Every finding on record at Atterdag Care Center

Based on record review and interview, the facility failed to revise a care plan for one of two sampled residents (Resident 1) after Resident had multiple falls on 2/17/26,3/4/26, and 3/10/26, This facility failure placed Resident 1 at higher risk for falls with injuries.During a review of the admission Record (AR) for Resident 1, admission date 8/26/24, The AR indicated Resident 1 was a [AGE] year old male with diagnosis including Senile Degeneration of the Brain (Progressive loss of cognitive function characterized by memory loss, confusion, behavioral changes, and impaired daily functions) and Alzheimer's Disease (Progressive, incurable disease causing brain shrinkage and neuron death characterized by memory loss, cognitive decline, and behavioral changes), Adjustment disorder with mixed anxiety and depressed mood, Abnormalities of gait and mobility.During a review of Resident 1's Post Fall Evaluation (PFE), dated 2/17/26, the PFE indicated Resident 1 experienced an unwitnessed fall on 2/17/26 at 3:45 P.M. The PFE also indicated in part Care Plan Focus: The resident has had an actual fall with More risk factors include lower body weakness, Vitamin D deficiency, difficulties with walking and balance, uses of medicines, vision problems, foot pain or poor footwear, throw rugs or clutter that can be tripped over, poor lighting, decreased muscle strength, sedentary lifestyle, cognitive impairment, incontinence, sudden condition changes such as fever, infection, delirium, anemia, arthritis, heart failure, neuro disorders. Goal: will identify injury x72 hours. Intervention: Neuro checks. Notify MD and POA monitor v.s. every shift x 72 hours monitor for pain notify MD if changes in quality or worsening pain immediate action taken to prevent fall, Notify POA and M.D. of any identified complications.During a review of Resident 1's PFE, dated 3/4/26, the PFE indicated Resident 1 experienced a fall on 3/4/26 at 3:45 P.M. The PFE also indicated the Care Plan Focus, Goals, and Interventions remain unchanged from the prior PFE dated 2/17/26.During a review of Resident 1's PFE, dated 3/10/26, the PFE indicated Resident 1 experienced an unwitnessed fall on 3/10/26 at 12:01 A.M. The PFE also indicated the Care Plan Focus, Goals, and Interventions remain unchanged from the prior PFE dated 2/17/26 and 3/4/26.During a concurrent interview and record review on 3/20/26 at 12:40 P.M. with the Director of Nursing (DON), Resident 1's Care Plan, initiated 9/6/24, had no focus, goals, or interventions revised following the reported falls on 2/17/26, 3/4/26, and 3/10/26. The DON agreed no care plan revisions were made following the three PFE's.During a review of the facility's policy and procedure titled, Fall Prevention Program, dated 9/24/12, indicated in part After any fall the licensed nurse will reassess the resident for fall risk and complete the Post Fall Evaluation. The licensed nurse will make an immediate decision as to applying an alarming device. The resident will be assessed by the IDT who will review the fall within 72 hours and will evaluate the need for a personal tab alarm or pressure pad alarm device in the wheelchair and/or for any other recommendation such as physical therapy, nonskid socks, etc. All interventions will be added to the fall care plan to prevent falls.During a review of the facility's policy and procedure titled Care Planning, revised 7/1/24, indicated in part To assure that all resident's care needs are identified through continuous assessments and that those needs are care planned with corresponding measurable objectives and adequate interventions. The policy also indicated in part 3. All newly identified problems, including condition changes, are to be care planned by the licensed nurse or other health care professional who assessed/identified the problem first . 4. On a weekly basis when summaries are completed, the licensed staff nurse completing the summary should update the care plan with new interventions, and resident's response from previous interventions . 7. The care plan should address special issues, concerns or wishes of the resident. It should present a current picture of the resident and the care they need.

Based on record review, interview, and policy and procedure, the facility failed to ensure the medical record contained documentation for a reason as needed (PRN) medication was given for one of two sampled residents (Resident 1).This failure had the potential to result in an incomplete medical record for a resident medication administration requirement. During a review of the admission Record (AR) for Resident 1, admission date 8/26/24, The AR indicated Resident 1 was a [AGE] year old male with diagnosis including Senile Degeneration of the Brain (Progressive loss of cognitive function characterized by memory loss, confusion, behavioral changes, and impaired daily functions) and Alzheimer's Disease (Progressive, incurable disease causing brain shrinkage and neuron death characterized by memory loss, cognitive decline, and behavioral changes), Adjustment disorder with mixed anxiety and depressed mood.During a review of the Administration Record (MAR), dated 3/1/26-3/31/26, The Mar indicated a physician order of Lorazepam Tablet (a medication used to treat anxiety disorders, short term insomnia, and active seizures) Give 1 mg (milligram) by mouth every 2 hours as needed for MOD (moderate) - Severe anxiety M/B (manifested by) vomiting, SOB (shortness of breath), Restlessness. The MAR further indicates that a dose of this medication was administered on 3/17/26 at 5:57 A.M. The MAR and the medical record contain no notes as to the reason why the medication was given.During an interview on 3/20/26 at 12:40 P.M. with the Director of Nursing (DON), DON agreed the MAR for Resident 1 was without documentation for the reason of the administration of the PRN medication on 3/17/26 at 5:57 A.M.During a review of the facility's policy and procedure titled Medication Administration, revised 10/8/24, indicated in part When a PRN medication is given, it shall be charted on the Medication Administration Record. The nurse shall document the reason given, route of administration, date, and time.

Based on record review and interview, the facility failed to meet federal regulatory requirements when the clinical record for one of three sampled residents (Resident 8) had no documented justification for extending a PRN (as needed) psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) order beyond 14 days.This failure had the potential to result in Resident 8 receiving an unnecessary psychotropic medication which could affect the resident's health and safety.Findings:During a review of Resident 8's admission Record (AR), dated 1/8/26, the AR indicated, Resident 8 was a [AGE] year-old female who was admitted to the facility on [DATE] with admission diagnoses including, Alzheimer's disease (a progressive brain disorder that primarily affects memory, thinking, and behavior), dementia with mood disturbance (a pattern of mental decline caused by different diseases or conditions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health condition characterized by excessive fear, worry, and anxiety that can interfere with daily activities).During a review of Resident 8's Order Summary Report (OSR), dated 1/8/26, the OSR indicated, the medication order, Lorazepam (a medication used to treat anxiety) tablet give one (1) milligram (mg) by mouth every 12 hours as needed for anxiety manifested by (m/b) frantic searching. The medication was ordered 12/18/2025 with no end date.During a concurrent interview and record review on 1/8/26 at 2:40 p.m. with the Director of Nursing (DON), Resident 8's clinical record including the OSR, dated 1/8/26, were reviewed. DON verified that the medication order for Lorazepam. which was ordered 12/18/25 had no end date and acknowledged that PRN psychotropic medication orders should be renewed every 14 days based on regulatory requirements. Further review of Resident 8's clinical record failed to show documented justification that would warrant not renewing the medication order every 14 days.

Based on record review and interview, the facility failed to ensure care plan interventions were properly implemented and documented in the clinical record for two of three sampled residents (Residents 8 and 2) when:1. Monitoring for wander guard device (a monitoring device used to ensure safety for residents at risk for elopement/wandering) placement and function was not implemented and documented in Resident 8's clinical record.2. Monitoring for pacemaker (a small, battery-powered device that prevents the heart from beating too slowly) status and function was not implemented and documented in Resident 2's clinical record.These monitoring oversight failures inaccurately reflect these residents' current health statuses which could potentially compromise their health and safety.Findings:1. During a review of Resident 8's admission Record (AR), dated 1/8/26, the AR indicated, Resident 8 was a [AGE] year-old female who was admitted to the facility on [DATE] with admission diagnoses including, Alzheimer's disease (a progressive brain disorder that primarily affects memory, thinking, and behavior), dementia with mood disturbance (a pattern of mental decline caused by different diseases or conditions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health condition characterized by excessive fear, worry, and anxiety that can interfere with daily activities).During a review of Resident 8's Wandering Risk Assessments (a tool used to assess the likelihood of wandering in residents, particularly those with cognitive impairments or dementia), completed on various dates, the assessments indicated the following wandering risk scores: 4/30/25 = 18 (high risk), 5/28/25 = 18 (high risk), 8/27/25 = 12 (high risk), and 11/27/25 = 11 (high risk).During a review of Resident 8's Care Plan Report, initiated 5/30/25, the Care Plan indicated in part, The resident is an elopement risk (refers to the likelihood a resident may leave the facility unsupervised and unnoticed)/wanderer r/t (related to) disoriented to place, history of attempts to leave facility unattended. The interventions/tasks for implementation specific to this care plan included, WANDER ALERT: wears on ankle, on nurses' EMAR (electronic medication administration record) for monitoring placement and function (initiated 5/30/25.During a review of Resident 8's Order Audit Report, dated 1/8/26, the Report indicated, a physician order dated 12/22/25, WANDER GUARD. check wander guard for placement and function every day shift.During a concurrent interview and record review on 1/8/26 at 2:45 p.m. with the Director of Nursing (DON), the DON confirmed the order was transcribed in the resident's Treatment Administration Record (TAR) instead of the EMAR as indicated in the care plan. Further review of Resident 8's November and December 2025 TARs revealed a lack of daily staff documentation for the order. The DON acknowledged the oversight and confirmed that staff should have properly implemented the monitoring order. 2. During a review of Resident 2's AR, dated 1/8/26, the AR indicated, Resident 2 was a [AGE] year-old female who was admitted to the facility on [DATE] with admission diagnoses including, paroxysmal atrial fibrillation (episodes of irregular heartbeat that start and stop spontaneously), old myocardial infarction (heart attack), ischemic cardiomyopathy (a heart condition caused by low blood flow to the heart muscle), and presence of cardiac pacemaker.During a review of Resident 2's Care Plan Report, initiated 11/11/24, the Care Plan indicated in part, The resident has a pacemaker. The care plan also indicated resident care interventions/tasks for implementation, initiated 11/11/24, including, Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of altered cardiac output or pacemaker malfunction: .PULSE RATE LOWER THAN PROGRAMMED RATE, LOWER THAN BASELINE B/P (blood pressure).During a concurrent interview and record review on 1/8/26 at 2:55 p.m. with DON, Resident 2's pacemaker care plan, initiated 11/11/24, was reviewed. The DON was unable to provide staff documentation the Resident 2's pacemaker monitoring intervention was implemented, as indicated on the resident's care plan. DON reviewed Resident 2's clinical record and determined that staff failed to transcribe the pacemaker monitoring intervention in either the resident's TAR or EMAR for proper tracking and oversight.During a review of the facility's policy and procedures (P&P) titled, Care Planning, dated 7/1/24, the P&P indicated in part, Purpose: To assure that all resident care needs are identified through continuous assessments and that needs are care planned with corresponding measurable objectives and adequate interventions. Measurable means 'how will anyone know it was accomplished' .

Based on interview and record review, the facility failed to ensure the provision of resident care and services were performed within acceptable professional nursing standards for three of six sampled residents (Residents 8, 45 and 36) when:1. Resident 8 missed their medication on several occasions, and there was no subsequent follow-up by the nursing staff.2. Resident 45's oxygen (O2) saturations (02 sats- measure of 02 in the blood) were not consistently documented in the clinical record.3. Resident 36 was treated with Calmoseptine Ointment (a multi-purpose moisture barrier used to soothe and protect irritated skin from moisture, itching, and discomfort) for a wound without a physician's order.These failures had the potential to result in unsafe nursing care practices which could compromise the health and safety of these residents.Findings:1. During a review of Resident 8's admission Record (AR), dated 1/8/26, the AR indicate, Resident 8 was a [AGE] year-old female who was admitted to the facility on [DATE] with admission diagnoses including, Alzheimer's disease (a progressive brain disorder that primarily affects memory, thinking, and behavior), dementia with mood disturbance (a pattern of mental decline caused by different diseases or conditions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health condition characterized by excessive fear, worry, and anxiety that can interfere with daily activities). During a review of Resident 8's Medication Review Report (MRR), dated 1/10/26, the MRR indicated the medication order, Quetiapine Fumarate [an antipsychotic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought) that treats schizophrenia (a serious mental health condition that affects how people think, feel and behave) and bipolar disorder (a mental health condition where you have extreme mood changes)] oral tablet. give 100 milligram (mg) by mouth at bedtime manifested by (m/b) frantic and fearful statements and pacing. ordered 9/29/25. During a concurrent interview and record review on 1/7/26 at 2:30 p.m. with the Director of Nursing (DON), Resident 8's Medication Administration Records (MARs), for the months of November and December 2025 were reviewed, respectively. The administration records for the medication Quetiapine Fumarate give 100 mg. at bedtime indicated Resident 8 missed this medication on several occasions as follows: for November 2025, 20 out of 30 days and for December 2025, 17 out of 31 days. The documented reason for these missed doses under the MAR's chart codes, was that Resident 8 was sleeping (number 7 on the chart code) at the time of the administration. Resident 8's clinical record failed to indicate documentation that the physician was notified, or nursing staff followed up on the resident for these missed doses. DON verified the findings and verbalized that staff should have followed up with the resident after each missed dose and should have informed the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their clients) so proper discussions were made in terms of managing the medication administration timing and frequency. During a review of the facility's policy and procedures (P&P) titled, Psychotherapeutic Medication (any drug that affects brain activities associated with mental processes and behavior) Use, dated 10/7/24, the P&P indicated in part, Purpose: To assure that monitoring is done when psychotherapeutic medications are given. Procedure: .5) Give medications as ordered. 7) Monitor for and document effectiveness of the medication. If ineffective, notify the physician. A 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. 2. During a review of Resident 45's AR, dated 1/8/26, the AR indicated, Resident 45 was admitted to the facility on [DATE] with a diagnosis of panlobular emphysema (a severe form of chronic obstructive pulmonary disease [COPD- a lung disease which makes it difficult to breathe] where the lung's air sacs are destroyed throughout causing large, air-filled pockets and impaired gas exchange, leading to shortness of breath.) During an observation on 1/6/26 at 12:10 p.m. in the Dining Room, Resident 45 was observed eating lunch while on 2 liters of oxygen. On 1/7/26 at 3:20 p.m. the resident was observed without oxygen self-propelling in the wheelchair towards Nursing Station 1 saying, I can't breathe, I can't breathe. I need my oxygen. During a review of Resident 45's Order Summary (OS), dated 1/8/26, the OS indicated, Supplemental O2 if below 88% for comfort, 2 liters as needed for O2 less than 88%. Review of Resident 45's The Hospice/Comfort Care Progress Notes, dated 11/22/25-1/1/26 indicated the O2 saturations were inconsistently monitored. Oxygen saturations were obtained on 11/22/25-11/25/25, 11/27/25-11/28/25, 12/4/25, 12/6/25, 12/9/25, 12/11/25, 12/18/25, 12/19/25, 12/24/25, 12/28/25, and 1/1/26. During an interview on 1/8/26 at 2:48 p.m. with the DON, the DON stated O2 saturations should have been documented every shift for Resident 45. The DON stated nursing staff needed to assess the status of the resident's breathing and O2 saturations to determine the resident's need for O2. During a review of the facility's P&P titled, Medication Administration, dated 10/8/24, the P&P indicated, A. Administration of Medication, 8. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing shall be completed prior to administration of the medication and recorded in the medical record i.e. BP, pulse, finger stick blood glucose monitoring, etc.Nursing Procedures 23. Obtain and record any vital signs taken by the CNA within 2 hours of the med pass. 3. During a review of Resident 36's AR, dated 1/8/26, the AR indicated, Resident 34 was admitted to the facility on [DATE] with a diagnosis of pressure ulcer (PU - injury to skin and tissue resulting from prolonged pressure) of left heel, stage 2 (a shallow open ulcer, with partial-thickness skin loss, and a red/pink base or intact/ruptured blister). During a review of Resident 36's admission Summary Progress Note, dated February 26, 2025, the Progress Note indicated in part, Has an old wound to his left heel measuring at 1.5 cm x 2cm. Area was cleaned and covered no drainage was noted area is tender.Redness to right heel was noted blanchable. Has slight redness to coccyx (small triangular bone on the base of the spinal column) area applying [NAME] (Calmoseptin ointment). Further review of Resident 36's Order Summary (OS), dated January 8, 2026, the OS indicated, no physician orders to treat skin wounds or an order to apply calmoseptine ointment to coccyx area. During a concurrent interview and record review on 1/8/26 at 3:48 p.m. with the DON, Resident 36's admission Summary Progress Note, dated 2/26/25 and OS, dated 1/8/26 were reviewed. DON acknowledged the admission nursing notes indicated Resident 36 was admitted with pre-existing skin integrity issue and the nurse documented the application of [NAME] ointment without obtaining physician orders for wound treatment. During a review of the facility's P&P titled, Medication Administration, dated 10/8/24, the P&P indicated, Policy: Medications shall be administered as ordered by a licensed nurse upon the order of a physician/licensed independent practitioner.

Based on interview, observation and record review, the facility failed to obtain monthly weights for one of four sampled residents (Resident 4).This failure had the potential for undetected weight fluctuations that could signal underlying health problems.Findings:During a concurrent interview and record review on 1/8/26 at 3:30 p.m. with Director of Nursing (DON), Resident 4's Current vital signs (CVS), dated 1/8/26 were reviewed. The CVS indicated, the last monthly weight for Resident 4 was obtained on 8/27/24. DON verbalized monthly weights should be obtained for every resident, a notation in the chart should indicate why a monthly weight was not obtained. DON confirmed there were no nursing notes or dietary notes present in Resident 4's medical record that provided an explanation for why the monthly weights were not done.During an interview on 1/8/26 at 3:45 p.m. with Resident 4, Resident 4 verbalized, the facility can weigh her, she has not refused, and has no problem with being weighed in a sling.During a review of the facility's policy and procedure (P&P) titled, Maintaining Acceptable Parameters of Nutritional Status (Nutrition and Weight Management), dated August 14, 2023, the P&P indicated, All residents, with the exception of residents admitted with a doctor's different stipulation, will be weighed upon admission and weekly for four weeks or until stable. Residents will be weighed once a month thereafter.

Based on interview and record review, the facility failed to ensure a physician provided timely consultation or treatment when contacted by the facility to address a change in condition for two of five sampled residents' (Residents 23 and 28). This deficient practice resulted in a delay in care and treatment to meet Residents 23's and 28's immediate care needs and had the potential to result in an avoidable deterioration in health. During review of the facility's policy and procedures (P&P) titled, Change of Condition, dated 9/30/24, the P&P indicated in part, Purpose: To ensure that appropriate care and documentation occurs when residents experience a change of condition. Procedure: 2. Notify the attending physician promptly.5. Follow up nursing assessments and monitoring until the condition has stabilized .What is a Change of Condition? .Any sudden or marked change in:.Abnormal lab or X-ray reports.Open or red areas.Bruises, lacerations, blisters, rashes, or skin tears. a. During review of Resident 23's admission Record (AR), dated 1/9/26, the AR indicated, the resident was admitted on [DATE] with diagnoses that included, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), dementia (a decline in thinking, memory, and reasoning skills severe enough to interfere with daily life, caused by brain cell damage), and Type 2 Diabetes Mellitus (the body cannot use insulin correctly and sugar builds up in the blood) with diabetic peripheral angiopathy (poor circulation in the legs/feet). During an interview with Resident 23's responsible party (RP) on 1/6/26 at 3:04 p.m., RP stated Resident 23 had developed blisters in September 2025 but there was a delay in care because the facility physician did not respond to the resident's change in condition. RP stated the staff were informed that Resident 23 had a medical history of bullous pemphigoid (a rare, chronic autoimmune skin disease causing large, itchy, fluid-filled blisters and hives) and needed to see a dermatologist (a medical doctor that specializes in conditions and diseases of the skin) yet no action was taken by the facility until approximately two weeks later after Resident 23's skin condition got worse. During review of Resident 23's Progress Notes (PN), dated 9/15/25 - 9/25/25, the PN's indicated, a licensed nurse had identified a 3 cm (centimeter - a metric unit of length) x 1.5 cm fluid filled blister on Resident 23's right outer index finger on 9/15/25. The physician and resident 23's RP were notified on 9/15/25. On 9/21/2025 the certified nursing assistant reported the resident may be biting or gnawing on hand. In the following days, additional fluid filled blisters developed on the resident's right hand fingers and right plantar foot and some blisters had busted open. Progress notes dated 9/22/25 and 9/24/25 indicated, staff were awaiting physician response. The physician called the facility on 9/25/25 (10 days after the initial notification in change of condition) with instructions to make an urgent dermatologist appointment. Resident 23 was seen by the dermatologist on 9/25/25 and returned to the facility with new medication orders. Review of Resident 23's Order Summary (OS), dated 1/9/25, the OS indicated, the following medications were ordered on 9/25/25 after the dermatology appointment:Doxycycline Monohydrate (antibiotic used to treat bacterial infections) 100 mg (milligrams - a unit of mass or weight) two times a day for bullous pemphigoid for 30 daysMupirocin (antibiotic used for bacterial skin infections) external ointment 2% (percent) apply to hands topically every shift to prevent cellulitis (bacterial infection of the skin's deeper layers and underlying tissues) until healed.Prednisone (medication to reduce swelling and redness) 50 mg in the morning for bullous pemphigoid for 30 days During a concurrent interview and record review on 1/9/26 at 9:38 a.m. with the Director of Nursing (DON) Resident 23's PNs, dated 9/15/25-9/25/25 were reviewed. DON acknowledged that Resident 23 had a change of condition and staff should have pursued daily facility physician notifications to ensure timely care. b. During review of Resident 28's AR, dated 1/9/26, the AR indicated, the resident was admitted on [DATE] with diagnoses that included, presence of urogenital implants (artificial devices or materials placed within the urinary or genital organs). Review of Resident 28's Care Plan (CP), dated 9/8/25, the CP indicated, the resident had an indwelling suprapubic catheter (a flexible tube that drains urine from the bladder through a small surgical opening in the lower abdomen) for neurogenic bladder (loss of bladder control caused by nerve damage). The nursing interventions indicated, monitor/record/report to MD (medical doctor) for signs/symptoms urinary tract infection (UTI): pain, burning, blood-tinged urine, cloudiness. During a review of Resident 28's laboratory urine culture results, collected on 12/13/25 and faxed to the facility on [DATE] indicated, a significant bacterial presence, suggesting infection of staphylococcus aureus (type of bacteria known to cause infection). During concurrent interview and record review on 1/09/26 at 9:38 a.m. with the DON, Resident 28's PNs, were reviewed. The PN's dated 12/12/25 - 1/02/26 indicated the following:12/12/25 Resident 28 was noted to have restless behavior during the evening shift. A urinalysis (urine test) was performed which resulted in a positive result for nitrites and leukocytes (white blood cells). The urinalysis results were sent to the physician via fax communication.12/13/25 Resident 28's suprapubic catheter was changed. The tubing had a white thick appearance. A urinalysis was performed and resulted in small traces of nitrites, leukocytes, and trace of blood. A urine sample was collected and sent for laboratory testing.12/13/25 and 12/15/25 Resident 28's lab results were received and faxed to the physician.1/2/26 Progress note indicating a physician order for Bactrim (prescription antibiotic combination used to treat bacterial infections) to treat Resident 28 for acute cystitis (sudden inflammation of the bladder, usually caused by a bacterial infection). DON acknowledged the physician provided treatment recommendation 22 days after the first MD notification for Resident 28's change of condition. DON stated staff should have pursued daily facility physician notifications to ensure timely care.

Based on observation, interview, and record review the facility failed to ensure nursing staff signed the controlled drug record after administering medication.This failure had the potential to result in unauthorized tampering and diversion of resident medications.Findings: During a concurrent interview and record review on 1/7/26 at 9:50 a.m. with Licensed Nurse (LN)1, Resident 24's Controlled Drug Record (CDR), dated 1/6/26 was reviewed. The CDR indicated, on 1/6/26 at 8:55 p.m. Resident 24 was administered Hydrocodone-Acetaminophen (a medication used to relieve severe pain). There was no licensed staff signature on the CDR indicating the medication was administered. LN1 verbalized the CDR should have been signed by the nurse administering the medication.During a review of the facility's policy and procedure (P&P) titled, Medication Administration Controlled Substance, dated 9/16, the P&P indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: Signature of the nurse administering the dose.

Based on observation, interview, and record review, the facility failed to dispose of expired medical supplies from a wound treatment cart (a mobile cart containing equipment, and supplies needed to treat wounds.)This facility failure had the potential for staff to utilize deteriorated and ineffective healthcare supplies for treatment of patients. Findings:During a concurrent observation and interview on [DATE] at 9:40 a.m. with Licensed Nurse (LN) 1 at the nurse's station, the wound treatment cart was inspected. Two one ounce bottles of Stomahesive powder (a non-medicated powder used to absorb moisture from slightly irritated or moist skin around the stoma - an ostomy is surgery to create an opening (stoma) from an area inside the body to the outside) were observed with an expiration date of [DATE]. LN1 verbalized all staff are responsible for making sure expired supplies are removed from the cart, these supplies should have been destroyed.During a review of the facility's policy and procedure (P&P) titled, Medication Administration, dated [DATE], the P&P indicated, If medication is discontinued, or outdated, remove medication for proper disposal.

Based on observation, interview, and record review, the facility failed to ensure food safety requirements were met when:1) Two dietary aides (DAs 1 and 2) did not completely cover their hair, with the required hair restraint, while in the food preparation area. 2) Dietary staff did not follow the facility's policy and procedure when cleaning and sanitizing kitchen surfaces. 3) Contaminated food was not removed from dry food storage area. These failures had the potential to cause food borne illness to the residents. 1) During an observation on 1/9/26 at 9:41 a.m. with Director of Nutrition Services (DNS), in the food preparation area, DAs 1 and 2 hair restraints were noted not properly covering the hair area. During a review of facility's policy and procedure (P&P) titled, Hair Restraints, dated 2020, the P&P indicated, Hair restraints, hats and beard covers will be worn in the food production area by all staff to prevent hair from falling into food. 2) During a review of the facility's P&P titled, Cleaning Instructions for Work Tables and Counters, dated 2020, the P&P indicated, the process for cleaning worktables and counters includes scrub top with hot soapy water, rinse with hot water .sanitize with no rinse multi surface food grade sanitizing wipes allow to air dry. During a concurrent observation and interview on 1/7/26 at 8:10 a.m. with DA1. DA1 was observed wiping down food preparation surface with a wet cloth with no bucket for hot soapy water or sanitizer cloth. DA1 stated food preparation counter is washed with soap and water, and sanitizer cloth is used and let sit for 20 seconds.During an interview on 1/7/26 at 8:12 a.m. with DA2, in kitchen tray line, DA2 stated sanitizer wipes are allowed to dry for five minutes.During an observation on 1/9/26 at 11:40, in food preparation area, a DA2 wiped a food preparation counter with a wet cloth and walked away. No sanitizing was observed. During concurrent observation and interview on 1/9/26 at 11:44 a.m., with DA1, in the food preparation area, DA1 was observed trimming meat for the lunch meal. DA1 stated, To clean the work surface after finishing I just use the wipes and let sit for twenty seconds. During an interview on 1/6/26 at 11:45 a.m. with DNS. DNS stated, surfaces are washed with soap and water, then sanitizing wipes used and let to air dry. No wet time stated.During an review of Sani Professional No Rinse Sanitizing Multi-Surface Wipes, manufacture's instructions for use (ISU) indicated, non porous surfaces to remain visibly wet for five minutes. 3) During a concurrent observation and interview on 1/6/26 at 11:08 a.m., of dry storage area, one unopened box of Kens dressings, received on 1/2/26 was noted with wet cardboard packaging and one squash with white spots was noted. The DNS stated those should have been removed from the area and placed on the return cart. During a review of Food and Drug Administration (FDA) Food Code 6-404.11, titled, Segregation and Location, dated 2022, the code indicated, Products that are held by the PERMIT HOLDER for credit, redemption, or return to the distributor, such as damaged, spoiled, or recalled products, shall be segregated and held in designated areas that are separated from FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on record review and interview, the facility failed to ensure the informed consent [a resident's right to make an informed voluntary decision about their care, requiring providers to clearly explain their health status, treatment risks/benefits, alternatives (including refusal)] for psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) had accurate information for one of three sampled residents (Resident 8).This failure had the potential to result in Resident 8 receiving inappropriate care and treatment.Findings:During a review of Resident 8's admission Record (AR), dated 1/8/26, the AR indicated, Resident 8 was a [AGE] year-old female who was admitted to the facility on [DATE] with admission diagnoses including, Alzheimer's disease (a progressive brain disorder that primarily affects memory, thinking, and behavior), dementia with mood disturbance (a pattern of mental decline caused by different diseases or conditions), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health condition characterized by excessive fear, worry, and anxiety that can interfere with daily activities).During a review of Resident 8's Order Summary Report (OSR), dated 1/8/26, the OSR indicated, the medication order, Lorazepam (a medication used to treat anxiety) tablet give one (1) milligram (mg) by mouth every 12 hours as needed for anxiety manifested by (m/b) frantic searching. The medication was ordered 12/18/2025 with no end date.During a review of Resident 8's Informed Consent Anxiolytic (medication used to reduce anxiety), dated 12/18/25 and signed by the resident's daughter, the medication dose and frequency written on the consent indicated, Ativan (brand name for Lorazepam) increase from 0.5 milligram (mg) to one (1) mg PO (by mouth) BID (twice a day) PRN (as needed).During a concurrent interview and record review on 1/8/26 at 2:40 p.m., with the Director of Nursing (DON), the documented information from Resident 8's OSR and Informed Consent Anxiolytic for the medication Lorazepam/Ativan were compared. DON noted the discrepancy on the medication administration frequency between Resident 8's OSR (which indicated the medication be administered every 12 hours) and Informed Consent (which indicated the medication be administered twice a day). DON acknowledged that any medication information added to the informed consent for any resident should match the actual medication order prescribed by the physician.During a review of the facility's policy and procedures (P&P) titled, Maintaining Content of Medical Records, dated 10/7/24, the P&P indicated in part, Procedure: 1) In accordance with accepted professional standards and practices, facility shall maintain medical records on each resident that are .ii) Accurately documented.A 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 observation, interview, and record review the facility failed to ensure infection control practices were implemented when: Laundry washing machine water temperatures were below the minimum required temperature for infection control. Personal protective equipment (PPE - protective equipment such as gloves, gowns, masks, and eye protection that creates a barrier to protect patients, healthcare workers from infectious materials, bloodborne pathogens, and other hazards, and to prevent the spread of illness to others) was not readily available in four out of four residents (Residents 6, 27, 36, and 48) on enhanced barrier precautions (EBP - Infection control measures the involves wearing PPE for specific high-contact tasks such as bathing, transfers, and wound care for at-risk residents to stop germ spread). These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for residents in an already compromised condition. a. During a review of the facility's Laundry Water Temperature Logs (Logs) for September, October, November and December 2025, the Logs indicated, multiple water temperatures were noted to have entries with wash temperatures below 140 degrees. For the months of September, October, and November 2025, 13 days were not within the acceptable range. During a concurrent interview and record review on 1/9/26 at 10 a.m. with the Environmental Services Supervisor (EVS), Laundry Water Temperature Logs for September, October, November and December 2025 were reviewed. EVS stated the minimum washing temperature must be at or above 140 degrees. EVS acknowledged the recorded temperatures were unacceptable. During a concurrent interview and record review on 1/9/26 at 10:05 a.m. with laundry staff (LS), the November and December 2025 laundry water temperature logs were reviewed. LS stated the minimum acceptable water temperature for colored clothes is 130 degrees and for whites it is 140 degrees. LS acknowledged the water temperature logs did not specify if white or colored laundry is washed. During a concurrent interview and review on 1/9/26 at 10:08 a.m. with LS and EVS, the facility's policy and procedure (P&P) titled, Laundry Procedures, dated 12/2025 was reviewed. The P&P indicated in part, During the wash cycle check the thermometer for water temperature. Input the date and temperature on the Water Temp Log posted on washing machine #1. Appropriate temperatures for infection control should range between 140 and 160 degrees. LS and EVS acknowledged that all (whites and colored) has a minimum water temperature requirement of 140 degrees. During a concurrent interview and record review on 1/9/26 at 10:28 a.m. with the Infection Prevention Nurse (IPN), the IPN stated the laundry temperature logs were reviewed monthly by the IPN to ensure the laundry is being washed under acceptable water temperatures and documented on a form titled Infection Control Surveillance – Laundry (ICS-L). The ICS-L's for the months of September, October, November, and December 2025 were reviewed. The ICS-L forms have question Washing machine wash temperature is maintained at min 140 F degrees with instruction to circle yes or no. The ICS-L forms dated: 9/20/25 had yes circled 10/28/25 had both the yes and no circled with handwritten documentation indicating Discussed with housekeeping/laundry supervisor about occasional 130 F.sometimes recorded before water/clean started.will adjust for future records. 11/20/25 had yes circled 12/30/25 had yes circled and handwritten documentation indicating 146-152 The September, October, November and December 2025 Laundry Water Temperature logs were reviewed with IPN. IPN acknowledged there were unacceptable wash temperatures for September, November and December that the IPN did not detect during the infection surveillance monthly review. b. According to the Centers for Disease Control (CDC) website https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), published 4/2/24, Effective implementation of EBP requires.the availability of PPE and hand hygiene supplies at the point of care. During an observation on 1/6/26 at 11 a.m. signs were posted outside the doors of resident rooms [ROOM NUMBERS] that indicated, ENHANCED BARRIER PRECAUTIONS Wear gloves and a gown for the following High-Contact Resident Care Activities - dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (indwelling catheter, trach/vent, central line, feeding tube), wound care. Resident does not need a private room. Resident may participate in communal activities and is not restricted to room. No PPE was visibly available near the rooms or down the hall other than antibacterial hand sanitizer. During an observation on 1/6/26 at 11:32 a.m. EBP signs were posted outside the doors of rooms [ROOM NUMBERS]. No PPE supplies were visible near the rooms or down the hall other than antibacterial hand sanitizer. During an interview on 1/7/26 at 4:11 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated staff obtain PPE from the storage closet. During an interview on 1/8/26 at 9:37 a.m. with the Director of Nursing (DON), the DON stated PPE was located inside the resident rooms in the resident's closet. When DON was asked about PPE use communication for visitors, DON stated visitors do not provide resident care. The IPN stated the facility opted not to have PPE in the hallways or outside of resident rooms on EBP to provide a homelike environment. During an interview on 1/8/26 at 9:42 with Licensed Vocational Nurse (LN 3), LN 3 stated PPE supplies are stored in the clean utility closet (located in the middle of the facility, in the corner across from Nurse Station 1) which is locked and requires entry of a security code to open. Staff get PPE supplies from the clean utility closet or from resident's bottom drawer. LN 3 stated that only residents on airborne, droplet, contact, or enhanced barrier precautions have PPE supplies in their closets. When asked how visitors are informed where to obtain PPE, LN 3 stated visitors do not provide resident care and would not need it for the residents currently on EBP. During an observation on 1/9/26 at 8:53 a.m. in Resident 48's room, the resident requested assistance to return to bed. Unidentified Certified Nurse Assistant (CNA) was asked, by the surveyor, to help resident to return to bed. Resident 48 is on Enhanced Barrier Precautions (EBP). No PPE was outside the resident's door or visible in the room. CNA donned gloves, physically assisted patient to stand and covered her with blanket on the bed and looked for television remote. CNA removed gloves and exited the room. No gown was donned to protect staff clothing from contact with patient. During a concurrent observation and interview on 1/9/26 at approximately 10 a.m. with Infection Preventionist (IP) outside Resident 48's room, the IP stated PPE is in the patients closet to keep a homelike atmosphere. IP located the gowns on the bottom shelf behind incontinence briefs (protective garments for managing urinary or fecal incontinence).

Based on interview and record review, the facility failed to revise one out of five sampled residents (Resident 36) care plan following minimum data set (MDS - a standardized, comprehensive assessment tool used to collect essential resident data) assessments. This failure resulted in inaccurate care planning for Resident 36's healthcare needs.During review of Resident 36's admission Record (AR), dated 1/8/26, the AR indicated the resident was admitted to the facility on [DATE] with diagnoses that included, chronic pain, pressure ulcer (PU - injury to skin and tissue resulting from prolonged pressure) of left heel stage 2 (a shallow open ulcer, with partial-thickness skin loss, and a red/pink base or intact/ruptured blister), encounter for palliative care (care focused on end of life comfort, relieving symptoms, stress, and improving the quality of life), and sepsis (an overactive response to an infection that damages its own tissues, organs, and systems, leading to potential organ failure and death if not treated rapidly). During review of Resident 36's Care Plan (CP), dated 2/27/25, the CP indicated, the resident used anti-anxiety medication (Ativan) related to end stage disease and hospice care and the CP dated 5/20/25 indicated, the resident uses antidepressant medication (Remeron) related to depression. Further review of Resident 36's Comprehensive MDS, dated [DATE] and Quarterly MDS assessments dated 5/27/25, 8/18/25, and 11/10/25, the MDS assessments indicated, the resident did not have anxiety or depression diagnoses and was not taking antianxiety or antidepressant medications. During review of Resident 36's Order Summary (OS), dated 1/08/26, indicates there are no active orders for Ativan (Lorazepam) or Remeron (Mirtazapine) or any other type of antidepressant or anti-anxiety medication. The OS indicates Lorazepam 0.5 mg (milligrams) every 2 hours as needed for anxiety m/b (manifested by) nausea, apprehension, uncontrolled movement for 14 days was ordered on 2/27/25 and discontinued on 3/13/25. The medication was re-ordered with a start date of 3/12/25 and discontinued on 3/26/25. Remeron 7.5 mg by mouth at bedtime for depression was ordered on 5/19/25 and discontinued on 5/20/25. During a concurrent interview and review on 1/8/26 at 3:45 p.m. with the Director of Nursing (DON), Resident 36's OS dated, 1/8/26 and CP's dated, 2/27/25 and 5/20/25 were reviewed. DON stated Resident 36 was prescribed Ativan and Remeron for hospice comfort care but the medications were discontinued because the resident never took them. DON acknowledged the resident's care plan was inaccurate and was not updated to reflect the resident's status at the time of the MDS assessments. During review of the facility's policy and procedure (P&P) titled, Care Planning, dated 7/1/14, the P&P indicated in part, Purpose: To assure that all residents care needs are identified through continuous assessments and that those needs are care planned with corresponding measurable objectives and adequate interventions.Procedure: 5.As the resident's assessment changes, the MDS nurse should update the care plan as appropriate.7. The care plan.should present a current picture of the resident and the care they need.

Based on interview and record review, the facility failed to ensure documentation by Social Services Designee (SSD) was completed for one of three sampled residents (Resident 1) medical records regarding allegations of abuse involving Resident 1.This facility failure resulted in Resident 1's medical record not accurately reflecting SSD follow-up on abuse allegations, potentially impacting the adequacy of care for Resident 1.During a review of Resident 1's admission Record, [undated], the admission Record indicated, Resident 1 was 94 years-old, admitted to the facility on [DATE] with the following diagnoses: senile degeneration of brain (decline in cognitive abilities that occurs with aging), generalized anxiety disorder (mental condition with excessive or unrealistic anxiety about two or more aspects of life), schizoaffective disorder bipolar type (a mental health condition that combines symptoms of schizophrenia [chronic mental health condition that affects a person's thoughts, feelings, and behavior] and bipolar disorder [chronic mental health condition characterized by extreme mood swings between mania (highs) and depression (lows)]), weakness, vascular dementia (impaired supply of blood to the brain with a decline in cognitive abilities), unspecified lack of coordination, cognitive communication deficit (communication challenge from problems with thinking), muscle weakness, essential tremor (brain disorder causing shaking of parts of body), mild cognitive impairment (not obvious but noticeable changes in cognitive function), macular degeneration (distortion or loss of central vision), cerebral ischemia (decreased blood flow to the brain), drug induced secondary parkinsonism (movement disorder), Diabetes Mellitus type 2 (body doesn't produce enough insulin [hormone] to regulate blood sugar levels), and history of falling. During an interview on 10/8/2025 at 11:56 a.m. with the SSD, SSD verbalized was aware of abuse allegations involving Resident 1. SSD stated, I did try talking to (Resident 1), but the resident can be challenging and dismissed me, but I observed him the rest of the day and he went about his normal routine. Resident 1 didn't mention anything and didn't give any feedback and was dismissive. SSD further stated, Since there wasn't any feedback, I didn't make a note, and I should have.During a review of Job Description Title Social Services Designee, revised 9/4/2025, Job Description Title Social Services Designee indicated Position Summary: Counsels and aids individuals and families who require assistance. Interviews new residents to assess their psychosocial needs. Obtains information such as medical, psychological and social factors contributing to the resident's situation and evaluates the resident's capabilities. Counsels residents individually or with family regarding assessment plans. Aids residents to improve social functioning.Essential Job Functions and Responsibilities . Provides resident services . one-on-one support, grief process . Acts as a liaison to family members, communicating resident needs, and social service concerns to families . Documents Social Service needs in ACC [abbreviation of facility] Medical Charts.Helps in bridging positive psychology between levels of care and assists with transitions . make reports and maintain files as required by state and federal regulations.During a review of the facility's Policy and Procedure (P&P) titled, Progress Notes, dated 9/26/2012, the P&P indicated, Each discipline shall be responsible for documenting the resident's progress according to regulation and the facility requirement. 1) All disciplines at this facility shall document progress notes in the appropriate section of the chart according to professional standards and regulations. Progress notes shall reflect resident's current status, progress or lack of progress, changes in condition, and adjustments to facility etc. 3) All progress notes shall be headed with the title of the person documenting the note i.e. physician note, nursing note, social service note, activity note, dietary note etc. 5) Progress notes shall be documented in a timely manner. Record Keeping Progress notes shall be maintained in the resident's medical record.

Based on interview and record review, the facility failed to ensure that the personal property inventory list was updated for one of two sampled residents (Resident 1). This facility failure had the potential for Resident 1's belongings to be lost or unaccounted for. Findings: During an interview with the Social Services staff (SS) on 7/2/25 at 11:08 a.m., the SS stated that Resident 1 had complained she could not locate a pair of pants she purchased (online store name). The SS assisted Resident 1 and located the missing pants, which had a tag with the resident's name. During an interview with Licensed Nurse 1 (LN1) on 7/2/25 at 11:22 a.m., LN1 stated that when a resident brings in new clothing, facility staff should label the items and update the inventory list kept in the resident's closet. During an interview with Certified Nursing Assistant 1 (CNA1) on 7/2/25 at 11:30 a.m., CNA1 stated that when a resident brings in new clothes, staff should label them and update the resident's inventory list when placing them in the closet. During a concurrent interview and record review with the Director of Nursing (DON) on 7/2/25 at 11:35 a.m., the resident's inventory list was reviewed and found to be outdated, having not been updated since admission. The DON acknowledged that the inventory list was not current and stated it should be updated once the resident's pants were labeled. During a review of the facility's policy and procedure titled Personal Property, dated 9/1/2011, indicated: Record additional belongings on the clothing list when they are brought in or remove them from the list

Based on observation, interview and review of facility documents, the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety when: 1. The high temperature dish machine was not reaching 150 degrees Fahrenheit (F) for the wash cycle and 180 degrees F for the rinse cycle and the facility did not have a mechanism to verify the plate level temperature was reached according to their policy and procedure; and 2. [NAME] 2 (C2) did not change gloves after touching raw meat then touching other items. These failures resulted in equipment, utensils, dishware and silverware not being properly cleaned and sanitized and had the potential to result in the growth of microorganisms which can cause foodborne illness for the 49 residents eating food from the kitchen. Findings: 1. During a concurrent observation and interview on 1/21/25 at 10:35 a.m. with Dishwasher 1 (DW1), the last rack was observed being placed in the dish machine. DW 1 stated he knows the dish machine is working properly when the wash temperature is 150 degrees F and rinse temperature is 180 degrees F. The gauges on front showed 130 degrees F. During an observation of the lunch meal service on 1/21/25 at 11:45 a.m., [NAME] 1 (CK 1) was calibrating thermometers in an ice water bath. Surveyor put in surveyor thermometer (DeltaTrak min/max) to calibrate with facility thermometers. Surveyor's thermometer read 33 degrees F and facility thermometers was 32 degrees F. During a concurrent observation and interview on 1/22/25 at 9:16 a.m. with Dishwasher (DW) in presence of the Director of Dietary Services (DDS) at dish machine in main kitchen, the gauges indicated, wash and rinse temperatures approximately 130/132 degrees F. Towards the back of the dish machine there was another gauge that indicated, final rinse temperature was 180 degrees F. There was an Ecolab display that indicated, Refill Detergent and temperature of 133.1 degrees F. DW stated the rinse temperature needs to be 180 degrees F. Surveyor put the DeltaTrak min/max thermometer (waterproof thermometer that can be used for dish machines) in the dish machine on a rack with dishes when the dishes were going through. Surveyor thermometer showed 136.4 degrees F as the max temperature. Surveyor placed it through on the racks a second times and got a temperature of 137.9 degrees F. The DDS stated they use the display gauges on the dish machine and not the Ecolab display monitor. The DDS stated the facility did not have any way to verify temperatures and would follow up with Ecolab. During the review of the manufacturer's directions posted on the dish machine, showed the hot water sanitizing recommended minimum temperatures for wash was 150 degrees F, final rinse 180 degrees F. During a concurrent observation and interview on 1/23/25 at 09:19 a.m. with DDS and Maintenance Engineer (ME1) in main kitchen at dish machine, surveyor min/max thermometer temperature was 139 degrees F. ME1 stated pipe labeled final rinse is water supplied to machine with temp reading 175 degrees F. ME1 infrared thermometer temp on water inside paused dish machine and the reading was 119 degrees F and concurrent measurement with survey thermometer reading was 129.6 degrees F. DDS stated he would reach out to ecolab again and let them know it was an emergency. During an interview on 1/23/25 at 11:15 a.m. with the Ecolab Vender Technician (VT1), VT1 stated the surface temperature was 149 degrees F when he checked it and then stated the dish machine needed to be at 160 degrees F at the plate level for proper sanitation. VT1 stated this was his first time to facility and if it cannot be repaired, will provide sanitizer. VT1 was changing out the Ecolab display monitor at the time. VT1 confirmed contracted vendor should be coming to facility once per month. DDS confirmed vendor should be coming once per month. During a concurrent observation and interview in the presence of DDS on 1/23/25 at 12:30 p.m., Ecolab monitor showed 114 degrees F for the wash and 150 degrees F for the rinse. Surveyor ran the DeltaTrak thermometer through the dish machine a couple times, all max temperatures showed similar readings to 124.9 degrees F. DDS drained the dish machine and restarted it, then the Ecolab monitor started showing temperatures of 140 degrees F for wash and rinse of 180 degrees F. DDS stated the verification strips would be in tomorrow morning and they would verify if the gauges were accurate. During an interview with the Registered Dietitian (RD) on 1/23/25 at 10:56 a.m., the RD stated she periodically goes into the kitchen to do inspections. RD stated she probably should be doing those monthly. During an interview on 1/23/25 at 11:24 a.m., with the RD stated was not aware of any problems with the dish machine. RD stated there were surface temperature devices to verify high temperature dish machine and she was not aware the facility had no way to verify temperatures of the gauges or that plate/surface level was met. RD stated she does periodic kitchen inspections and that means quarterly. RD stated she does not verify if the dish machine was meeting appropriate temperatures. During a concurrent interview and record review on 1/24/2025 at 10:10 a.m. with the DDS, the Dish machine Temperature Logs dated November 2024, December 2024, and January 2025 were reviewed. The Dish machine Temperature Log for November 2024 indicated five recordings of a final temp below 180F. The Dish machine Temperature Log for December 2024 indicated three recordings of final temp below 180F. DDS states was not made aware of low temperature readings. It is unclear if or when he checks the logs. During a review of the January Dish machine temperature logs, showed there was 13 times the wash temperature was not 150 degrees F. The January logs dated on the 21st showed for breakfast the wash temperature was 141 degrees F. The 22nd showed for breakfast the wash temperature was 149 degrees F and for the lunch meal it was 147 degrees F and dinner it was 145 degrees F. The log showed the code for adequate temperature for wash was 150 and rinse 180 or higher. Under Litmus strips it showed a zero with a line through it. During a review of Dishmachine Temperature Log dated November 2024, December 2024, and January 2024 the Dishmachine Temperature Log indicated missing weekly surface temperatures for all three months. During a review of Eco lab Regular Service Call, the Regular Service Call indicated last service visit date of 11/29/2024 at 12:07 p.m. During a review of facility's policy and procedure titled Dishwashing Procedure dated 11/19/2019, the policy indicated, Once a week the Dietary Manager should check the accuracy of the gauges by sending a lollipop thermometer or a T-strip through the dish machine. It indicated the thermometer or test strip will measure surface or utensil temperature. Surface temperature is the temperature of the water that is contacting the dish, utensil, etc. Surface temperature should be 160 F or above. Wash, & rinse temperatures must be observed and logged during the dishwashing period 3 times a day. The rack level temperature must be logged once a week. Final Rinse Temperature [greater than or equal to] 180F. During a review of the facility's policy and procedure titled Recording of Dishmachine Temperatures, dated 08/29/2023, the policy indicated, Any inaccurate temperatures must be brought to the attention of the Director of Food and Nutrition Services or other clinically qualified nutrition professional immediately. 2. During an observation on 1/22/25 at 9:38 a.m. main kitchen griddle, C2 used gloved hands to repeatedly obtain raw meat from storage container, place on griddle, use tongs to remove meat, and placing cooked meat on pan with grate. Using same gloves, cooked meat was adjusted on pan with grate. At 10:04 a.m. C2 used same gloved hands to obtain more grates from stack of grates and rested tongs used for raw meat on grates. During an interview on 1/23/2025 at 11:24 a.m. with RD, RD stated the expectation of glove use would be staff would change them [gloves] after touching raw meat and would not want the same gloves when they touch raw meat and meat that is cooked even if it goes in oven for additional cooking. RD stated staff can get a false sense of security with gloves on their hands. According to the Food and Drug Administration (FDA) Food Code 2022, Annex 3, showed the failure of food-handlers to wash hands in certain situations (such as . handling raw meat .), wear clean disposable gloves, or use clean utensils is responsible for the foodborne transmission of these pathogens. According to the FDA Food Code 2022, Section 3-304.15 Gloves, Use Limitation. It showed if used, single-use gloves shall be used for only one task such as working with .or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.

51706 Based on observation, interview and record review, the facility failed to ensure the menus were followed when: 1. The incorrect portion sizes for meat and vegetables were served for the puree diet during the lunch meal on 1/22/25 for four residents (Residents 2, 3, 29, 35); and 2. The incorrect portion sizes were served for one resident (Resident 30) for the lunch meal on 1/21/25. This failure has the potential to result in residents not having their nutritional needs met. Findings: 1. During a review of the facility document titled, Daily Spreadsheet, dated 1/22/25 for the lunch meal, the Daily Spreadsheet indicated, for the puree diet, #6 scoop (2/3 cup) [NAME] broil (red meat), 1 ounce gravy, #8 scoop (1/2 cup) puree potatoes, and #10 scoop (3/8 cup) puree zucchini. During a concurrent observation and record review on 1/22/25 at 11:49 a.m., the lunch meal service steamtable contained puree meat ([NAME] broil) with a #8 scoop (1/4 cup), puree zucchini with a #8 scoop and mashed potatoes with a #8 scoop. [NAME] 1 (C1) was observed using a #8 scoop for the puree diets. Residents 2, 3, 29 and 35 received their puree diets with the incorrect amounts of meat, potatoes and zucchini. Review of the residents meal tickets indicated: Resident 2 was on regular, pureed, mildly thick, fortified diet. Resident 3 was on consistent carbohydrates, pureed, regular diet. Resident 29 was on regular, pureed diet. Resident 35 was on special nutrition fortified, pureed diet. During an interview on 1/22/25 at 12:24 p.m. with C1, and the Director of Dietary Services (DDS), C1 confirmed using #8 scoops for the puree diets and #8 scoops were not the correct portion sizes for the meat and vegetable. The DDS confirmed C1 was supposed to use a #6 scoop for the meat and #10 scoop for the vegetable. 2. During a review of the facility document titled, Daily Spreadsheet, dated 1/21/25, the lunch meal indicated, the regular diet, regular portion was to receive 3 ounces baked cod with panko crust, #8 scoop (1/2 cup) sun dried tomato polenta, #8 scoop sauteed fresh spinach and a dinner roll. During an observation of the lunch meal service starting at 11:45 a.m., C1 had two different scoops in the food products, #8 for regular portions and #12 scoops (1/3 cup) for small portions. C1 would scoop portions onto the plate depending on the diets called out by another kitchen staff. During an observation and review of the meal ticket for Resident 30, C1 portioned 1/2 serving of cod, #12 scoops of polenta and spinach on the plate which was placed on the tray and then into the meal cart. During a concurrent observation and interview on 1/21/25 at 12:20 p.m. with the Clinical Nutrition Coordiantor (CNC), Resident 30's plate was observed and meal ticket was reviewed. The CNC confirmed the portion sizes of the sides looked smaller than the other regular portion plates. CNC then asked C1 to portion another plate with regular portions for Resident 30. During a concurrent interview and record review on 1/23/25 at 10:56 a.m. with the Registered Dietitian (RD), the RD stated occasionally does an observation of tray accuracy or test tray but that is more about checking temperatures and that it had been awhile since she had done one of those. RD stated was not aware staff was not following menu portion sizes. Review of the daily spreadsheet indicated, portion sizes were not consistent day to day. RD stated was not aware that some says the portion sizes were different than on other days and confirmed they were not consistent. During an interview on 1/23/25 at 11:25 a.m. with the RD, RD stated expectation is that kitchen staff follow the menu daily spreadsheet and the portion sizes on the menu.

Based on review of the medical record for resident and interview with the facility's Director of Nursing (DON) on 1/23/2025, regarding resident 20's blood pressures, the facility had failed to ensure that this resident's blood pressure monitoring had been ordered by the resident's physician and not by the facility's nursing staff. The facility also failed to develop a policy and procedure which identified hypotension for the nursing staff. The facility's failure had the potential to put this resident at risk of severe hypotension which could result in ultimate organ failure and shock. Findings: Review of resident 20's clinical record revealed that this resident had been admitted to the facility on [DATE]. On revealed that this resident's physician had ordered, Coreg 6.25mg (a blood pressure medication) to be given twice daily for hypertension, please give with meals. without any blood pressure or pulse parameters on 9/11/2024. This resident continued to receive his Coreg from 9/12/2024 to 10/13/2024 without regard for the resident's blood pressure (BP) and pulse (P). Interview with the DON on 1/23/2025 at 3:45 pm confirmed that none of the facility's nurses had reached out to the resident's doctor to clarify if this blood pressure order needed clarification (as the order did not address the resident's BP and/or P). Further review of resident 20's medical record and interview with the facility's DON revealed that on 10/13/2024 at 4:10 pm, one of the facility's nurses revised this resident's BP medication on the Medication Administration Record (MAR) without obtaining direction from the resident's physician. The resident's MAR after 10/13/2024, now included recordings of a daily BP and a Pulse. Part of the concern was that nursing staff were not using the blood pressures and the pulses which were being taken by the nursing staff and using these parameters to determine whether the resident should be given his Coreg twice daily. During an interview with resident 20's medication nurse on 1/23/2025 at 3:45pm, the medication nurse was asked if she knew the definition of hypotension. The medication nurse then went to the Mayo Clinic and found the definition of hypotension and she found the following definition: Low blood pressure is a condition in which the force of the blood pushing against the artery walls is too low. It's also called hypotension. Blood pressure is measured in millimeters of mercury (mm Hg). In general, low blood pressure is a reading lower than 90/60 mm Hg. Review of resident 20's MAR from 10/13/2024 to 1/23/2025 revealed the following hypotensive episodes during which this resident received his BP medication: on10/16/2024 at 7:30 am (104/48), on10/23/2024 at 7:30 am (115/45), on11/13/2024 at 7:30 am (115/50), on11/13/2024 at 4:30 pm (102/49), on12/10/2024 at 7:30 am (104/43), on12/13/2024 at 7:30 am (97/46), on12/14/2024 at 4:30 pm (97/46), on12/23/2024 at 4:30 pm (102/46), on12/31/2024 at 4:30 pm (91/44). These example above show that this resident's blood pressure had already been low prior to recieving his blood pressure medication (Coreg) and the administration of this medication could have resulted in an abnormal drop in this resident's blood pressure which ultimately could have lead to this resident having vital organs not getting enough oxygen and nutrients, which could ultimately lead to this resident going into shock.

Based on interview and record review, the facility failed to monitor the medication refrigerator temperature twice a day and maintain the temperature within acceptable range. This failure had the potential for the residents to receive ineffective medications due to improper storage. Findings: During an interview on 1/21/25 at 3:26 p.m. with the Director of Nursing (DON), in the medication storage room, the DON stated the temperatures of the refrigerator in the medication storage room are monitored once a day in degrees Fahrenheit (F). During a concurrent interview and record review on 1/21/25 at 4:20 p.m., with the DON, Medical Room Refrigerator Temperature Monitoring Log (MRRTML), for October 2024, November 2024, and December 2024 were reviewed. The MRRTMLs indicated the following temperatures in Farenheit (F): 12/8/24: 34 degrees 11/14/24: 34 degrees 11/22/24: 34 degrees 11/24/24: 30 degrees 11/27/24: 32 degrees 11/28/24: 34 degrees 11/29/24: 34 degrees 11/30/24: 34 degrees 10/12/24: 32 degrees Additionally, the MRRTML indicated Report all temperatures that do not meet standards. Note corrective action. The DON acknowledged the temperature readings of the above said dates are below accepted temperature range of 36-46 degrees F and there is no documented evidence that there was any corrective action when the temperatures were noted out of range. During an interview on 1/24/25 at 12:07 p.m. with the DON, the DON confirmed influenza vaccines are stored in the medication room refrigerator and stated, Our policy states we should have been monitoring the temperature twice a day and we were not. During a review of the facility's Policy and Procedure (P&P) titled, Medication Storage, storage of medication (California Specific), dated 01/23, the P&P indicated, Medications requiring 'refrigeration' or 'temperatures between 2 C (Celsius) (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring . The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily.

51706 Based on observation, record review, and interview the facility failed to ensure residents were provided a well-balanced, physician prescribed diet that met their nutritional needs when meal ticket and diet order did not match for seven (7) residents (Residents 7, 23, 29, 34, 35, 37, and 38). This failure had the potential for residents to receive incorrect diets and have nutritional deficits. Findings: During a concurent observation and interview in the kitchen on 1/21/25 starting at 11:45 a.m. with the Director of Dining Srvices (DDS), a lunch meal service was observed. Resident 33's meal ticket showed the resident was on a puree small portion diet. Further review of the meal ticket indicated, the resident was to receive a #6 scoop (5.33 ounces) of lamb. The DDS stated was not sure why the meal ticket showed #6 scoop, but they use half portions on all items when serving a small portion diet. During a concurrent interview and record review on 1/23/2025 at 10:56 a.m. with Registered Dietitian (RD), the PontClickCare (PCC) diet report electronic record was reviewed. The PCC indicated, there were diets that were not the same as on the meal ticket report. During an interview on 1/23/25 at 11:24 a.m. with the RD, the RD stated will run a diet type report from both PCC and [NAME] diet list every couple of months. RD stated there are diet discrepancies between those reports. During review of facility documents of the PCC diet report and the [NAME] meal ticket diet report on 1/23/2025 at 11:24 a.m., RD confirmed the following: Resident 7's PCC diet order indicated, Regular, Fortified. Resident 7's [NAME] meal ticket diet report indicated, Regular, Fortified, Small Portion. Resident 23's PCC diet order indicated, Regular, Fortified. Resident 29's [NAME] meal ticket diet report indicated, Regular, Fortified, Small Portion. Resident 29's PCC diet order indicated, Regular, Pureed. Resident 29's [NAME] meal ticket diet report indicated, Pureed, Small Portion. Resident 34's PCC diet order indicated, Regular, Easy to Chew. Resident 34's [NAME] meal ticket diet report indicated, Easy to Chew, Small Portion. Resident 35's PCC diet order indicated, Regular, Pureed, Fortified. Resident 35's [NAME] meal ticket diet report indicated, Regular, Pureed, Consistent Carbohydrate (CCHO), Fortified. Resident 37's PCC diet order indicated, Regular. Resident 37's [NAME] meal ticket diet report indicated, Regular, Small Portion. Resident 38's PCC diet order indicated, Regular, Easy to Chew, Chopped Meat. Resident 38's [NAME] meal ticket diet report indicated, Regular, Easy to Chew. During a review of the facility's Policy and Procedure (P&P) titled, Transmission of Diet Orders, dated 09/04/2018, the P&P indicated, 2. Upon admission or change of diet order, a Dietary Communication form should be completed, dated, signed by a Licensed Nurse, and sent to Dietary with a confirmation of the prescribed diet order and a copy goes in Dietary section of the chart .4. A tray card is prepared according to the prescribed diet and inserted in its proper place for tray setup.

Based on record review and interview, the facility failed to ensure one of three sampled residents (Resident 3) received supervision and assistive devices to prevent an accident and/or injury. Resident 3, who was assessed by the facility as a high risk for falls and required extensive assistance (Resident involved in activity, staff provide weight-bearing support) with toileting, was placed on a toilet and left unattended and unsupervised. As a result of these failures, Resident 3 fell from the toilet and sustained subcapital fracture of the left proximal femur with overriding (left hip fracture)," which placed the resident at risk for pain, deformity, and complications of her fractures, which included fat embolism (a process caused by a bone fracture by which fat tissue passes into the bloodstream and lodges within a blood vessel), and death. Findings: During a review of the clinical record for Resident 3, the admission record indicated [DIAGNOSES REDACTED]. A review of the facility's Fall Risk Assessment, dated 3/15/14, identified Resident 3 as a "HIGH RISK" for falls due to: intermittent confusion, being bed bound, requiring assistance with toileting, inability to balance on both feet without holding onto something, medications, and predisposing diseases. The Fall Risk assessment dated from 1/14/13-6/4/14 indicated Resident 3 had multiple falls while at the facility, which included the following dates: 4/1/2013, 4/26/13, 6/5/2013, 6/20/2013, and 10/22/13. The facility's comprehensive assessment, dated 3/17/14, indicated Resident 3 required extensive assistance of one person's physical assistance for activities of daily living which included transferring, dressing, and toileting. A review of the facility's care plan titled, "At risk for fall or injury," dated 1/23/13, indicated Resident 3 was a fall risk. The facility's interventions to prevent Resident 3 from falls or injury included: monitoring Resident 3's location especially in the bathroom, alarms and an antiroll back device for Resident 3's wheelchair, nonskid socks, and keeping Resident 3 near the nurses station. On 3/27/13 the facility revised and updated this care plan with the intervention "Don't leave (Resident 3) alone on toilet." A review of the licensed nurses progress notes indicated on 6/3/14, Resident 3 fell from a toilet and was assessed to be in pain. Two hours later (at 12:10 a.m.) Resident 3 complained of severe back pain radiating to the pelvis upon extension of her left leg, and could not bear weight on the left leg. Resident 3's physician gave an order to transport the resident to the acute hospital's emergency room via ambulance for an evaluation and treatment. Review of the acute care hospital emergency room Consultation Notes dated 6/4/14, indicated that Resident 3 had sustained a left hip fracture post fall at the skilled nursing facility, and was "markedly confused and disoriented and essentially nonverbal." Review of the acute care hospital emergency room document titled "X-Ray of Left Hip, Complete" dated 6/4/14, indicated a "subcapital fracture of the left proximal femur with overriding (left hip fracture)." During an interview on 7/1/14, at 2:05 p.m., the director of nursing (DON) stated the facility's policy was: not to leave cognitively impaired residents alone on a toilet or in the bathroom. During an interview on 7/1/14, at 12:35 p.m., the director of staff development (DSD) stated the facility trains staff to "never leave cognitively impaired residents alone in the bathroom." The facility's policy and procedure titled "Toileting" dated 9/1/11, indicated "Provide particular patient centered assistance (while toileting) required for the individual resident while maintaining safety." The facility policy and procedure titled "Fall Prevention Program" dated 9/24/12, indicated "all interventions will be added to the care plan to prevent falls." The facility's care plan for Resident 3 titled "At risk for fall or injury" dated 1/23/13, and revised on 3/27/13 indicated "Don't leave (Resident 3) alone on toilet." During an interview on 7/1/14, at 11:45 a.m., a certified nurses assistant (CNA 1) stated she was aware Resident 3 was cognitively impaired when she left the resident alone in the bathroom unsupervised on 6/3/14, stating "It was my fault for leaving the resident."