Every finding on record at Arroyo Grande Care Center

Based on observation, interview, and record review, the facility failed to appropriately label and store drugs when three cartons of Med Pass 2.0 fortified nutritional shake were found to be expired in the medication room of nursing station two.This failure had the potential to result in residents possibly receiving expired and ineffective medication.During a concurrent observation and interview on [DATE] at 10:12 A.M. with licensed nurse (LN 3), while checking medications in Station 2 medication room, found three cartons of Med Pass 2.0 fortified nutritional shake, (drink to add additional dietary calories and protein Fortified with vitamins and minerals), expired. Two expired [DATE] and one expired [DATE]. LN 3 confirmed they are expired and stated, Those need to go. It's all med nurses responsibility to check them.During a review of the facility's policy and procedure titled Medication Storage dated [DATE], indicated, . N. Outdated .medications .are immediately removed from stock, disposed of according to procedures for medication disposal .

Based on observation, interview and record review, the facility failed to follow the nutritional needs of a residents in accordance with recommended guidelines diet prescription for a renal diet for one of one resident (Resident 72) when Certified Nurse Assistant (CNA) 4 added salt to the resident's meal. This failure has the potential of not meeting the nutritional goal of the resident as prescribed diet. During an observation on 7/22/25 at 7:48 am at the dining room, Resident 72 was observed for her meal intake. Certified Nurse Assistant (CNA) 4 was overheard offering Resident 72 if she wanted to have salt and pepper on her meal with the resident responding with a nod. CNA 4 opened the salt packet and sprinkled salt into resident 72's meal.During a concurrent interview and record review on 7/22/25 at 7:48 am with CNA 4, the meal ticket of Resident 72 was reviewed. The meal ticket indicated in part, Minced Meat, Renal, Nectar Thick Large Minces /LS. CNA 4 stated that she reviewed the meal ticket and is aware that it is a renal diet and states that the LS means low salt that is why she added salt and pepper to the meal.During an interview on 7/22/25 at 7:55 am with the Registered Dietician (RD) and Dietary Manager (DM), both stated that LS stands for low sugar and renal diets are not supposed to have no salt added to their meals.During a review of Policies and Procedures (P&P) titled Diets Available on Menu, the Diets Available on Menu indicated in part, 1. Diets will be offered as ordered by physician or his/her designee . The therapeutic diet orders that will be offered are g. Low Sugar (LS), 2. In an effort to individualize therapeutic orders, secondary diet orders may be offered and can be combined with the main diet order to achieve desired results: a. No salt packets/No salt on table.

Based on observation, interview, and record review, the facility failed to ensure food safety standards were followed when an expired milk, brought in by family, was found in the snack refrigerator in nursing station 2.This failure had the potential to cause food- borne illness to a vulnerable resident.During a concurrent observation and interview on 7/22/2025 at 10:35 A.M., with licensed nurse (LN 2), while checking the snack refrigerator in Station 2, found an Alta Dena reduced fat milk (brought in by family) was expired on 6/17/2025. LN 2 confirmed the milk was expired and stated, We usually check items brought in by family. We should check it daily.During a review of the facility's policy and procedure titled, Resource: Food Safety for Your Loved Ones, dated 2022, indicated in part ., Food or beverages should be labeled and dated to monitor for food safety: . Foods and beverages that have passed the manufacturer's expiration date will be discarded.

Based on interview, and record review, the facility failed to complete an accurate nursing assessment for one of two sampled residents (Resident 1). This failure resulted in the receiving facility not having sufficient information necessary to develop and implement a care plan to meet Resident 1's needs. Findings: During a review of Resident 1's Care Plan (CP) (a document that outlines a patient's health needs and the care they will receive) dated, 1/24/25, the CP indicated, Resident 1 had impaired skin integrity, erythema (skin redness) to sacrococcygeal (the area at the base of the spine) and groin. During an interview on 2/10/25 at 3:05 p.m. with Licensed Nurse (LN 4), LN 4 verbalized they did the assessment, they saw some redness on Resident 1's bottom, got busy and did not document the redness. During a review of Resident 1's Needs upon discharge assessment, dated 1/27/25, the Needs upon discharge assessment indicated, Resident 1's skin was intact. Review of [NAME] and [NAME], Tenth Edition, Fundamentals of Nursing, page 365 in the section titled, Informatics and Documentation, indicated, Documentation is a key communication strategy that produces a written account of pertinent data, clinical decisions and interventions, and patient responses in a health record. Documentation in a patient's health record is a vital aspect of nursing practice.

Based on interview and record review, the facility failed to ensure a proper system was in place to safeguard one of three sampled residents (Resident 1) personal funds when the facility's billing department deposited Resident 1's personal check for rent payment into the facility's bank account. This failure resulted in the misappropriation of Resident 1's personal funds which had the potential to cause emotional distress and anxiety to the resident. Findings: During a review of Resident 1's Face Sheet (FS), dated 8/9/23, the FS indicated in part, Resident 1 was a [AGE] year-old female, who was admitted to the facility on [DATE] with admitting diagnoses including, pneumonia (infection of the lungs) and acute kidney failure (rapid loss of kidney function). The FS also indicated, Resident 1 was discharged from the facility on 10/20/22. During a phone interview on 8/9/23 at 5:25 p.m. with Resident 1, Resident 1 verbalized, asking a facility staff to mail out a personal check as payment for a leased residential property. Resident 1 also verbalized the check was made payable to (name of Resident 1's lease property management) as payment for the month of October 2022. Resident 1 found out the lease property management did not receive the check after receiving a call from them. Resident 1 later confirmed, through her bank, that the check was processed and deposited into an account named after the facility. During an interview on 8/9/23 at 6 p.m. with the Assistant Director of Nursing (ADON), ADON verbalized that the facility's social services department handles all resident requests for mails to be sent out. During a phone interview on 8/9/2 at 6:20 p.m. with an accounts receivable/billing (ARB) staff for the facility, ARB staff recalled, Resident 1's check was endorsed to the facility's billing department and confirmed the check was made payable to Resident 1's lease property management. ARB staff also verbalized, Resident 1's rent check was mistakenly endorsed to be deposited into the facility's bank account thinking it was Resident 1's co-payment for the charges incurred while admitted in the facility. ARB staff further verbalized, that somehow the bank processed the check and the check was cleared. During a review of the facility's policy and procedures (P&P), titled, Protection/Management, Accounting and Records, Notice, and Conveyance of Personal Funds, dated 3/1/18, the P&P indicated in part, (Corporate Name) facilities have established and maintain a system that assures a full, complete, and separate accounting of funds entrusted to (corporate name) facilities on the resident's behalf. The accounting system is established according to generally accepted accounting principles.

Based on interview and record review the facility failed to notify Resident 1's physician of change of condition in a timely manner. This failure has the potential for adverse consequences and impending the resident's progress towards therapeutic goals. Findings: During a review of facility policy and procedure titled, Alert Charting Procedure undated, the policy and procedure indicated in part, When you have identified that the patient's condition requires alert charting, you must complete the following: Physician notification and any orders received . During a review of Resident 1's, Clinical Notes Report, dated 4/13/22, at 9:29 a.m., the report indicated, Resident with an appointment today .Resident left at around 930 am today .Per resident when riding the Ride on Bus, he was jolted leaning on the right side of the wheelchair .Resident stated with pain on right side of the body, administered PRN [as needed] [MEDICATION(S)] [pain medication for moderate to severe pain] . During an interview and concurrent record review of Resident 1's medical record on 10/10/22, starting at 3:05 p.m., with the director of nurses (DON), the DON acknowledged that there were no nursing notes indicating Resident 1's physician was notified of alleged injury and complaint of pain. The DON stated, Yes, I know we are supposed to notify the doctor and I don't see any (notification).

Based on observation, interview, and record review, the facility failed to ensure: 1. Expired medications were not stored and available for staff use, in two of two first aid kits, and in one of two treatment carts. These failures had the potential for unsafe and ineffective medication administration that can cause harm to the residents. 2. A licensed nurse followed the facility's policy and procedures (P&P) on medication administration. Findings: 1. During a concurrent interview, and inspection of the facility's two Disaster Kits (D-Kit), on 8/9/21 at 9:45 a.m., with Assistant Director of Nursing (ADON), items observed in a D-Kit, included, a heavy-duty extension cord, flashlight, floor plans, a typed list of area hospitals and nursing homes, a First Aid Kit (FA-Kit) with manual, and other supplies. The two FA-Kits, one in each D-Kit, had a stamped expiration date of 2/18. The labels on the FA-Kits indicated, the kits contained items such as gauze dressing pads, tweezers, scissors, adhesive bandages, tape, and other supplies. In addition, the labels also indicated, the kits contained oral and topical (to apply directly to a body part) medications. According to the manufacturer's product information included on the labels, This kit may contain dated items. Please check before use. Further inspection of the contents of the FA-Kits revealed, expired medications: a total of 12 (six in each kit) packets of First Aid/burn cream 0.9 grams (expired 6/18), a total of 12 (six in each kit) BZK (Benzalkonium Chloride - alcohol-free, non-sting wipes used to disinfect the skin) antiseptic towelettes (expired 5/18), a total of 12 (six in each kit) insect sting relief pads (expired 4/20), a total of 12 (six in each kit) packets of antibiotic ointment (expired 5/18), a total of two (one in each kit) 4 oz. (ounce) containers of [MEDICATION(S)] solution (expired 6/18), and a total of 20 (10 in each kit) two-pack Aspirin (medication used to reduce pain, fever, or inflammation) packets (expired 6/18). During an interview, on 8/9/21 at 10:18 a.m., with the Central Supply Supervisor (CSS), the CSS stated, a central supply staff conducts the weekly audit of the facility's D-Kits. The CSS further stated, I never really checked for the (first aid kit's) expiration date. During an interview, on 8/9/21, at 11:48 a.m., with the Director of Nursing (DON), the DON stated, There should be a First Aid Kit available for emergency use, at all times, in the facility. The DON also stated, they were the only available FA-Kits in the facility. During a concurrent interview, and inspection with the ADON, on 8/9/21 at 11:40 a.m., the Treatment Cart (a wheeled, storage unit carrying supplies, such as dressings, ointments, creams, bandages, etc., used for treatment procedures) was inspected at the facility's Nurse Station 2. The following expired medications were found inside the cart: two tubes of Skin Integrity Hydrogel (used to treat and prevent diaper rash, and minor skin irritations, and ideal for cleaning wounds that helps create a moist, wound environment), that expired 1/21, two tubes of [MEDICATION(S)] ointment (an antibiotic used to prevent infection in minor cuts, scrapes, and burns), that expired 6/21, and three individual packs of Colactive Plus Ag Collagen Dressing (an advanced wound dressing that facilitates natural wound healing), that expired 6/21. The ADON stated, The nurse assigned with the cart (referring to the treatment cart) for that shift is ultimately responsible in checking that supplies he/she uses are not expired. The ADON confirmed the medications found in the treatment cart were expired. During a review of the facility's policy and procedures (P&P), titled, Storage of Medications, undated, the P&P indicated, in part, Medications and biologicals are stored properly, following the manufacturer or provider pharmacist's recommendations, to maintain their integrity and to support safe, effective drug administration. The P&P indicated further, Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock. 2. Prior to the start of the facility's 9 a.m. medication pass on 8/10/21, Medication Nurse 1 (MN1) began passing 9 a.m. medications to unsampled Resident 1 at 7:39 a.m., on the morning of 08/10/2021. Interview with MN 1, MN1 stated, that she would commonly start her 9 a.m. medication pass at 8 a.m., however she would start early if a resident had asked for a PRN (as needed dose of a medication). MN1 passed the following medications to unsampled Resident 1, between 7:39 am and 7:50 am on the morning of 08/10/2021: Multivitamins, [MEDICATION(S)] (laxative) 17 grams, [MEDICATION(S)] (steroid) 40 mg (milligrams), [MEDICATION(S)] (blood pressure) 12.5 mg, [MEDICATION(S)] (blood pressure) 20 mg, [MEDICATION(S)] (antidepressant) 20 mg, [MEDICATION(S)] (bladder) 50 mg, ASA ([aspirin]blood thinner) 81 mg, Preformist (bronchodilator) 20 mcg (micrograms) /2 ml (milliliter) vial. During a concurrent interview and review of the facility's policy and procedure (P&P) titled, Nursing Care Center Pharmacy Policies and Procedures, undated, on 8/10/21 at 8 a.m., the P&P indicated: Medications are administered within 60 minutes of scheduled time . In addition, the P&P indicated, all routine 9 a.m. medications are to be administered between the hours of 8 a.m. and 10 a.m., The DON confirmed the policy's medication administration times.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety when: 1) kitchen staff did not have all their hair restrained, and 2) food items were past their best buy date in the reach-in refrigerator. This had the potential for food to be contaminated by hair and the quality of the food may change past the use by date. The census of the facility was 74. Findings: 1. During an observation on 8/09/21, at 10:57 a.m., in the kitchen, Kitchen Staff (KS) 1, was making peanut butter and jelly sandwiches with hair under hat but hair in back not restrained while making sandwiches. During an observation on 8/10/21, at 10:37 a.m., in the kitchen, KS 1 was scooping fruit cocktail with 4 ounce slotted ladle into bowls. KS 1 had a hat on head and hair in back not restrained and sides hair coming out of hat down the side of her face. During an observation on 8/10/21 at 11:53 a.m., in the kitchen, KS 2 had hair out the back of hair restraint and down her back. KS 2 was observed putting away clean equipment then putting food items on trays throughout lunch meal service. During an interview on 8/11/21, at 10:08 a.m., with the Registered Dietitian (RD), the RD stated, the expectation is that all hair should be in hair nets or restrained. The surveyor showed RD pictures of KS 1 and 2, RD confirmed the hair was clearly down her back and not in hair net regarding KS 2. RD stated KS 1 should also have a hair net for the rest of her hair with her hat. The RD acknowledged hair was not restrained. During an interview on 8/11/21 at 11:25 AM, with the RD, the RD stated the policy is vague regarding hair restraints. During a review of the facility policy and procedure (P&P) titled, Food and Nutrition Services - Dress Code Policy, undated, the P&P indicated, employees shall cover hair with appropriate hair hat and/or beard nets as appropriate. According to the 2017 Federal Food and Drug Administration (FDA) Food Code, the Code indicated, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. 2. During the initial kitchen tour and concurrent interview, on 8/9/21, starting at 9:00 a.m., with the Kitchen Manager (KM), an observation of a crate of approximately 40-50 cartons (8-ounce cartons) of Fat Free milk with a best by date of 8/8/21. The KM stated, they go by the best by date, and it should not be used. KM stated, did not realize this date was yesterday and they will put something on it, so it won't be used.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for: 1) Two of two residents (Residents 4 and 36) on the small portion minced and moist diet, and 2) Two of two residents (Residents 6 and 16) on the small portion soft and bite sized diets for the lunch meal on 8/9/21. This failure had the potential to result in not meeting the nutritional needs of the residents and further compromising their medical status. Findings: During a review of the lunch menu for day 23 (8/9/21), the menu indicated, for MM5 (minced and moist) diet: three ounces chicken baked, #8 scoop (1/2 cup or 4 ounces) MM pasta and sauce, #8 scoop MM zucchini. The lunch menu indicated, SB6 SM (small and bite sized, small portion) chicken baked - 2 ounces, SB pasta and sauce #10 scoop (2.75 ounces), #8 scoop SB zucchini. There was no menu column that indicated what the small portion, minced and moist diet should receive. During an observation on 8/9/21, at 11:57 a.m, of the lunch meal service, the following was observed, a #16 scoop (1/4 cup or 2 ounces) and a #8 scoop in the pasta and couscous, 2 ounce ladle in chicken SB and #16 scoop for MM chicken, and 4 ounces ladle in the zucchini pan. The Diet Aide called out the diet that was written on the tray tickets to the cook and the cook dished up food onto the plates. Each tray ticket indicated, the food items for the meal and the portion of the diet. The Diet aide did not call out the portion sizes for each diet, just the type of diet. Further observation on 8/9/21, at 11:57 a.m., of the lunch meal service, Kitchen Staff (KS) 3 was observed using a small 2 ounce meat and #16 starch scoop for all small diets. KS 3 served 1. Residents 36 and Resident 4, #16 scoop MM5 pasta and 2 ounces for chicken; and 2. Residents 6 and 16, #16 scoop for SB pasta and 2 ounces for SB chicken. Review of Residents 4, 36, 6, and 16 tray tickets, indicated, both MM5 and SB6 small portions were to receive #10 scoop of pasta and 2 ounces chicken. During an interview on 8/09/21 at 12:31 p.m., after the lunch meal service was completed, with KS 3, KS 3 confirmed 2 ounces of chicken meat for small portions and #16 scoop (1/4 cup) for starch either pasta or couscous. During an interview on 8/11/21, at 9:30 a.m., with the Registered Dietitian (RD), the RD stated, they have been working with the company that puts out the menu and tray card system since they have implemented the International Dysphagia Diet Standardisation Initiative (IDDSI) diets (MM and SB diets) as it has been a work in progress. During an interview on 8/11/21 at 10:08 a.m., with the RD, the RD stated, the expectation is to follow menus and she acknowledged they have some issues with small portions and will need to work on it. During an interview on 8/11/21 at 12:25 p.m., with the RD, the RD state, that maybe they need to look at the system more closely to see if they are able to have the same scoops across the board for all types of small portion diets to make it easier on the cooks. The RD stated, KS 3 had been on vacation and came back to work early due to another cook was sick and she hadn't had a chance to work with her much since her being FT at the facility. The RD stated, there may be an opportunity to review the menu with her. During a review of the facility In-Service dated, 1/21/21, to teach and reinforce personnel the importance of following the menu spreadsheets, the sign-in sheet indicated, KS 3 was present. The In-service indicated the method of evaluation was a paper test. The facility did not provide KS 3's evaluation test from the In-Service. During a review of the facility In-Service dated 3/31/21 with course content to Identify IDDSI diet labels, definition of characteristic of food, physiological rationale, the in-service indicated, the method of evaluation was questions and answers. Review of the content for the In-Service did not indicate the staff was trained on the small portions however, they did receive training on MM and SB diets. Review of the sign in sheet indicated, KS 3 was not in attendance. During an interview on 8/12/21 at 2:33 p.m., with the DON , the DON stated, the facility could not locate a job competency for KS 3.

Based on Observation, interview, and record review, the facility failed to use appropriate alternatives prior to installing bed rails (adjustable metal or rigid plastic bars that attach to the bed) for five of 5 sampled residents (Resident 35, 41, 54, 61, and 62). This facility failure had the potential to result in an increased risk for entrapment (strangulation, suffocation, bodily injury or death when a resident or part of their body is caught between the bed rail and mattress) or falls. Findings: During a review of the facility's policy and procedure (P&P) titled, Bedrails/Siderails, dated 3/1/18, the P&P referenced the regulation, F700, and indicated, Alternative interventions should always be considered prior to use of Side Rails or in combination with Side Rail use. According to Fundamentals of Nursing (Potter et al.; Elsevier: 2017, p. 392), . many deaths and injuries related to entrapment and falls for both adult portable bedrail products and hospital bed rails have been reported . The FDA [U.S. Food and Drug Administration] recommends that all bedrails be used with caution, especially with older adults and people with altered cognition, physical limitations, and certain medical conditions. During an observation on 08/9/21, at 10:17 a.m., in Resident 54's room, Resident 54's bed upper rails were observed raised on each side of the bed. During an observation on 08/9/21, at 3:42 p.m., in Resident 41's room, Resident 41's bed upper rails were observed raised on each side of the bed. During an observation on 8/10/21, at 10:28 a.m., in Resident 35's room, Resident 35's bed upper rails were observed raised on each side of the bed. During an observation on 8/10/21, at 10:45 a.m., in Resident 62's room, Resident 62's bed upper rails were observed raised on each side of the bed. During an observation on 8/10/21, at 11:20 a.m., in Resident 61's room, Resident 61's bed upper rails were observed raised on each side of the bed. During a concurrent interview and record review on 8/12/21, starting at 9:11 a.m., with a director of nursing (DON), the DON reviewed the electronic health records (eHR) of Residents 35, 41, 54, 61, and 62 and stated there was no documentation of alternatives that were attempted prior to the use of the bed rails. During a review of Resident 35's electronic health records (eHR), the: 1) Face Sheet (FS) a document that gives a resident's pertinent information at a quick glance), indicated, Resident 35 was admitted on [DATE] at 4:30 p.m., age 94, admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Compass Health Verification Of Informed Consent for Use of Side Rails (Consent), dated 6/18/21, at 3:21 p.m., indicated Resident 35 or their representative consented to using bedrails. 3) Side-Rail Use Evaluation Form (Eval), dated 06/18/21, at 3:24 p.m., indicated, on 6/21/21 the interdisciplinary team (IDT) a team of different healthcare disciplines working together to plan a resident's care) recommended alternative interventions of low bed, call light within reach, and answering call light promptly. During a review of Resident 41's eHR, the: 1) FS, indicated, Resident 41 was admitted on [DATE] at 12:36 p.m., age 84, admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Consent, dated 06/13/21, at 11:02 a.m., indicated Resident 41 or their representative consented to using bedrails. 3) Eval, dated 6/13/21, at 11:06 a.m., indicated, on 6/14/21 and 6/16/21 the IDT recommended alternative interventions of low bed, call light within reach, and answering call lights/alarms promptly. During a review of Resident 54's eHR, the: 1) FS, indicated, Resident 54 was admitted on [DATE] at 1:50 p.m., age 88, admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Consent, dated 7/9/21, at 1:02 p.m., indicated Resident 54 or their representative consented to using bedrails. 3) Eval, dated 7/9/21, at 1:32 p.m., indicated, on 7/9/21, 7/11/21, and 7/12/21 the IDT recommended alternative interventions of low bed, bed alarm, call light within reach, answering call light/alarms promptly, and pad alarm in wheelchair. During a review of Resident 61's eHR, the: 1) FS, indicated, Resident 61 was admitted on [DATE] at 1:45 p.m., age 84, admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Consent, dated 7/15/21, at 1:40 p.m., indicated Resident 61 or their representative consented to using bedrails. 3) Eval, dated 7/15/21 and 7/16/21, at 8:49 a.m., indicated, on 7/15/21 and 7/16/21 the IDT recommended no alternative interventions. During a review of Resident 62's eHR, the: 1) FS, indicated, Resident 62 was admitted on [DATE] at 2:30 p.m., age 70, admitting diagnosies included, [CONDITION(S)] (a disease that affects the function or structure of the brain) and muscle weakness. 2) Consent, dated 7/16/21, at 12:40 p.m., indicated Resident 62 or their representative consented to using bedrails. 3) Eval, dated 7/16/21, at 12:51 p.m., indicated, on 7/19/21 the IDT recommended no alternative interventions.

The facility failed to ensure that one resident was free from unnecessary drugs. Resident #15 Unnecessary Meds, [CONDITION(S)] Meds, and Med Regimen Review Based on resident interview, clinical record review, and review of the drug manufacturer's specifications, the facility failed to ensure that, each resident's drug regimen was free from unnecessary drugs, including medications used for an excessive duration. This medication used in this manner, could have prevented this resident from reaching her highest functional capacity. Findings: Review of the clinical record for sampled Resident 15 on 8/12/2021 at 10:15 am with the Director of Nurses (DON), confirmed that this resident had been taking [MEDICATION(S)] (Ambien) a sleeping medication 5 mg as needed during her hour of sleep. This medication was ordered by the resident's physician on 6/11/2021 (one day after the resident's admission to the facility). Interview with Resident 15 on 8/12/2021 at 9:20 am Resident 15 stated that she was unable to sleep at night because of the light in her eyes from the hallway and the room light above her bed. The Resident's inability to sleep because of the light in her eyes had not been care planned or documented into the resident's care plan or medical record. Resident 15 also indicated that she did not request for her sleeping pill at night, but she indicated that nursing staff were bringing this medication to her even though she had not requested this sleeping medication. This resident received the first dose of [MEDICATION(S)] 5mg on the evening of 6/12/2021 and she only received 6 more doses for the remainder of 6/2021. For the month of 7/2021, Resident 15 received this sleeping medication 29 times during the month of 7/2021, and between 8/1/2021 and 8/11/2021 this resident received this medication 9 times. Review of the drug manufacturer's (Sanofi-Aventis) package insert reads: Because sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, symptomatic treatment of [CONDITION(S)] should be initiated only after a careful evaluation of the patient. The failure of [CONDITION(S)] to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated. Worsening of [CONDITION(S)] or the emergence of new thinking or behavior abnormalities may be the consequence of an unrecognized psychiatric or physical disorder. Such findings have emerged during treatment with sedative/hypnotic drugs, including [MEDICATION(S)]. Interview with the DON on 8/12/2021 at 10:15 am confirmed that neither a physician nor a psychiatrist had evaluated this resident for a psychiatric or medical illness related to this resident's [CONDITION(S)] to resolve within the 7-10 days for which this resident received treatment. This resident's medication use, clearly exceeded the manufacturer's 7-10 days of treatment, leading to an excessive duration for the use of this medication for Resident 15. Interview with the DON on 08/12/2021 at 10:15 am revealed that the DON was unaware at the time of our discussion that Resident 15 had any trouble sleeping.

Based on observation and interview, the facility failed to: 1. Maintain the flooring in one of three shower rooms (shower room between room [ROOM NUMBER] and MDS office) in a homelike manner. This facility failure had the potential to negatively impact residents quality of life, the potential to spread infection, and allowed residents to shower or bathe in an unmaintained environment. 2. Provide an emergency pull cord in two of three separate shower rooms. This facility failure had the potential for residents to be unable to call for help in the event of an emergency in the shower. Findings: 1. During an observation and concurrent interview with the Maintenance Supervisor (MN1), on 10/09/19, at 05:10 p.m., in the shower room (between room [ROOM NUMBER] and MDS office), flooring had multiple areas of splitting and peeling in both stalls. MN1 stated, the splitting and peeling was due to an epoxy floor that wasn't sanded before the new floor was laid over it. 2. During an observation and concurrent interview with the Administrator (ADM), on 10/10/19, at 10:30 a.m., the first stall in the shower room across from the main dining room, and the second stall in the shower room across from room [ROOM NUMBER] both had a fixture with written directions stating, Pull Cord For Help, and no pull cord was available. The ADM acknowledged that the pull cords were missing.

Based on observation, interview, and record review, the facility failed to ensure two sampled residents (Resident 43 and Resident 70), received oxygen (a gas used to treat people with breathing problems) as ordered by their medical doctor (MD). These facility failures had the potential for Resident 43, and Resident 70 to suffer complications (i.e. shortness of breath, chest pain, restlessness, and unconsciousness) of incorrect oxygen (O2) administration. Findings: According to Potter and Perry's, 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice, Nurses are obligated to follow physician order unless they believe they orders are in error or would harm clients. 1. During an observation, and concurrent interview with a licensed nurse (LN1), on 10/7/19, at 2:23 p.m., in Resident 43 room the oxygen tank connected to Resident 43 was empty. The LN 1 confirmed Resident 43's O2 tank was empty and should have been administering O2 at 2 liters/min via NC as indicated in the MD order. During a review of Resident 43's clinical record, and concurrent interview with the assistant director of nursing (ADON), on 10/10/19, at 10:40 am, the clinical record indicated Resident 43's [DIAGNOSES REDACTED]. The ADON confirmed Resident 43's current MD order dated 8/29/18 indicated, O2 at 2 liters/min via NC (Nasal Cannula is a device use to deliver supplemental oxygen). The ADON further acknowledged that the MD order was not followed when O2 tank was found to be empty. 2. During an observation in Resident 70's room, and concurrent interview with the licensed nurse (LN 2), on 10/07/19, at 12:00 p.m., the O2 concentrator (a device that concentrates the oxygen), was set at a flow of 2.5 liters (L). The LN 2 confirmed the flow was set at 2.5 L with a head nod up and down. During a review of the clinical record for Resident 70, the, (MONTH) 2019 Physician Order Sheet indicated the physician order of, O2 at 2L/m via nasal cannula - no humidification, two times daily starting 9/24/19, shift 1 and shift 2. During a review of the facility policy titled, Oxygen Procedure undated, indicated in part . Patients that require oxygen as ordered by a physician will be placed on an oxygen concentrator or oxygen tank. The oxygen therapy will be administered as ordered.

Based on record review and interview, the facility failed to provide justification for one of five sampled residents(Resident 51), with dementia (memory disorder) receiving a routine antipsychotic medication (a class of medication used to manage [MEDICAL CONDITION] in [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder). This facility failure has the potential for adverse medication side effects including falls, drowsiness, low blood pressure, and ultimately death. Findings: According to Daily Med, Elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION NAME] is not approved for the treatment of [REDACTED]. During a review of the clinical record for Resident 51, the Face Sheet, dated 10/9/19, included a [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 51, the physician's orders [REDACTED]. During a review of the clinical record for Resident 51, and concurrent interview with the Director of Nursing (DON), on 10/9/19, at 2:57 p.m., there was no evidence that the pharmacist had made notification to the MD that Resident 51 had a primary [DIAGNOSES REDACTED]. The DON stated, There is no documentation of this notification. The DON also verified that a gradual dose reduction had not been attempted since Resident 51 was started on [MEDICATION NAME] in (MONTH) 2019. During an interview, on 10/10/19, at 11:21 a.m., the DON indicated the MD came in to the facility yesterday (10/09/19), and wrote a note stating that the resident (Resident 51) should stay on the [MEDICATION NAME]. The DON verified Resident 51 had been on [MEDICATION NAME] since (MONTH) of 2019, and the first time the benefits, versus the risks of [MEDICATION NAME] for Resident 51 was addressed by the MD was yesterday (10/09/19). During a telephone interview, on 10/10/19, at 11:45 a.m., the attending physician (MD1) stated Resident 51 benefits from the [MEDICATION NAME], and should stay on this medication. The MD1 acknowledged the risks, versus the benefits were documented yesterday (10/09/19), but had not been documented since Resident 51 began on this medication in (MONTH) of 2019, and no gradual dose reductions(GDR) had been attempted.

Based on observation, interview, and record review, the facility failed to: 1. Ensure used utensil handles did not touch food. 2. Discard expired foods. 3. Ensure clean pots were not stored above dirty dish sink area. These facility failures had the potential to result in residents developing a foodborne illness. Findings: 1. During an observation of the kitchen, and concurrent interview with Kitchen Manager (KM), on [DATE], at 12:17 pm, used utensil handles slid into the food container with green beans on steam table. The KM and Registered Dietician (RD) acknowledged used utensil handles should not touch food. Review of the Food Code (YEAR), section ,[DATE].11, indicated in part, Food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to such contamination. The handles of utensils, even if manipulated with gloved hands, are particularly susceptible to contamination. Review of the facility policy titled, Handling Clean Equipment and Utensils, dated 2014, indicated in part, .When handling cleaned and sanitized equipment and utensils, staff will avoid touching the parts that will come in contact with the food. 2. During an observation of the dry storage area, and concurrent interview with RD and KM, on [DATE], at 8:12 am, a bin of oranges dated [DATE], were expired, a bin of pears was not dated. The KM stated, They look like they need to be thrown out. The RD and the KM confirmed oranges and pears were expired. Review of the facility policy titled, Dry Storage Areas, dated 2014, indicated in part, .Foods with expiration dates are used prior to the date on the package. Review of the facility Kitchen Reference Book, undated, indicated in part, .Oranges are good for 3 to 4 days at room temperature. 3. During an observation in the kitchen, and concurrent interview with RD, on [DATE], at 7:56 am, three clean pots were hanging above the dirty dish sink where dirty dish water could spray on clean pots. The RD confirmed dirty dish water could spray on clean pots. Review of the facility policy titled, Handling Clean Equipment and Utensils, dated 2014, indicated in part, .Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from splashes, dust, or other contamination.

Based on observation, interview and record review, the facility failed to implement fall precaution interventions as ordered by the physician for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1 to have a recurrent fall, and further injury. Findings: During a review of the clinical record for Resident 1, the nurses notes dated 2/8/19 at 4:25 a.m., indicated resident was found sitting on the floor near her bed, with an injury to her left wrist. A physician's orders [REDACTED]. The Resident Care Summary (a document used to provide direct care staff information on care planned interventions) indicated resident is a fall risk, and precautions were to include a pressure pad alarm in chair. The Interdisciplinary Team Conference /Care Plan review form dated 2/8/19 indicated, IDT reviewed the plan of care, and agrees with addition of a bed alarm along with a scoop mattress, and wheelchair alarm. During an observation on 2/27/19, at 3:12 p.m., Resident 1 was seated in a wheelchair in the dining room without a pad alarm in place. During an interview with the director of nurses (DON), on 2/27/19 at 3:12 p.m., the DON confirmed there was no pad alarm in place for Resident 1.

Based on obseravtion, interview, and record review the facility failed to ensure all drugs were stored appropriately when 7 packs of expired [MEDICATION NAME] (medication for nausea/vomiting) for 5 Residents (Residents 39, 45, 22, 88, 3) were found in the medication cart (Medication Cart A). This facility failure had the potential for unsafe medication administration due to decreased potency and efficacy of medications. Findings: During an observation and concurrent interview on [DATE], at 10:15 a.m., at nurses station one, licensed nurse (LN 1) acknowledged that medication cart A had: 1. 1 pack of [MEDICATION NAME] 4 mg (milligram) tablets that expired on [DATE] for Resident 39. 2. 1 pack of [MEDICATION NAME] 8 mg tablets that expired on [DATE] for Resident 45. 3. 1 pack of [MEDICATION NAME] 4 mg tablets that expired on [DATE] for Resident 22. 4. 2 packs of [MEDICATION NAME] 4 mg tablets that expired on [DATE] and 1 pack of [MEDICATION NAME] 4mg tablets that expired on [DATE] for Resident 88. 5. 1 pack of [MEDICATION NAME] 4 mg tablets that expired on [DATE] for Resident 3. The facility policy and procedure titled Storage of Medication undated, indicated in part .medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration .outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock.

Based on observation and interview, the facility failed to ensure six of six residents (Residents 00, 17, 38, 77, 82, and 87) were not served with overcooked food, mushy in appearance, and out of temperature range. These failures had the potential for residents losing their appetite to eat and skipping meals. Findings: During a lunch dining observation and concurrent interview with three residents (Resident 00, 17, and 82) on 10/02/18, at 12:48 PM, the steam mixed yellow and green zucchini was observed overcooked with a mushy appearance. Resident 00 stated The vegetables are always overcooked. Resident 17 stated The food is always salty. The vegetables are always mushy. Resident 82 stated Food presentation not good at all. The vegetables are always mushy they are overcooked. The vegetables should be crunchy. I don't expect gourmet food. But the food needs to be eatable at least. During an interview with Resident 77 on 10/02/18, at 03:50 PM, Resident 77 explained the soups are always too salty. It gets better for one day but then it's back to being salty. Its salty most of the time. The food does not look good. The vegetables are so overcooked the resident does not know what they are. During an interview with Resident 38 on 10/03/18, at 09:45 AM, the resident stated The food is bad .The vegetables are overcooked .I like my vegetables not being mushy, they don't appear good and appetizing. Further, Resident 38 stated I have lost my appetite for a lot of foods I used to eat. They (food) just doesn't look good. During a test tray process and concurrent interview with Resident 87, while eating inside her room on 10/03/18, at 12:46 PM, the resident stated the vegetables were mushy. During the same test tray process on 10/03/18, at 1:05 PM with the dietary manager (DM) and the registered dietician (RD) present, the test tray food temperatures where measured. The peaches and cream temperature was 50 degrees, and the milk was 46 degrees. The RD acknowledged the cold foods were out of the acceptable temperature range (41 degrees). During the test tray food tasting and concurrent interview with the RD on 10/03/18, at 01:21 PM, the steam cauliflower vegetable was observed mushy and overcooked. The RD stated The cauliflower could be less cooked. Less mushy. The RD acknowledged that the vegetable was overcooked therefore nutrients were loss. RD stated Ok, we can work on making sure the vegetables are less cooked and more crunchy.

Based on observation, interview and record review, the facility failed to ensure dietary staff: 1. Maintains 3 of 3 sanitizer red buckets within the proper sanitizer concentration range. 2. Label and date stored foods. 3. tested and monitored the sanitizing buckets for proper sanitizer concentration per their instructions. These failures placed residents at risk for cross contamination and acquiring foodborne illnesses. Findings: 1. During a tour of the kitchen on 10/02/18, at 07:59 AM., three sanitizer buckets which consisted of sanitizer and water were observed. Bucket #1 was close to the hand washing sink. Bucket #2 was close to the 3 compartment sink/cook area. Bucket #3 was close to the food preparation sink. Dietary aide (DA) tested the sanitizer in the red buckets using a QUAT (Quaternary Ammonia compound) test strip to check for proper sanitizer concentration levels in each bucket. The QUAT test strip needed to turn green in color to indicate there was proper sanitizer concentration (200 parts per million PPMs) once submerged into the sanitizer solution for 10 seconds. However, test strips turn orange in color, indicating sanitizer concentration level was 0-100 (PPMs). The following were observed: Bucket 1 = test strip indicated 0 PPM (orange color strip) bucket 2 = test strip indicated 100 PPM (darker orange color strip) bucket 3 = test strip indicated 100 PPM (darker orange color strip) During a concurrent interview the DA stated It (the buckets) does not have enough sanitizer. Yes, its a concern. During a concurrent interview with the registered dietitian (RD), the RD acknowledged the observation and confirmed the buckets sanitizer concentration should be 200 PPMs and that three of three sanitizer buckets were out of the proper sanitizer range. 2. During a tour of the kitchen and observation of the groceries refrigerator and concurrent interview with the RD on 10/02/18, at 08:35 AM, a bag with lemons, and a bag with carrots were observed without a label. The RD explained the vegetables are dated with the date they arrived to the facility and they are good for three days or longer depending on the type of vegetable. The RD acknowledged the observation and stated They should be dated During an observation of the reach in refrigerator and concurrent interview with the RD on 10/02/18, at 08:40 AM, an ice tea container dated 2/29/18 was observed. The RD explained the ice tea is prepared and dated with the date of preparation and then its good for three days (including preparation date). The RD acknowledged the ice tea in the container was past due. The facility policy and procedure titled Food Storage dated 3/17, indicated in part All foods should be covered, labeled and dated. 3. During a review of the three sanitizer bucket logs for the month of (MONTH) and (MONTH) and concurrent interview with the dietary manager (DM) on 10/03/18, at 08:16 AM, the logs were observed incomplete. The Sanitizer Bucket Test Strip Log in the Instructions part indicated Employees will check sanitation concentration after initial fill of the sanitation buckets every morning and record the sanitation concentrations below . Sanitation buckets are to be replaced with fresh sanitizer solution a minimum of every four (4) hours or if the water and /or kitchen wiping cloths are soiled to ensure proper sanitation of food contact surfaces . The sanitizer bucket logs for (MONTH) and (MONTH) (YEAR) indicated the sanitizer buckets were not tested and monitor every four hours as per the instructions. The DM acknowledged the staff was not checking the buckets and recording the sanitizer concentration every 4 hours.The DM stated I agree there are missing sanitizer concentrations times in the logs. During concurrent interview with the RD, the RD acknowledged staff was not checking the buckets and recording the sanitizer concentration every 4 hours as per the instructions.

Based on record review and interview, the facility failed to ensure activities care plans were initiated or completed for two of two sample residents (Resident 66 and 83). This failure place residents at risk of not having their interest met and not supporting the physical, mental and psychosocial well-being of each resident. Findings: The facility policy and procedure titled Care Plans Procedure, dated 3/1/18 indicated The purpose of this procedure is to ensure that staff initiates care plans for identified needs and /or problems of the resident. The facility policy and procedure titled Care Plan Timing and Revision dated 3/1/18, indicated .The comprehensive care plan will be developed within 7 days after the completion of the comprehensive assessment . The facility policy and procedure titled Develop/Implement Comprehensive Care Plan dated 3/1/18, indicated (Company's Name) facilities will develop and implement a comprehensive person-centered care plan for each resident using the results of the comprehensive assessment .The comprehensive care plan will describe services furnished to attain or maintain the resident's highest practical physical, mental, and psychological well-being . 1. During a review of Resident 66's clinical record and concurrent interview with the activities director (AD) on 10/03/18, at 4:43 PM, the record indicated the resident was admitted to the facility on [DATE]. An Activities Care Plan, dated 10/3/18 was located in the record. AD confirmed meeting with resident today (10/3/18). and initiating the Activities Care Plan today. AD stated I just started the activities care plan today. AD acknowledged and confirmed not having a care plan for activities before 10/3/18 for this resident. 2. During a review of Resident 83's clinical record and concurrent interview with the activities director (AD) on 10/03/18, at 4:45 PM. The record indicated Resident 83 was admitted to the facility on [DATE]. An Activities care plan was requested from AD. The AD provided an Activities care plan that was incomplete. The care plan did not contain any interventions. AD stated I don't know why the interventions are not showing on the care plan. The AD acknowledged and confirmed the Activities care plan did not contain any interventions at all. AD agreed this care plan was not complete and there were no interventions to be implemented from the beginning.