7 reps [repetitions] 3x/wk.A review of Resident 14's, Documentation Survey Report, for November 2025, in the section titled, Intervention/Task, indicated, RNA Program PROM on RUE all planes 10 reps x 2 sets then apply R WHFO for 4 hours or as tolerated 6x/wk NA (Not Applicable) was documented on the following dates: 11/3/25, 11/4/25, and 11/5/25 and on RNA Program: PROME on BLE all planes with end range stretching towards knee extension x 30 secs hold x 7 reps 3x/wk NA was documented on 11/4/25.During a concurrent observation and interview on 1/6/26, at 9:25 AM with Resident 14, in Resident 14's room, Resident 14 was observed having difficulty opening his right hand. Resident 14 stated that both left and right arm muscles felt tight and had trouble opening his right hand. Resident 14 further stated that staff sometimes missed performing the restorative exercises. Resident 14 stated that since he was not in rehabilitation therapy but in a restorative program, it was very important for him not to miss the exercises.During a concurrent interview and record review on 1/8/26, at 8:21 AM, with the Restorative Nursing Assistant (RNA - helps residents practice everyday skills like moving safely after therapy ends or alongside nursing care so they don't decline), Resident 14 EHR was reviewed. The RNA confirmed that Resident 14 had RNA orders for upper extremities, specifically Resident 14's right hand six times per week from Monday to Saturday and for lower extremities three times per week implemented every Monday, Wednesday, and Friday. The RNA stated that the RNA programs for Resident 14 were crucial to prevent muscle stiffness and joint contractures. The RNA reviewed facility documentation for Resident 14 from date 12/11/25 to 1/7/26 and confirmed that RNA documentation in the section titled, Task RNA Program: Gentle PROM to RUE then apply R WHFO for 4 hours or as tolerated 6x/week, indicated NA on the following dates 1/1/26, 1/2/26, 1/3/26, and 1/5/26 and for RNA Program: PROME on BLE all planes with end range stretching towards knee extension x 30 secs hold x 7 reps 3x/wk, indicated NA on 1/2/26 and 1/5/26. The RNA stated that 'NA' meant the tasks were not done as ordered by the doctor. The RNA further stated that if Resident 14's RNA programs were not followed, it could lead to increased muscle stiffness, loss of remaining functional ability, and worsening of contractures.During an interview on 1/8/26, at 2:05 PM, with the Director of Staff Development (DSD), the DSD stated that RNAs were expected to implement and perform all RNA programs as ordered by the doctor. The DSD further stated that not following the RNA program could cause Resident 14's condition to potentially decline functionally. The DSD stated they will assign extra staff, especially during the week of monthly weighing of residents, to ensure the RNA programs ordered by the doctor were implemented.During an interview on 1/9/26, at 10 AM, with the Director of Nursing (DON), the DON stated that RNAs were expected to follow the doctor's orders and carry out all RNA instructions unless the residents refused. The DON further stated that the RNA program was important to keep the residents' functional mobility and maintain their range of motion as much as possible.Review of a facility policy and procedure titled, Restorative Nursing Programs, dated 8/1/25, indicated, . It is the policy of this facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. assisting residents with range of motion exercises, performing passive range of motion for residents who lack the active range of motion ability. Restorative Nurse is responsible . for ensuring that all elements of each resident's program are implemented . Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form or other facility designated form .

Based on observation, interview, and record review, the facility failed to ensure podiatry care (Podiatrists (foot care specialists) deal with medical problems related to the feet - in the skin or toenails) was provided to 1 out of 44 sampled residents (Resident 1) when Resident 1 had long, thickened, hard, chipped, toe nails that were sensitive to touch and a request for podiatry service on 12/28/25 was not followed up on by facility staff. This failure had the potential for Resident 1 to sustain injury, impaired skin integrity, and/or acquire an infection.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was originally admitted to the facility with diagnoses including Alzheimer's disease (a chronic gradual /worsening of memory, attention, and reasoning), dementia (a progressive decline in mental functions, marked by memory loss, reasoning, judgement, abstract thought, learning, task execution, and use of language), age related osteoporosis (loss of bone mass that occurs throughout the skeleton leading to weak bones), chronic kidney disease (renal disease-a disease where damaged kidneys cannot filter waste and fluid from the blood), restlessness and agitation.During an observation on 1/6/26, at 9:37 a.m., in Resident 1's room, Resident 1 was observed lying in bed with her left foot dangling out of bed. Resident 1's foot was observed to have long, thickened, hard, yellowish toenails.During an interview on 1/7/26, at 10:52 a.m., with the ADON, the ADON confirmed she was notified about Resident 1's podiatry consultation request. The ADON stated it was everyone's responsibility to set up podiatry appointments for residents, including nursing staff.During a concurrent interview and record review on 1/9/26, at 10:30 a.m., with Minimum Data Set Coordinator (MDS, an assessment tool), Resident 1's nursing progress note, dated 12/28/25, was reviewed. The MDS confirmed Licensed Nurse (LN) 2 documented he had requested a podiatry consultation for Resident 1 because Resident 1's Responsible Party (RP) requested one on 12/28/25. The MDS stated she did not know whether the consultation was ever done. The MDS stated the wound care nurse was responsible for the weekly nail or podiatry care assessment. During an interview on 1/9/26, at 10:51 a.m., with LN 2, LN 2 confirmed he requested a podiatry consultation for Resident 1 as Resident 1's RP was requesting one. LN 2 stated he notified the Assistant Nursing Director (ADON) and documented it in Resident 1's progress notes. LN 2 further stated he had checked Resident 1's toenails and agreed there was a need for a podiatry consultation. LN 2 explained Resident 1's nails were overgrown and when staff attempted to touch her nails, they were sensitive and Resident 1 would draw back her feet or yell. LN 2 stated he attempted to touch Resident 1's toes today (1/9/26) and they were still sensitive to touch.During an interview on 1/9/26, at 1:14 p.m., with the Social Services Director (SSD), the SSD stated she did not follow through with the podiatry care request for Resident 1. The SSD stated podiatry care was important for residents because it was for their comfort and wellbeing, and their rights as a resident living in the facility. During an interview on 1/9/26, at 11:33 a.m., with the Director of Nursing (DON), the DON stated podiatry should have been consulted if the resident needed nail care. The DON further stated if the resident were diabetic (the inability to control sugar levels in the body leading to poor healing) the facility would set up a podiatry visit for the resident, and if they were non-diabetic then staff could trim their nails. The DON further stated the appropriate course was for staff to notify social services there was a need for podiatry and then social services would carry out the referral. The DON further stated the importance of providing nail care for Resident 1 was to prevent Resident 1's toenails from growing into the skin, it could cause skin injury, and it would not be comfortable to have an unattended long thickened, hard nail. The DON stated the expectation for skin assessment was facility nursing staff should conduct a weekly head-to-toe assessment. The DON stated nursing staff should follow this practice to look for any changes in the resident's skin.A review of facility's policy and procedures (P&P) titled, Nail Care, dated 8/1/25, indicated, . the purpose of this procedure is to provide guidelines for provision of care to resident's nails for good grooming and health. 1. Assessment of resident's nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nailcare, if possible. a. Report unusual or abnormal conditions of the nails to the physician and the responsible party (e.g., curling, color changes, separation from the nailbed, redness, bleeding, pain, odor, infection, etc.). c. Obtain history and preferences regarding podiatrist. 2. Identify conditions that increases risk for foot or nail problems. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 4. Principles of nail care. a. Nails should be kept smooth to avoid skin injury. c. If residents have a toe infection.renal failure.toenail trimming should be performed by a physician or practitioner. 5. Procedures. 5. Document completion of task, any complications, or if resident refuses.

Based on observation, interview, and record review, the facility failed to ensure safe medication management for 1 out of 44 sampled residents (Resident 52) when Resident 52's two inhalers were allowed to remain at Resident 52's bedside for self use without a determination made by the interdisciplinary team if self-administration of medications was safe and appropriate for Resident 52. This deficient practice placed Resident 52 at risk for unsupervised medication administration, incorrect dosing, misuse, adverse medication effects, and lack of monitoring for effectiveness and side effects.Findings:A review of Resident 52's admission RECORD, indicated Resident 52 was admitted to the facility with diagnoses including acute respiratory failure (when not enough oxygen passes from the lungs to the blood), chronic obstructive pulmonary disease (COPD - a lung condition that makes it hard to breathe because airflow into and out of the lungs get blocked), difficulty in walking, nicotine dependence, and anxiety disorder (when normal, occasional worry, turns into intense, persistent, and excessive fear about everyday things, making it hard to control and interfering with daily life).A review of Resident 52's, Order Details, dated 8/21/25, indicated that the Medical Doctor (MD) had prescribed Breyna Inhalation Aerosol (medicine that helps people with COPD breathe easier) 2 puffs inhale orally two times a day for shortness of breath (SOB).A review of Resident 52's, Order Details, dated 9/13/25, indicated that the MD had prescribed Albuterol Inhalation Aerosol (medicine that helps people with COPD breathe easier) 2 puffs by mouth every four hours as needed for SOB.During a concurrent observation and interview on 1/6/26, at 2:46 PM, with Resident 52, in Resident 52's room, a red and a blue inhaler were seen on Resident 52's bedside table. Resident 52 stated she used the red inhaler two times in the morning and two times at night, and the blue inhaler every two to four hours as needed. Resident 52 further stated that she had brought the inhalers from home. Resident 52 stated that the nurses also had their own supply, but no nurses checked on her while she used the inhalers by herself. Resident 52 stated that no one had completed an assessment regarding her ability to use the inhalers on her own.During a concurrent observation, interview, and record review on 1/6/26, at 4:48 PM, with the Assistant Director of Nursing (ADON), in Resident 52's room, the ADON confirmed that Resident 52 had two inhalers on the bedside table. The ADON stated that Resident 52 preferred to self-administer the inhalers, and Resident 52 needed a doctor's order and a self-administration of medication assessment and a care plan. Upon reviewing Resident 52's Electronic Health Record (EHR), the ADON confirmed that an assessment for self-administration of medication was not completed for Resident 52. The ADON further confirmed there was no care plan that reflected the use of the two inhalers found on Resident 52's bedside table. The ADON stated that by not performing a self-administration of medication assessment and not creating a care plan for Resident 52, Resident 52's safety was at greater risk. The ADON further stated that staff did not know if Resident 52 was safe to use the inhalers, which could lead to improper use or an overdose. The ADON stated that she expected nurses to complete the self-administration of medication assessment and care plan before allowing Resident 52 to use the inhalers on her own.During an interview on 1/7/26, at 8:31 AM, with licensed nurse (LN) 11, LN 11 stated that Resident 52 had kept the inhalers at the bedside since the day Resident 52 was admitted to the facility. LN 11 stated that staff needed to watch how Resident 52 used the inhalers to avoid using too much or too little medicine.During an interview on 1/9/26, at 9:50 AM, with the Director of Nursing (DON), the DON stated that if Resident 52 wanted to use her inhalers by herself, licensed nurses needed to complete a self-administration of medication assessment to make sure Resident 52 could use her inhalers safely. The DON further stated it was also important to make a care plan for Resident 52's ability to use the inhalers by herself.Review of a facility policy and procedure titled, Self-Administration of Medications, revised 6/5/24, indicated, . Facility should comply with facility policy, applicable law and the State Operations Manual with respect to resident self-administration of medications . the manner of storage shall prevent access by other residents . facility staff shall record in the patient health record the bedside medications used . facility in conjunction with the interdisciplinary care team [a group of people from different professional backgrounds who work closely together, sharing knowledge and making joint decisions to achieve a common goal], should assess and determine . whether self-administration of medications is safe and clinically appropriate . facility should document in the resident's care plan whether the resident or facility staff is responsible for the storage of the resident's medications . facility should document the self-administration and self-storage of medications in the resident's care plan.

Based on interview and record review the facility failed to follow their surveillance plan (oversight plan to prevent the spread of infection) for scabies (an infection that causes an itchy skin rash when mites [tiny insects] burrow under the skin) prevention and control for one of four sampled residents (Resident 1) when, the Infection Preventionist (IP) did not implement the required six-week contact identification list and failed to train and notify all key healthcare personnels on how to recognize and report signs and symptoms consistent with scabies infestation.These failures had the potential to result in continued transmission of scabies among staff and residents within the facility. Findings:During a review of Resident 1's clinical record titled, admission Record, the record indicated Resident 1 was admitted to the facility in 2020 with a diagnosis which included respiratory failure. A review of Resident 1's clinical record titled, Order Summary, dated 8/26/25 at 11:33 AM, indicated the medical provider ordered permethrin cream (medicine that kills mites) and Ivermectin tablets (medicine that kills tiny bugs or worms that live in or on the body) to be administered to Resident 1. A review of Resident 1's clinical record titled, Scabies Examination, dated 8/30/25, indicated, .scabies mites seen.During a concurrent phone interview and record review on 9/23/25 at 2:05 PM with the Infection Preventionist (IP), the facility's surveillance plan titled, PREVENTION AND CONTROL OF SCABIES IN CALIFORNIA HEALTHCARE SETTINGS, was reviewed. The IP stated the PREVENTION AND CONTROL OF SCABIES IN CALIFORNIA HEALTHCARE SETTINGS was intended to guide the facility's response to a scabies infestation. The IP stated she verbally notified the following individuals of Resident 1's scabies diagnosis; the staff during a huddle (a quick and informal meeting), Resident 1's responsible party (RP), and the RPs of Resident 1's three roommates. The IP also stated that she did not follow the submitted surveillance plan when instead of conducting contact identification for six weeks as outlined, she only did for six days (8/21/25 through 8/26/25). Additionally, the IP stated she did not assign a dedicated care team member to provide care for Resident 1 as specified in the plan. During a phone interview on 9/23/25 at 2:30 PM, with the Director of Staff Development (DSD), the DSD stated the facility had not provided a stand-up meeting to all of the staff regarding Resident 1's scabies diagnosis.During a phone interview on 9/23/25 at 2:40 PM, with the IP, the IP stated that the risk of the facility not following their submitted surveillance plan was that the scabies infection could have spread within the facility. During interview on 9/24/25 at 3:05 PM with the Janitor (J) 1, J 1 stated that he heard from other janitors and housekeeping staff that there was a case of scabies in the facility; however, he did not know which resident was affected and believed the affected resident was only under observation for scabies and the case had not been confirmed.During an interview on 9/24/25 at 3:14 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was not part of a huddle when scabies was discussed, and that the huddle was only conducted with the staff who cared for Resident 1 (on the north hallway). CNA 1 stated that all staff should have been informed of the scabies diagnosis because staff were sometimes required to work in other hallways of the facility and could have been exposed. CNA 1 stated that she learned of Resident 1's diagnosis after she was assigned to deliver meal trays to the north hallway and was advised by other staff to wear Personal Protective Equipment (PPE, gown, gloves, mask, booties) when going into Resident 1's room. CNA 1 also stated she had not attended an in-service about scabies. During an interview on 9/24/25 at 3:31 PM with CNA 2, CNA 2 stated that she normally worked at the north station and was unaware that Resident 1 had tested positive for scabies. CNA 2 stated she learned of it only when another CNA informed her while passing meal trays. CNA 2 denied attending a huddle or being notified by the IP regarding the Resident 1's positive scabies case and could not recall receiving any scabies in-services. CNA 2 stated that if anyone who cared for Resident 1 (who was positive for scabies) should have worn a gown, washed hands before and after care, and thrown the gown in the trash can located inside Resident 1's room.During an interview on 9/24/25 at 3:44 PM, with Housekeeper (H) 1, H 1 stated that her duties included cleaning inside the resident rooms. H 1 stated she became aware of Resident 1's diagnosis of scabies after she observed an isolation sign posted by the door (a sign that indicates what PPE was necessary to wear before entering the room) and after a nurse informed her of the scabies. H1 stated she did not attend a huddle or receive in-service training regarding scabies. During an interview on 9/24/25 AT 3:53 PM with CNA 3, CNA 3 stated she was unaware that any resident (Resident 1) at the facility had scabies in 8/25 and did not know of any staff huddles that were conducted. During an interview on 9/24/25 at 3:57 PM with Licensed Nurse (LN) 1, LN 1 stated he was not informed of any staff huddle or of a positive case of scabies in the building. LN 1 stated he recalled receiving a scabies in-service in the year 2023 or 2024, but nothing in the year 2025. During an interview on 9/24/25 at 4:06 PM with LN 2, LN 2 stated that she knew about a positive scabies case because another nurse from north station informed her. LN 2 stated no in-service training on scabies was provided. During an interview and record review, on 9/24/25 at 4:11 PM with the IP, Resident 1's progress notes, the facility's huddle sign in sheets, the facility's in-service training records, and the facility's line lists (lists of residents/staff who have been tested or have signs and symptoms of an infection) were reviewed. The IP stated that she conducted a staff huddle on 8/26/25 at the north station only, during a shift change (one set of nurses end their shift and a new set of nurses come on shift). The IP stated there was no sign-in sheet for the huddle, so she did not have a record of who attended the huddle. The IP also stated she did not document any communication or education regarding scabies education in Resident 1's progress notes. The IP stated that no in-service training on scabies was provided after Resident 1's positive scabies diagnosis. The IP stated she did not create a line list and reiterated that contact identification was conducted for only one week and not the six weeks required by the surveillance plan. A review of the facility's surveillance plan titled, PREVENTION AND CONTROL OF SCABIES IN CALIFORNIA HEALTHCARE SETTINGS, dated 8/20, indicated, .All Healthcare facilities (HCF) should develop, implement, and periodically evaluate a scabies prevention control , and outbreak management program.the IP should be responsible for preventing or managing an outbreak.outbreak management program should include training all physicians, nurses and other HCP to recognize and report.signs and symptoms consistent with scabies infestation.All HCP and volunteers should be instructed to report any potential exposure to scabies in the home or community.An outbreak of scabies.might be defined as. 1 confirmed case and at least 2 suspect cases. An outbreak should be assumed to be occurring following diagnosis of a single case, until screening of all new patients and staff for scabies has been completed without identifying additional suspect cases. An outbreak cannot be conclusively excluded for at least 6 weeks following the last unprotected exposure to the case.the IP should develop a contact identification list. This list should identify every patient/resident , HCP, volunteer and visitor who may have direct, physical contact with the case within the previous 6 weeks.Notification of Key Personnel. should include representatives from all departments including.environmental services, and laundry.All HCP and volunteers should be notified as soon as possible. Initially, a communication memo should be distributed to all departments. should briefly describe. the symptoms, a brief description of the treatment.and whom to call if there are questions.CONTROLLING THE OUTBREAK.failure to identify and treat even one contact can result in continued propagation of the outbreak.Isolation of Patients/Residents.A team of HCP should be assigned to care only for patients/residents with atypical or crusted scabies during isolation period. A review of the facility's policy titled, Transmission-Based (Isolation) Precautions, dated 8/1/2025, indicated, .'Contact precautions' refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident of the resident's environment.8. Prompt recognition of need: a. All staff receive training on transmission-based precautions upon hire and at least annually.b. Nursing staff receive training on signs and symptoms of infection, common organisms that require additional control measures, and considerations for residents who are colonized with infectious organisms.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents' (Resident 1) hydration requirements were met when Resident 1 did not have water available within reach.This failure placed Resident 1 at risk for dehydration (a condition where your body loses more fluids than it takes in, meaning it doesn't have enough water to perform its normal functions) and could have led to illness or kidney injury. Findings:During a review of Resident 1's clinical record titled, admission RECORD, the record indicated Resident 1 was admitted to the facility with a diagnosis of dehydration, acute kidney failure (when your kidneys suddenly stop working well and can't clean waste from your blood, balance fluids, or regulate electrolytes), and essential hypertension (high blood pressure- which can damage kidneys). A record review of Resident 1's clinical record titled, Minimum Data Set (MDS, an assessment tool used to plan care) . Section GG - functional status, dated 11/5/25, indicated Resident 1 had impairment on one side of upper extremity (shoulder, elbow, wrist, hand).A review of Resident 1's clinical record titled, Order Summary Report, dated 11/18/25, the order summary indicated, .Triamterene & Hydrochlorothiazide [a combination of two diuretic medications to assist the body of eliminating excess salt and potassium from the body, and increase urine flow, which reduces blood pressure] .1 tablet by mouth one time a day.A review of Resident 1's dehydration care plan (a guide that healthcare workers used to ensure Resident 1 received tailored care to meet individual needs and goals), the care plan indicated, .offer and encourage snack/fluids between meals.During a concurrent observation and interview on 11/18/25 at 9:15 a.m., with Resident 1, Resident 1 was observed in bed, his water pitcher was on the dresser to the left of Resident 1's side of the bed and the straw was still wrapped in the paper wrapping. Resident 1 stated he could not reach his water pitcher.During a concurrent observation and interview on 11/18/25 at 1:55 p.m., with Licensed Nurse (LN) 1, LN 1 verified Resident 1's water pitcher was observed on the dresser and out of Resident 1. LN 1 stated that he was on diuretic medications (drugs that help the kidneys remove extra salt and water from the body via urine output) and that Resident 1 was at risk for dehydration.During an interview on 11/18/25 at 2:45 p.m. with the Assistant Director of Nursing (ADON), the ADON stated it was her expectation for Resident 1 to have water within reach. ADON further stated all residents should have had water within reach as long as they do not have any fluid restrictions (when too much water would cause harm to the resident due to their diagnosis) or contraindications (a physician's order for no fluid because of upcoming medical procedure).During a review of the facility's policy and procedure (P&P) titled, Hydration the P&P indicated, . the facility offers each resident sufficient fluid, including water and other liquids.to maintain proper hydration and health.ensure beverages are available and within reach.

Based on observation, interview, and record review failed to implement a comprehensive care plan (a guide that healthcare workers used to ensure residents receive tailored care to meet individual needs and goals) for one of four sampled residents (Resident 1) when Resident 1 did not have water available within reach.This failure placed Resident 1 at risk for dehydration (a condition where your body loses more fluids than it takes in, meaning it doesn't have enough water to perform its normal functions).Findings:During a review of Resident 1's clinical record titled, admission RECORD, the record indicated Resident 1 was admitted to the facility with a diagnosis of dehydration, acute kidney failure (when the kidneys suddenly stop working well and can't clean waste from your blood, balance fluids, or regulate electrolytes), and essential hypertension (high blood pressure- which can damage kidneys). A record review of Resident 1's clinical record titled, Minimum Data Set (MDS, an assessment tool used to generate a plan of care) . Section GG - functional status, dated 11/5/25, indicated there was impairment on one side of the upper extremity (shoulder, elbow, wrist, hand).A review of Resident 1's clinical record titled, Order Summary Report, dated 11/18/25, the order summary indicated, .Triamterene & Hydrochlorothiazide [a combination of two diuretic medications to assist the body of eliminating excess salt and potassium from the body, and increase urine flow, which reduces blood pressure] .1 tablet by mouth one time a day.A review of Resident 1's dehydration care plan (a guide that healthcare workers used to ensure Resident 1 received tailored care to meet individual needs and goals), the care plan indicated, .offer and encourage snack/fluids between meals.During a concurrent observation and interview on 11/18/25 at 9:15 a.m., with Resident 1, Resident 1 was observed in bed, and his water pitcher was on the dresser to the left of Resident 1's side of the bed and the straw was still wrapped in the paper wrapping. Resident 1 stated he could not reach his water pitcher.During a concurrent observation and interview on 11/18/25 at 1:55 p.m., with Licensed Nurse (LN) 1, LN 1 verified Resident 1's water pitcher was on the dresser out of Resident 1's reach. LN 1 stated that he was on diuretic medications (drugs that help kidneys remove extra salt and water from the body via urine output) and he was at risk for dehydration.During an interview on 11/18/25 at 2:45 p.m., with the Assistant Director of Nursing (ADON), the ADON stated it was her expectation for Resident 1 to have the water within reach. ADON further stated all of the residents should have water within reach as long as they do not have any fluid restrictions (when too much water would cause harm to the resident due to their diagnosis) or any contraindications (a physician's order for no fluid because of upcoming medical procedure).During a review of the facility's policy and procedure (P&P) titled, Hydration the P&P indicated, . the facility offers each resident sufficient fluid, including water and other liquids.to maintain proper hydration and health.ensure beverages are available and within reach.

Based on observation, interview, and record review, the facility failed to maintain a safe and supervised environment to prevent accidents and hazards for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when: 1a. Resident 1 was moved, prior to being assessed, following Resident 1's fall on 3/16/25; b. Resident 1's physician was not notified of Resident 1's blurred vision, on 3/17/25, following a fall on 3/16/25, resulting in a 5-day delay in treatment; 2. Resident 2's clinical documentation was incomplete for a fall on 3/23/25; 3a. Resident 3's clinical documentation was incomplete for a fall on 3/31/25; and, b. Resident 3's care plan interventions to prevent falls were not followed on 5/1/25. These failures resulted in delayed treatment for Resident 1, the potential for Resident 1 to experience further injuries following Resident 1's fall, and had the potential for Resident 1, Resident 2, and Resident 3 to experience falls, negatively affecting their health and well-being. Findings: 1a. During an interview with licensed nurse (LN) 2, on 5/2/25, at 2:20 p.m., LN 2 stated he had observed Resident 1's fall. LN 2 explained Resident 1 was walking when she slipped and then fell on the roommate's floor mat. LN 2 further explained Resident 1 bumped her head on the side rail. LN 2 stated a certified nursing assistant (CNA) assisted him to get Resident 1 in her bed and then LN 2 assessed Resident 1. LN 2 explained he should not have moved Resident 1 before she was assessed because if Resident 1 was injured, the move could have made the injury worse. LN 2 further explained it was kind of the shock in the moment and that is why he moved Resident 1 prior to her being assessed. During an interview with CNA 3, on 5/6/25, at 8:38 a.m., CNA 3 stated LN 2 called her to assist him with getting Resident 1 back to bed. CNA 3 explained they lifted Resident 1 up and got her back to bed. CNA 3 further explained after getting Resident 1 back to bed, LN 2 assessed Resident 1 for any injuries. During an interview with the Director of Nursing (DON), on 5/6/25, at 1:08 p.m., the DON stated the process for post fall assessments were to assess for any injuries, conduct neurochecks (alert and oriented status, headache), and vital signs (blood pressure, heart rate and respiratory rate per minute, pain assessment, temperature, and oxygen saturation percentage). The DON explained licensed nurses were supposed to check for injuries before they moved Resident 1. The DON further explained the importance of the assessment was to ensure there was not an injury before Resident 1 was moved. A review of the facility policy titled, Fall Prevention and Response, dated 8/2023, indicated, . When any resident experiences a fall, the Licensed Nurse should . Evaluate for signs of physical injury or trauma prior to moving the Resident . b. A review of Resident 1's clinical record titled, ADMISSION RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included multiple rib fractures on Resident 1's left side of her ribcage. A review of Resident 1s clinical record titled, SBAR [SBAR - Situation, Background, Assessment, and Recommendation - a communication tool used in healthcare], dated 3/16/25, at 10:29 AM, indicated, . Resident [1] was attempting to walk to the bathroom when she was seen slipping and falling onto roommate's fall mat. Resident [1] was witnessed hitting her head on roommates bed rail . A review of Resident 1's clinical record titled, Progress Notes, dated 3/17/25 at 3:10 p.m., indicated, . [Resident 1] c/o [complained of] headache . around 10:00 AM [Resident 3] assessed by physiotherapist and c/o head pain and double vision to him . A review of Resident 1's clinical record titled, Progress Notes, dated 3/21/25, at 1:07 p.m., indicated, . [Resident 1] has been refusing OT [occupational therapy] d/t [due to] headache and double vision . A review of Resident 1's clinical record titled, Progress Notes, dated 3/21/25, at 2:07 p.m,, indicated, . Writer was informed [Resident 1] was refusing OT due to headache and blurred vision . writer notified MD . sent to ED [emergency department] . During an interview with the physician (MD) 1, on 5/6/25, at 3:10 p.m., MD 1 stated he had not been informed that Resident 1 had experienced double vision on 3/17/25 and stated the facility staff should have called and informed him. MD 1 further explained it was important to ensure Resident 1 did not have a head injury. MD 1 further explained if he had been informed Resident 1 was having double vision, the day after her fall on 3/16/25, he would have had Resident 1 transferred to the hospital emergency room . During a concurrent interview and record review of Resident 1's clinical record titled, Progress Notes, dated 3/17/25, with the Assistant Director of Nursing (ADON), on 5/15/25 at 3:56 p.m., the ADON stated MD 1 should have been notified of Resident 1's double vision. The ADON explained MD 1 should have been notified to ensure Resident 1 received appropriate treatment following a fall. A review of Resident 1's clinical document from an outside acute care hospital, titled, CT [catscan - a medical imaging technique that uses X-rays to create detailed cross-sectional images of the body] Cervical Spine [upper part of the spinal column, also known as the neck] WO [without] Contrast [a substance, like a dye, that is injected into the body or taken orally to help make certain structures or organs more visible on the images], dated 3/21/25, indicated, . T1 [thoracic vertebra - spinal column bone right before the neck spinal bones start] . compression fracture [bone in spine collapses or flattens] . acute [a condition that is sudden in onset] . A review of the facility policy titled, Fall Prevention and Response, dated 8/2023, indicated, . When any Resident experiences a fall, the Licensed Nurse should . Monitor Resident's condition for at least 72 hours for any post-fall complications . A review of the facility policy titled, Change of Condition, dated 2016, indicated, . Purpose . appropriately assess, document and communicate changes of condition . to the primary care provider in accordance with the resident needs . Document assessment findings and communications as soon as practical . Notify the physician of assessment findings . 2. A review of Resident 2's clinical record titled, ADMISSION RECORD, indicated Resident 2 was admitted to the facility with diagnoses which included muscle weakness. A review of Resident 2's clinical record titled, SBAR (Situation Background Assessment Recommendation - a communication tool used in healthcare), dated 3/23/25, indicated the assessment for night shift, on 3/25/25, was not completed. During a concurrent interview and record review on 5/1/25, at 3:05 p.m., Resident 2's clinical record titled SBAR, dated 3/23/25, was reviewed with the Director of Nursing (DON). The DON confirmed Resident 2's post fall assessment for night shift, on 3/25/25, was not completed. The DON explained the purpose of the post fall assessments were to ensure there were no hidden injuries and to implement post fall interventions. 3a. A review of Resident 3's clinical record titled, ADMISSION RECORD, the record indicated Resident 3 was admitted to the facility with a diagnoses that included hemiplegia and hemiparesis (a medical condition that causes paralysis or weakness on one side of the body). A review of Resident 3's clinical document titled, Neurocheck [monitoring for any signs of deterioration or developing problems]-Q [every] 15 X4 [every 15 minutes for the first hour], Q30 X4 [every 30 minutes for the next two hours], Q60 X2 [every 60 minutes for the next two hours], dated 3/31/23, indicated, of the 10 neurochecks that were supposed to have been completed, 8 neurochecks used vital signs taken, on 3/31/25, at 7:38 AM, prior to Resident 3's fall at 8:15 AM. b. During a concurrent observation and interview with Resident 3, on 5/1/25, at 2:04 p.m., Resident 3 was in his wheelchair, outside of his room, dressed and wearing regular socks. Resident 3 stated he has had fallen three times in the facility. During a concurrent observation and interview with certified nursing assistant (CNA) 1, outside of Resident 3 room with Resident 3 present, on 5/1/25, at 2:06 p.m., CNA 1 confirmed Resident 1 was wearing regular socks. CNA 1 explained Resident 3 should have been wearing nonskid socks. CNA 1 further explained, by Resident 3 not wearing the appropriate nonskid socks, Resident 3 could have had another fall with injury. During a concurrent observation and interview with licensed nurse (LN) 1, outside of Resident 3 room with Resident 3 present in his wheelchair, on 5/1/25, at 2:08 p.m., LN 1 stated when Resident 3 was up in his wheelchair he was supposed to be wearing nonskid footwear. LN 1 explained Resident 3 was supposed to wear nonskid footwear to prevent Resident 3 from falling. LN 1 stated Resident 3 was at risk of injury if he had fallen. A review of Resident 3's clinical document titled, Care Plan Report, (contains Focus, Goals and Interventions for care) dated 3/5/25, indicated, . Focus . At risk for falls and injuries r/t [related to] Medications . Goal . Decrease risk of fall and/or minimize injuries from falls x 90 days . Provide/Reinforce use of non-skid foot wear . During a concurrent interview and record review of Resident 3's clinical record, on 5/1/25, at 3:18 p.m., with the Director of Nursing (DON), the DON confirmed post fall documentation and assessments were incomplete after Resident 1's fall, A review of the facility policy titled, Fall Prevention and Response, revised 8/2023, indicated, . Each Resident will be assessed for fall risk factors and will receive care and services in accordance with individualized level of risk to minimize the likelihood of falls . When any Resident experiences a fall, the Licensed Nurse should . Evaluate for signs of physical injury or trauma prior to moving the Resident . Assist Resident to a safe and comfortable position . Obtain vital signs and conduct a physical assessment . Implement neurological checks for known, reasonably suspected, or verbalized head injury . Notify Physician and Responsible Party . Review Resident's care plan and update (as indicated) to address any immediate safety needs .

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1)'s, management and administration of pain relieving medication, (including a narcotic [a drug that could have induced sleep, stupor, or a state of insensitivity to pain]), was done according to professional standards of practice and the narcotic pain medication did not have pain level parameters in place (pain level parameter are assessed using the numeric pain assessment tool: 0=no pain and 10=the worst pain) associated with the narcotic medication order. These failures resulted in Resident 1 not receiving the appropriate type of pain medication for the assessed pain level. Findings: A review of Resident 1's clinical document titled, ADMISSION RECORD, indicated Resident 1 was admitted to the facility with multiple rib fractures on the left side of his ribcage. A review of Resident 1's clinical document titled, Care Plan Report, (contained focus, goals and interventions that addressed Resident 1's pain) dated 3/7/25, indicated, Focus . The resident has acute pain r/t [related to] rib fracture . Goal . verbalize adequate relief of pain . Interventions . Administer analgesia [pain medication] as per orders . A review of Resident 1's clinical document titled, Medication Administration Record, (MAR - contained physician orders) dated 3/1/25 through 3/31/25, indicated the following pain medications were administered for Resident 1, as follows, Acetaminophen (pain medication) . 2 tablets . every 6 hours as needed for mild pain (1-3 on the numeric pain assessment tool) . was administered as follows: 3/9/25 at 5:01 a.m. for a pain level of 4; 3/19/25 at 1:54 p.m. for a pain level of 5; 3/23/25 at 8:25 a.m. for a pain level of 4; and, 3/31/25 at 6:52 p.m. for a pain level of 4. HYDROcodone-Acetaminophen (narcotic) . 1 tablet by mouth every 6 hours as needed for pain . was administered as follows: 3/10/25 at 7:25 a.m. for a pain level of 3; 3/11/25 at 9:29 a.m. for a pain level of 3; 3/12/25 at 9:42 a.m. for a pain level of 3; 3/25/25 at 8:45 a.m. for a pain level of 3; 3/27/25 at 4:44 p.m. for a pain level of 3; 3/28/25 at 7:55 p.m. for a pain level of 3; and, 3/29/25 at 8:18 p.m. for a pain level of 3. During a concurrent interview and record review of Resident 1's clinical record, with the Director of Nursing (DON), on 5/6/25, at 1:38 p.m., the DON confirmed the above medications and pain levels for Resident 1. The DON explained it was important to have administered the least amount of medication possible (for the assessed pain level) and assessed if the medication was effective. The DON further explained that when pain medications were given outside of ordered parameters, she would expect to see a progress note that indicated the rationale. The DON verified there were no progress notes that indicated the rationale for the administration of the pain medication (Acetaminophen) outside of the pain level parameters ordered by the physician. The DON further explained the hydrocodone could have caused neurological symptoms (dizziness, confusion, disorientation), and it could have increased Resident 1's risk for falls. The DON explained it was important to have adequate pain control, and Resident 1 should have been educated on sufficient pain control interventions for pain levels above 3. During an interview with physician (MD) 1, on 5/6/25, at 3:10 p.m., MD 1 stated he typically placed parameters (pain level 1-10 using the numeric pain assessment tool) in the order set for pain medication. MD 1 stated the facility should have contacted him for parameters for the hydrocodone order. MD 1 further stated he would have used hydrocodone for moderate pain (4-6 on the numeric pain assessment tool). MD 1 further explained Resident 1 had significant dementia (a group of thinking and social symptoms that could interfere with daily functioning) and MD intended to use the hydrocodone sparingly. A review of the facility policy titled, . PAIN MANAGEMENT PROCESS, dated 6/2009, indicated, . It is the responsibility of the licensed nurse to consistently assess, manage, and monitor pain for all residents . The objective of the pain management process is to identify resident needs and determine potential referrals/interventions to affect positive functional change through pain reduction, modification of perception of pain, and enhancement of the quality of life . Documenting pain assessment effectiveness of both routine and prn [as needed] pain medication in the nurses progress notes and/or MAR every shift using scale of 0 - 10 .

Based on interview and record review, the facility failed to notify Resident 1's Responsible Party (RP - responsible for making medical and healthcare decisions) when Resident 1 fell on [DATE]. This failure had the potential for Resident 1's necessary and/or preferred medical decisions to be delayed, which could have negatively affected Resident 1's health and well-being. Findings: A review of Resident 1's clinical document titled, ADMISSION RECORD (a document that contained Resident 1's demographic information), indicated Resident 1 was admitted to the facility with a diagnoses which included multiple rib fractures on Resident 1's left side of the ribcage. A review of Resident 1's clinical document titled, SBAR [SBAR - Situation, Background, Assessment, and Recommendation - A structured communication tool to relay critical information] Fall Report of Incident . , dated 3/16/25, indicated, . Responsible Party Notified . Self RP . During an interview with licensed nurse (LN) 2, on 5/2/25, at 2:20 p.m., LN 2 confirmed he documented Resident 1 was her own RP, and did notify Resident 1's RP. During a concurrent interview and record review of Resident 1's clinical record, with the Director of Nursing (DON), on 5/1/25, at 3:51 p.m., the DON stated Resident 1's clinical record titled, SBAR . dated 3/16/25, was inaccurate when it listed Resident 1 as her own RP. The DON explained that the Resident 1's RP was required to be notified in case the RP wanted to send Resident 1 to the emergency room . The DON further explained, RP notification included that the facility provided the RP with a complete and accurate accounting of Resident 1's condition. A review of the facility policy titled, Fall Prevention and Response, revised 8/2023, indicated, . Each Resident will be assessed for fall risk factors and will receive care and services in accordance with individualized level of risk to minimize the likelihood of falls . Notify Physician and Responsible Party .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1)'s Responsible Party (RP - person responsible for making healthcare and medical decisions) was informed and consented to the use of psychotropic (drugs that affect a person's mind, emotions, and behavior) medications for Resident 1 when, the facility had Resident 1 sign the informed consent for psychotropic medications instead of Resident 1's RP. This failure resulted in Resident 1 receiving the psychotropic medication quetiapine (used to manage symptoms of various mental health condition) for four days. This failure also resulted in the use of the medication escitalopram (used to treat depression) for the entirety of Resident 1's stay at the facility, without having an informed consent in place, potentially negatively affecting Resident 1's psychosocial health and physical well-being. Findings: A review of Resident 1's clinical document titled, ADMISSION RECORD (a document that contained Resident 1's demographic information), indicated Resident 1 was admitted to the facility with diagnoses which included depression. A review of Resident 1's clinical document titled, FACILITY VERIFICATION / INFORMED CONSENT FOR PSYCHOTHERAPEUTIC [psychotropic] DRUGS, dated 3/7/25, indicated, . Quetiapine . Escitalopram . Please do not sign until you have had the opportunity to speak with your physician about the potential risks and benefits of using each medication . The Informed Consent was signed by Resident 1 (who did not have the mental capacity to give consent). A review of Resident 1's clinical document titled, Medication Administration Record (MAR - contained physician's orders and dates and times of medication administration), dated 3/1/25 through 3/31/25, indicated the following psychotropic medication orders: . Escitalopram . 1 tablet by mouth at bedtime for Depression . Order Date . 03/06/2025 . and, QUEtiapine . 1 tablet by mouth for bi-polar [a mental health condition characterized by extreme mood swings, ranging from periods of elevated mood to periods of low mood] Order Date . 03/06/2025 . D/C [discontinue] 03/11/2025 . A review of Resident 1's clinical document titled, Order Details, dated 3/7/2025, indicated, . MD [physician] determines that Resident does NOT have the Mental Capacity [an individual's ability to understand, retain, and use information to make decisions, communicate those decisions, and appreciate the consequences of their actions] to make Healthcare decisions . During a concurrent interview and record review, of Resident 1's clinical record, with the Director of Nursing (DON), on 5/1/25, at 3:51 p.m., the DON verified Resident 1 signed the Informed Consent for the quetiapine and escitalopram. The DON explained Resident 1 did not have the capacity to sign the Informed Consent and Resident 1 would not have understood the risks and benefits of the medications. The DON further explained Resident 1's RP should have signed the Informed Consent. During an interview with Resident 1's RP, on 5/2/25, at 9:50 a.m., Resident 1's RP stated the facility never discussed the quetiapine medicaion or escitalopram medicaion with Resident 1's RP, and the risks and benefits of the medications were not discussed. Resident 1's RP explained the RP was never asked to sign an informed consent regarding the use of quetiapine or escitalopram. A review of the facility policy titled, Psychotropic Medication Management, dated 11/2017, indicated, . Psychotropic Medications will only be used when necessary to promote or maintain a Resident's highest practicable mental, physical, and psychosocial well-being . PURPOSE To Avoid unnecessary medications and facilitate the proper use, dose, and duration of psychotropic agents in accordance with Resident assessed need(s) and condition(s) . When psychoactive medications are prescribed, the clinical record should reflect the diagnosis and specific condition or targeted behavior being treated . Informed Consent for psychoactive medications must be verified prior to use .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect when Resident 1's request to use the bathroom was denied. This failure had the potential to negatively impact Resident 1's psychosocial well-being. Findings: A review of Resident 1's clinical document titled, ADMISSION RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included muscle weakness and multiple fractures of ribs on the left side of the ribcage. A review of Resident 1's clinical document titled, Care Plan Report, (contains goals and interventions for Resident 1), dated 3/6/25, indicated, . Toilet upon rising and before or after meals at bedtime and PRN [as needed] as tolerated . During an interview on 5/6/25, at 8:38 a.m., Certified Nursing Assistant (CNA) 3 stated following Resident 1 ' s fall, on 3/16/25, Resident 1 stated she needed to go to the bathroom. CNA 3 explained she had informed Resident 1 that she was wearing a brief (incontinence brief - disposable undergarment designed to absorb urine) and that she could go to the bathroom in the brief. During an interview on 5/6/25, at 2:40 p.m., CNA 4 stated she would never tell a resident to use their brief to go to the bathroom if they verbalized, they wanted to get up and go to the restroom and were able to do so with assistance. CNA 4 further stated it was a dignity concern. During an interview with the Director of Nursing (DON), on 5/6/25, at 1:20 p.m., the DON stated Resident 1 was on a toileting program. The DON explained it was not appropriate to tell Resident 1 to go to the bathroom in her brief when Resident 1 had requested to use the bathroom. The DON stated it was important to preserve Resident 1 ' s dignity and to prevent psychosocial harm. A review of the facility policy titled, Dignity - Promoting/Maintaining Dignity, implemented 10/22, indicated, . It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality . Staff members involved in providing care or interacting with residents must promote and maintain resident dignity and respect's Resident Rights . Respond to requests for assistance in a timely manner . Speak respectfully to residents .