Every finding on record at Auburn Ravine Healthcare Center

Based on interview and record review, the facility failed to develop and implement policies and procedures for the safe and effective use of insulin (used to control blood glucose levels) when:Seven of seven residents (Residents 3, 38, 37, 29, 51, 9, and 32) receiving prandial insulin (mealtime insulin) had blood glucose results monitored using FSBS (finger stick test to check blood glucose) obtained up to 1.5 hours before meals instead of current mealtime readings.Four of four residents (Residents 3, 38, 37, and 29) receiving insulin had insulin doses administered up to 1.5 hours before scheduled meals, not in accordance with physician orders or manufacturer guidelines, and outdated FSBS values were used to determine sliding scale insulin doses (correctional insulin based on the current glucose level).These failures created the risk for incorrect insulin dosing, including potential overdose if meals were refused, and increased the potential for uncontrolled blood glucose levels, placing residents at risk for adverse effects such as rapid heartbeat, confusion, seizures, and loss of consciousness.Findings:1 a. A clinical record review indicated Resident 3 was admitted on [DATE] with Type 1 diabetes mellitus (the body does not produce insulin, causing high blood glucose), polyneuropathy (nerve damage), and chronic kidney disease (long term kidney damage).A review of Resident 3's physician orders indicated: Insulin lispro 2.5 units with meals (fixed mealtime dose used to process glucose from the meal); hold if not eating or if FSBS < 90 mg/dL. Order start date: 7/6/26. Insulin lispro sliding scale (SSI) with meals (correctional insulin; dose based on the current blood glucose). Order start date: 5/16/26.A review of the facility's Dietary Department Mealtimes schedule indicated breakfast was served from 7:15-8:15 a.m., lunch from 11:30 a.m.-12:30 p.m., and dinner from 5:15-6:15 p.m.A review of the August MAR and FSBS indicated:8/1/26FSBS at 5:38 a.m.; SSI 10 units at 5:38 a.m. (1 hr 37 min before breakfast).FSBS at 4:35 p.m.; SSI 8 units at 4:35 p.m. (40 min before dinner).8/2/26FSBS at 5:38 a.m.; SSI 10 units at 5:38 a.m. (1 hr 37 min before breakfast).FSBS at 4:17 p.m.; SSI 2 units at 4:17 p.m. (58 min before dinner).FSBS at 4:17 p.m.; fixed-dose 2.5 units 4:24 p.m. (51 min before dinner).8/3/26FSBS at 5:53 a.m.; fixed dose lispro 2.5 units at 5:52 a.m. (1 hr 23 min before breakfast).FSBS at 5:53 a.m.; SSI 10 units at 5:53 a.m. (1 hr 23 min before breakfast).FSBS at 6:37 p.m.; SSI 4 units at 6:37 p.m. (1 hr 22 min after dinner).FSBS at 6:37 p.m.; fixed dose lispro 2.5 units at 6:39 p.m. (1 hr 24 min after dinner).8/4/26FSBS at 6:04 a.m.; fixed dose lispro 2.5 units at 6:05 a.m. (1 hr 10 min before breakfast).FSBS at 4:09 p.m.; SSI at 4:09 p.m. (1 hr 6 min before dinner).8/5/26FSBS at 3:13 a.m.; fixed dose lispro 2.5 units at 5:50 a.m.;FSBS at 3:13 a.m.; SSI 6 units at 6:00 a.m.;(FSBS result was 2 hr 37 min old)These insulin doses were administered 1 hr 25 min and 1 hr 15 min before breakfast. A clinical review of Resident 3's August MAR and FSBS from August 1 through 5, 2026 indicated FSBS checks were frequently completed more than 1 hr before scheduled meals, and these early readings were used to determine sliding scale insulin (SSI) dosing. This resulted in 13 insulin administrations that were not given according to physician orders or manufacturer guidelines requiring rapid acting insulin to be administered with meals. Several doses were administered more than 1 hr before meals or were based on outdated FSBS readings. There were also four times when both SSI and fixed dose lispro were administered during the same dosing period using the same FSBS result. These practices resulted in insulin dosing that did not reflect mealtime blood glucose levels and were inconsistent with mealtime insulin requirements, creating the potential for hypoglycemia or hyperglycemia, with symptoms such as dizziness, sweating, shakiness, confusion, headache, blurred vision, and in severe cases, loss of consciousness or seizure. A review of the Prescribing Information (PI) for insulin lispro, revised December 2018, indicated the medication should be administered within fifteen (15) minutes before a meal or immediately after a meal. The PI also stated, hypoglycemia may be life threatening and advised increased glucose monitoring with changes in dose, medications, or meal patterns.During an interview and record review on 8/4/26 at 10:39 a.m., Licensed Nurse (LN 3) stated she confirmed from Resident 3's record that the scheduled 2.5 unit mealtime lispro dose was administered at 6:05 a.m. by the night nurse, although breakfast was not served until approximately 7:40 a.m.1 b. A clinical record review indicated Resident 38 was admitted on [DATE] with Type 2 diabetes mellitus.A review of Resident 38's active physician orders indicated: Insulin lispro 5 units with meals (fixed dose). Order start date: 6/30/26. FSBS before meals and at bedtime; notify the physician if FSBS < 60 mg/dL or > 300 mg/dL.FSBS checks for August 2026 were often completed more than 1 hr before meals, contrary to physician orders requiring FSBS monitoring before mealtimes.A review of the August MAR and FSBS indicated:8/1/26FSBS at 5:37 a.m.; lispro 5 units at 8:34 a.m. (FSBS taken 2 hr 57 min before dose).FSBS at 3:57 p.m.; lispro 5 units at 5:28 p.m. (FSBS taken 1 hr 31 min before dose).8/2/26FSBS at 5:36 a.m.; lispro 5 units at 7:54 a.m. (FSBS taken 2 hr 16 min before dose).FSBS at 12:28 p.m.; lispro 5 units at 1:14 p.m. (given 44 min after lunch).8/3/26FSBS at 5:52 a.m.; lispro 5 units at 7:05 a.m. (FSBS taken 1 hr 13 min before dose).FSBS at 10:36 a.m.; lispro 5 units at 11:55 a.m. (FSBS taken 1 hr 19 min before dose).8/4/26FSBS at 5:48 a.m.; lispro 5 units at 6:17 a.m. (58 min before breakfast).8/5/26FSBS at 6:30 a.m.; lispro 5 units at 6:30 a.m. (45 min before breakfast).A clinical review of August 1-5, 2026 indicated Resident 38 received two doses of 5 units of scheduled prandial lispro, ordered to be administered with meals, at 45 min and 58 min before breakfast tray service. Administering rapid acting insulin this far in advance of the meal is not consistent with manufacturer guidelines or physician orders and placed the resident at risk for hypoglycemia. Possible symptoms of hypoglycemia include palpitations, shakiness, sweating, dizziness, confusion, and, in severe cases, seizures or loss of consciousness.1 c. A clinical record review indicated Resident 37 was admitted on [DATE] with Type 1 diabetes mellitus and diabetic neuropathy.A review of Resident 37's physician orders indicated: Insulin lispro 5 units with meals (fixed dose). Order start date: 7/18/26. Sliding scale insulin lispro (SSI) with meals. Order start date: 7/18/26.A review of the August 2026 MAR and FSBS indicated:8/1/26FSBS at 6:44 a.m.; SSI lispro 2 units at 6:44 a.m. (31 min before breakfast).8/2/26FSBS at 5:42 a.m.; SSI lispro 8 units at 5:42 a.m. (1 hr 33 min before breakfast).8/3/26FSBS at 11:14 a.m.; fixed dose lispro 5 units at 1:22 p.m. (FSBS taken 2 hr 8 min before dose; dose given 52 min after lunch).8/4/26FSBS at 6:13 a.m.; SSI lispro 2 units at 6:13 a.m. (1 hr 2 min before breakfast).8/5/26FSBS at 6:02 a.m.; SSI lispro 2 units at 6:02 a.m. (1 hr 13 min before breakfast).A clinical review of August 1-5, 2026 indicated Resident 37 received insulin doses that were not timed with meals as ordered. FSBS checks were repeatedly completed more than 1 hr before breakfast and were used to determine four SSI doses. In total, five insulin administrations were not consistent with physician orders or manufacturer guidelines for rapid acting insulin. These practices created the potential for hypoglycemia or hyperglycemia, with symptoms including shakiness, sweating, dizziness, confusion, headache, blurred vision, and, in severe cases, loss of consciousness or seizure.1 d. A clinical record review indicated Resident 29 was admitted on [DATE] with Type 2 diabetes mellitus and diabetic neuropathy.A review of Resident 29's physician orders indicated: Sliding scale insulin lispro (SSI) before meals. Order start date: 5/1/26.A review of the August 2026 MAR and FSBS indicated:8/2/26FSBS at 9:44 a.m.; SSI lispro 1 unit at 9:44 a.m. (2 hr 29 min after breakfast).FSBS at 3:58 p.m.; SSI lispro 1 unit at 3:58 p.m. (1 hr 17 min before dinner).8/3/26FSBS at 10:32 a.m.; SSI lispro 1 unit at 10:32 a.m. (58 min before lunch).A clinical review of August 2026 indicated Resident 29 received three SSI insulin doses at times not consistent with physician orders requiring SSI before meals. These doses were administered 2 hr 29 min after breakfast, 1 hr 17 min before dinner, and 58 min before lunch. Additional FSBS checks were completed more than 1 hr before breakfast on two dates, with no SSI administered because values were outside sliding scale parameters. These practices resulted in insulin dosing based on outdated FSBS values rather than current mealtime glucose levels.During an interview on 8/4/26 at 10:23 a.m. at Medication Cart 2, Licensed Nurse (LN 5) stated that Resident 29's lunch sliding scale insulin order appears in the electronic system at 10:30 a.m., one hour before the scheduled 11:30 a.m. meal, which can lead to early administration. She stated she tries to give insulin as close to mealtime as possible, noting, I don't want to give insulin 1.5 hours before his meal.1 e. A clinical record review indicated Resident 51 was admitted to the facility on [DATE] with the Type 2 diabetes mellitus with diabetic chronic kidney disease.A review of Resident 51's physician orders indicated the following order:- Insulin Regular (short acting insulin) SSI with meals. Order start date 6/11/26. A clinical review of Resident 51's MAR and FSBS from August 1-4, 2026 indicated FSBS checks were consistently completed more than 1 hr before breakfast, ranging from 59 min to 1 hr 36 min early. Because these early FSBS readings were outside sliding scale parameters, no SSI doses were administered during the morning medication pass. Lunchtime FSBS values were elevated on 8/1, 8/2, and 8/3, resulting in SSI dosing at lunch. These practices were not consistent with physician orders requiring FSBS checks before meals or with manufacturer guidelines directing timely dosing of short acting insulin. The use of early, outdated FSBS values contributed to inaccurate monitoring of meal related glucose levels and created the potential for hypoglycemia or hyperglycemia A review of the Prescribing Information (PI) for Insulin Regular, revised May 2025, indicated the medication is to be injected 30 minutes before a meal. The PI also stated, Hypoglycemia is the most common adverse reaction of all insulins, including insulin regular. Severe hypoglycemia can cause seizures, may lead to unconsciousness, may be life threatening or cause death. The PI further noted that changes in meal patterns, including timing of meals, may increase the risk of hypoglycemia. 1f. A clinical record review indicated Resident 9 was admitted on [DATE].A review of Resident 9's active physician orders indicated: Insulin aspart (rapid acting insulin) sliding scale (SSI) with meals (correctional insulin; dose based on current blood glucose). Order start date: 2/20/26.A clinical review of Resident 9's August MAR and FSBS from August 1 through 5, 2026 indicated FSBS checks were routinely completed more than 1 hr before breakfast, ranging from 1 hr 23 min to 1 hr 43 min early. Dinner FSBS checks were also completed early, between 47 min and 57 min before the meal. As these FSBS readings were outside sliding scale parameters, no SSI doses were administered during this period. These early FSBS checks did not reflect mealtime blood glucose and were not consistent with physician orders or manufacturer guidelines for rapid acting insulin, creating the potential for inaccurate assessment of meal related glucose and future risk for hypoglycemia or hyperglycemiaA review of the Prescribing Information (PI) for insulin aspart, revised February 2023, indicated the medication is to be injected within 5-10 minutes before a meal. The Patient Information stated insulin aspart starts acting fast. You should eat a meal within 5 to 10 minutes after you take your dose. The PI also listed possible side effects, including serious side effects that can lead to death, such as low blood sugar (hypoglycemia). Signs and symptoms of hypoglycemia include dizziness, sweating, confusion, headache, blurred vision, shakiness, anxiety, and hunger.1 g. A clinical record review indicated Resident 32 was admitted on [DATE] with Type 2 diabetes.A review of Resident 32's active physician orders indicated: Insulin aspart sliding scale (SSI) with meals (rapid acting correctional insulin; dose based on current blood glucose). Order start date: 12/17/25.A clinical review of Resident 32's August MAR and FSBS from August 1 through 5, 2026 indicated FSBS checks were routinely completed more than 1 hr before breakfast and dinner, ranging from 48 min to 1 hr 43 min early, with one FSBS completed 49 min before lunch. Insulin was not indicated based on FSBS results, and no SSI doses were administered during this review period. These early FSBS checks did not reflect mealtime blood glucose and were not consistent with physician orders or manufacturer guidelines for rapid acting insulin, creating the potential for inaccurate assessment of meal related glucose levels and future risk for hypoglycemia or hyperglycemia.During an interview on 8/4/26 at 10:23 a.m. at Medication Cart 2, Licensed Nurse (LN 5) stated that blood glucose checks are performed before meals. She explained that the electronic medication administration system opens orders one hour early, causing some insulin doses and FSBS checks to appear on the prior shift. LN 5 stated this can result in insulin being administered before meals instead of with meals as ordered. This practice is not consistent with manufacturer guidelines. During an interview on 8/4/26 at 10:39 a.m. at Medication Cart 1, Licensed Nurse (LN 3) stated that insulin may be administered within one hour before its scheduled time. During an interview on 8/5/26 at 8:26 a.m., the Director of Nursing (DON) stated that medications ordered before meals are administered 30 minutes prior to the meal, and medications ordered with meals are administered when the meal tray is in front of the resident. She stated FSBS checks begin at 6:30 a.m. and that the facility follows a one hour before and one hour after window for medication administration. During review of clinical records for Residents 3, 38, 37, 29, 51, 9, and 32, the DON acknowledged that FSBS checks were not consistently performed with meals and, in some instances, were done up to 1.5 hours early. She stated this could result in hypoglycemia or hyperglycemia when insulin does not align with the resident's current blood glucose level or meal timing. During concurrent review on 8/5/26, she also confirmed that scheduled insulin lispro and sliding scale insulin doses were not consistently administered with meals for Residents 3, 38, 37, and 293, in August 2026, creating risk for hypoglycemia and hyperglycemia. During a phone interview on 8/5/26 at 11:05 a.m., the Consultant Pharmacist (CP) stated FSBS checks should be performed as ordered by the physician, and when ordered with meals should be completed about 20 minutes before meal service. He acknowledged the facility did not have a standard policy for FSBS timing and confirmed the medication administration policy requires medications ordered before meals or with meals to be administered at those times, but the facility did not have standardized administration times for those orders. The CP stated residents commonly have both prandial insulin and sliding scale (correctional) insulin ordered, and both must be administered with meals. He explained that FSBS values determine sliding scale doses and must reflect the resident's current blood glucose level. FSBS checks performed too early or not timed with meals can result in incorrect sliding scale dosing and increase the risk for hypoglycemia or hyperglycemia.A review of the facility's Insulin Administration policy, dated, March 2025, indicated no guidance for the timing of finger-stick blood glucose monitoring or insulin administration timing.A review of the facility's Obtaining a Fingerstick Glucose Level procedure, dated October 2010, indicated no guidance for the timing of finger stick testing.A review of the facility's Medication Administration-General Guidelines policy, dated March 2018 indicated, medications were administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes.A review of the Medication Administration Time document indicated standard administration times for daily insulin (6 a.m.) and twice daily insulin (6 a.m. and 4 p.m.), further review indicated, no times standard administration times for before meals or with meals.A review of the Institute for Safe Medication Practices (ISMP, a nonprofit organization dedicated to preventing medication errors) publication High Alert Medications in Long Term Care Settings, dated May 2021, indicated all insulin products as high alert medications. ISMP defines high alert medications as drugs that bear a heightened risk of causing significant patient or resident harm when used in error.A review of the ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults, dated, 2017 further indicated that a lack of coordination between meals, glucose checks, and insulin administration can have a significant impact on the effectiveness of diabetes management and the prevention of hyper and hypoglycemia, and that variability in timing can lead to harmful outcomes for the patient.

Based on observation, interview, and record review, the facility failed to ensure safe and proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) for four out of 17 sampled residents (Resident 1, Resident 2, Resident 42, and Resident 61) when resident's oxygen nasal cannulas (NC- a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) were not changed every seven days and/or per physician's orders.These failures had the potential to result in unsafe and unsanitary delivery of oxygen and for residents not to achieve their highest practicable well-being.Findings:A review of Resident 61's clinical record indicated Resident 61 was admitted July of 2026 with diagnoses which included chronic respiratory failure (lungs cannot send enough oxygen into the blood) and malignant neoplasm (cancerous growth) of unspecified bronchus (large airway passage) or lung. A review of Resident 61's physician's order, start date 7/24/26, indicated, OXYGEN D/T [due to] SOB [shortness of breath] HYPOXIA [body organs do not get enough oxygen to function properly]/SOB at 2-5L [liters per minute-unit of measurement] PER MIN [minute] VIA NASAL CANULA CONTINOUS. every shift.During a concurrent observation and interview on 8/2/26, at 10:08 a.m., with Licensed Nurse (LN) 1, in Resident 61's room, LN 1 stated the facility policy was to change oxygen tubing every Friday and to label it with the changed date. LN 1 acknowledged Resident 61's oxygen tubing was not labeled and stated it was supposed to be labeled. LN 1 further stated if oxygen tubing was not labeled the facility staff would not know how old the tubing was and potentially not sanitary. A review of Resident 42's clinical record indicated Resident 42 was admitted July of 2026 with diagnoses which included acute respiratory failure with hypoxia. A review of Resident 42's physician's order, start date 7/7/26, indicated, OXYGEN D/T Hypoxia 0.5L PER MIN VIA NASAL CANULA CONTINOUS. every shift.A review of Resident 42's physician's order, start date 7/10/26, indicated, CHANGE HUMIDIFIER BOTTLE(if empty), O2 [oxygen] TUBING, and clean filter by washing with water and soap, then rinse and squeeze dry. Must me [sp] done weekly and PRN [as needed] every night shift every Fri [Friday].During a concurrent observation and interview on 8/2/26, at 11:45 a.m., with LN 1, in Resident 42's room, LN 1 acknowledged Resident 42's oxygen tubing change date label was dated 7/25/26. LN 1 stated the oxygen tubing was supposed to be changed every Friday night and should have been changed yesterday. A review of Resident 2's clinical record indicated Resident 2 was admitted June of 2026 with diagnoses which included cerebral infarction (narrowed artery blocks blood flow to part of the brain) and dysphagia (trouble swallowing). A review of Resident 2's physician's order, start date 7/3/26, indicated, CHANGE HUMIDIFIER BOTTLE(if empty), O2 TUBING, and clean filter by washing with water and soap, then rinse and squeeze dry. Must me [sp] done weekly and PRN every night shift every Fri.During a concurrent observation and interview on 8/2/26, at 12:14 p.m., with Certified Nursing Assistant (CNA) 2, in Resident 2's room, CNA 2 confirmed Resident 2's oxygen tubing change date label was dated 7/25/26.A review of Resident 1's clinical record indicated Resident 1 was admitted July of 2026 with diagnoses which included acute and chronic respiratory failure with hypoxia. A review of Resident 1's physician's order, start date 7/12/26, indicated, OXYGEN: OXYGEN D/T Acute on Chronic Respiratory Failure with Hypoxia at 2L PER MIN VIA NASAL CANULA CONTINOUS. every shift.A review of Resident 1's physician's order, start date 7/17/26, indicated, CHANGE HUMIDIFIER BOTTLE(if empty), O2 TUBING, and clean filter by washing with water and soap, then rinse and squeeze dry. Must me [sp] done weekly and PRN every night shift every Fri.During a concurrent observation and interview on 8/2/26, at 3:15 p.m., with CNA 1, in Resident 1's room, CNA 1 confirmed Resident 1's oxygen tubing change date label was dated 7/25/26. A review of the facility's P&P titled, Oxygen Administration, revised 10/2014, indicated, Review the physician's orders or facility protocol for oxygen administration.1. Change oxygen tubing every week.23. Replace oxygen tubings every 7 days; label with date when changed.A review of the facility's P&P titled, Physician Orders, undated, indicated, Medications and treatments are administered according to standards of clinical practice upon the written order of a person duly licensed and authorized to prescribe such medications and treatments in this state.

Based on observation, interview, and record review, the facility failed to ensure medications were administered without error. During the medication administration observation, 5 medication errors were identified out of 38 opportunities, resulting in a medication error rate of 13.16% for five of seven residents observed (Resident 3, Resident 14, Resident 6, Resident 32, and Resident 29). This failure resulted in medications not being administered as prescribed, delays in treatment, and failure to observe residents during breathing treatments, creating the potential for less effective medication delivery, delayed pain relief, and negative health outcomes.Findings:1 a. During a medication pass observation on 8/2/26 at 11:45 a.m. with Licensed Nurse (LN 4), LN 4 was observed at Medication Cart 1 preparing Resident 6's breathing (inhalation) treatment. The medication consisted of one vial of ipratropium (opens airway passages and reduces mucus), 0.5 mg (milligrams, unit of strength), combined with albuterol (fast acting medication that opens airways) 5 mg in 3 mL (milliliters, unit of volume) of solution, to be administered by nebulization (a device that delivers liquid medication as a mist to be inhaled).At 11:47 a.m., on 8/2/26, LN 4 was observed at Resident 6's bedside adding the solution to the nebulizer device. LN 4 handed the resident the nebulizer mask (a face mask with straps that fits over the nose and mouth to allow the medication to be inhaled) and turned on the machine. The resident was observed holding the mask; LN 4 did not secure it.LN 4 stated she would return shortly, set an alarm on her phone for 15 minutes (the approximate duration of the treatment), and then proceeded to another resident's room to pass medications.At 12:20 p.m., on 8/2/26, LN 4 returned to Resident 6's bedside, stated the treatment was complete, and turned off the nebulizer. LN 4 did not remain with Resident 6, observe the treatment, or monitor the resident for potential side effects while the treatment was in progress.A clinical record review indicated, Resident 6 was admitted on [DATE] with the following medical conditions: acute respiratory failure with hypoxia (an acute emergency in which the lungs cannot supply enough oxygen to the body), interstitial pulmonary disease (inflammation or scarring in the lungs that makes breathing difficult), and pulmonary fibrosis (scarring of lung tissue that stiffens the lungs and reduces oxygen exchange).Further review identified an active physician order dated 6/16/26: Ipratropium Albuterol 0.5 mg/3 mg per 3 mL solution, to be administered every 6 hours., for desaturation (a drop in oxygen in the blood). Scheduled for: midnight, 6 a.m., 12 p.m., and 6 p.m.1 b. During a medication pass observation on 8/2/26 at 12:22 p.m. at Medication Cart 1, LN 4 was observed preparing one breathing treatment medication for Resident 14, ipratropium 0.5 mg with albuterol 3 mg/3 mL. LN 4 added the medication to the nebulizer, placed the mask on the resident, and started the device.At 12:26 p.m. on 8/2/26, LN 4 stated she would return in 15 minutes and proceeded to pass medications to other residents.At 12:49 p.m. on 8/2/26, LN 4 checked on Resident 14 and stated the machine was still running because the resident preferred to receive all the medication.At 1:29 p.m., on 8/2/26, LN 4 returned to Resident 14's bedside and turned off the nebulizer. LN 4 stated the resident had placed the mask beside her.A clinical record review indicated Resident 14 was admitted on [DATE] with medical conditions including: chronic obstructive pulmonary disease (COPD, long term lung disease that causes blocked airflow and makes breathing difficult), emphysema (damage to the air sacs that makes breathing hard), and chronic respiratory failure with hypoxia (long term condition in which the lungs cannot supply enough oxygen to the blood, leading to persistent low oxygen levels).Further review identified an active physician order dated 4/16/26: Ipratropium Albuterol 0.5 mg/3 mg per 3 mL solution, to be administered after meals and at bedtime, for shortness of breath related to chronic obstructive lung disease. Scheduled for 9 a.m., 1 p.m., 6 p.m., and 10 p.m.During an interview on 8/2/26 at approximately 1:30 p.m., LN 4 confirmed she did not observe the breathing treatments for Residents 14 or 6, stating, I wish I could stay and wait the fifteen minutes, and acknowledged she set a timer on her phone to remind herself to return.During an interview on 8/3/26 at 8:20 a.m., LN 5 stated she stays with residents during breathing treatments to ensure they receive the full dose, noting the mask could come off.During an interview on 8/3/26 at 3:04 p.m., the Director of Nursing (DON) stated she expects nursing staff to remain with the resident throughout the entire nebulizer treatment. She acknowledged the mask could come off or the device could malfunction, preventing the resident from receiving the full treatment.A review of the facility's policy titled Medication Administration-General Guidelines, effective March 2018, indicated, .The resident is always observed after administration to ensure that the dose was completely ingested.A review of the prescribing information for Ipratropium Bromide 0.5 mg and Albuterol Sulfate 3 mg Inhalation Solution (revised April 2025) indicated: Worsening of the narrowing in your airways (bronchospasm). can be life threatening. get emergency help if breathing problems worsen while or after using the medication.Common side effects include sore throat, chest pain, leg cramps, nausea, and pain. Further review indicated, Patient must avoid exposing their eyes to this product as temporary pupillary dilation [pupil, black portion of the eye gets larger], blurred vision, eye pain, or precipitation or worsening of narrow-angle glaucoma [fluid accumulates in the eye, causing pressure to rise and threats vision], may occur, and therefor proper nebulizer technique should be assured, particularly if a mask is used.2. During a medication pass observation on 8/3/26 at 11:52 a.m., LN 4 confirmed Resident 3 requested acetaminophen for right foot pain rated at 7 (on a scale of 0 to 10).At 11:55 a.m. on 8/2/26, LN 4 poured two tablets of acetaminophen 325 mg into a medicine cup and placed the cup inside Medication Cart 1. LN 4 then administered two other medications to Resident 3 and continued passing medications to other residents. The poured acetaminophen remained stored in the cart.At 12:50 p.m. on 8/2/26, LN 4 removed the acetaminophen from the cart and prepared the medication for Resident 3 by crushing the tablets and mixing them in pudding along with another crushed medication.At approximately 12:56 p.m. on 8/2/26, LN 4 administered the pudding mixture containing the acetaminophen to Resident 3-approximately one hour after Resident 3 initially requested pain relief-and apologized to the resident for the delay.During a follow up interview, LN 4 acknowledged she administered the acetaminophen about one hour after the resident requested it and confirmed the poured medication had been stored in the cart prior to administration.A review of Resident 3's physician orders dated 5/16/26 indicated: Acetaminophen 325 mg, give 2 tablets (650 mg) by mouth every four hours as needed for mild pain.During an interview on 8/3/26 at 3:04 p.m., the Director of Nursing (DON) stated she expects nursing staff to assess pain, administer pain medications as ordered, and treat pain promptly. She further stated she would not expect staff to store medication in the medication cart or delay administering pain medication to a resident experiencing pain.A review of the facility's policy titled Medication Administration-General Guidelines, effective March 2018, indicated, .Medications are administered at the time they are prepared. Medications are not pre poured.3 a. During a medication pass observation on 8/3/26 at 8:22 a.m., LN 5 prepared Resident 32's morning medications, including famotidine 20 mg (medication to lower stomach acid).At approximately 8:35 a.m., LN 5 administered the medications and Resident 32 was observed taking the pills with water. Resident 32's breakfast tray was on the bedside table and appeared to have been consumed.A review of Resident 32's physician orders, dated 8/6/25, indicated: Famotidine Tablet 20 mg, give 1 tablet twice daily for acid indigestion (stomach discomfort due to too much stomach acid), give at least 30 minutes before meals. Scheduled administration times: 9 a.m. and 5 p.m.3 b. During a medication pass observation on 8/3/26 at 8:54 a.m., LN 5 prepared Resident 29's morning medications, including omeprazole 40 mg (medication to reduce the production of stomach acid).At 9:01 a.m., LN 5 was at Resident 29's bedside, and the resident took the medications with water.A review of Resident 29's physician orders, dated 4/16/26, indicated: Omeprazole Capsule 40 mg, give 1 capsule once daily for acid reflux [when stomach acid flows back into the esophagus (the food pipe), causing a burning feeling], give on an empty stomach. Scheduled administration time: 9 a.m.During an interview and medication review on 8/3/26 at 11:44 a.m., at the Medication Cart 2, LN 5 stated breakfast begins between 7:45 a.m. and 8:10 a.m. She confirmed that Resident 32's famotidine and Resident 29's omeprazole were both administered after breakfast, not per the physician orders to give 30 minutes before meals and give on an empty stomach, LN 5 acknowledged the medications may not be as effective when given after meals.During an interview and concurrent clinical record review with the DON on 8/3/26 at 3:08 p.m., the DON stated she expects staff to administer medications according to physician orders, including timing related to meals. She confirmed breakfast starts at 7:15 a.m. and acknowledged both medications were not given at the correct times. She further acknowledged their effectiveness may be reduced when given after meals.A review of the facility's policy titled Medication Administration-General Guidelines, effective March 2018, indicated, .Medications are administered in accordance with written orders of the attending physician. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes.

Based on observation, interview, and document review, the facility failed to ensure food safety when;1. staff left personal belongings in the resident beverage preparation area,2. one [NAME] did not completely cover facial hair with a proper restraint, and 3.staff did not discard an opened package of sliced yellow cheese that was past the use by date in the walk in refrigerator.These failures had the potential to cause food contamination and food borne illness in 51 of 51 medically vulnerable residents who consumed food prepared in the facility's kitchen. The census was 52.Findings:1. During the kitchen inspection on 8/2/26 at 9:43 a.m., staff left a pink insulated tumbler on the residents' beverage preparation counter.During an interview with the Dietary Manager (DM) and Dietary Lead (DL) on 8/2/26 at 10:24 a.m., DM and DL confirmed the pink insulated tumbler belonged to a dietary staff member and should not have been placed in the residents' beverage preparation area. DM and DL stated the facility had a designated area for staff belongings and drink containers across from the residents' beverage preparation area.During an interview with the Registered Dietitian (RD) on 8/4/26 at 9:31 a.m., RD stated personal belongings should be placed in the staff's designated area to prevent cross contamination.A review of the facility's policy and procedure titled Food Preparation and Service, dated 2004, indicated: .Food Distribution and Service.5.All personal belongings should be placed in a designated area.2. During the kitchen inspection on 8/2/26 at 9:51 a.m., [NAME] (CK) was preparing food in the food preparation area. CK had a mustache and beard and wore a facial hair restraint; however, the restraint did not completely cover the facial hair, leaving the mustache exposed. In a concurrent interview, DL confirmed CK's mustache was exposed and stated the facial hair restraint should completely cover both the mustache and the beard.During an interview with RD on 8/4/26 at 9:31 a.m., RD stated all mustache and beard hair needed to be covered with a facial hair restraint.A review of the facility's policy and procedure titled Food Preparation and Service, dated 2004, indicated: .Food Distribution and Service.8. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.3. During the inspection of the walk in refrigerator on 8/2/26 at 9:53 a.m., staff stored an opened package of sliced yellow cheese labeled with a use by date of 7/31/26. In a concurrent interview, DL confirmed the sliced yellow cheese was past its use by date and stated it should have been discarded. DL stated all dietary staff should monitor the refrigerator.During an interview with the RD on 8/4/26 at 9:31 a.m., the RD stated products past the use by date should be discarded and dietary staff needed to monitor the refrigerators, pay attention, and check the dates.A review of the facility's policy and procedure titled Food Receiving and Storage, dated 2001, indicated: .Refrigerated/Frozen Storage.7. Refrigerated foods are labeled, dated and monitored so they are used by their 'use-by' date, frozen, or discarded.

Based on interview and record review, the facility failed to ensure physician orders and consistent monitoring were followed in accordance with professional standards for three out of 17 sampled residents (Resident 1, Resident 2, and Resident 42) when:1. Resident 1's, Resident 2's, and Resident 42's weight changes were not communicated to the physician as ordered; and,2. Resident 2 did not receive his heart medications in accordance with physician orders.These failures had the potential to negatively affect Resident 1's, Resident 2's, and Resident 42's health and their ability to achieve their highest practical well-being.Findings: 1. A review of Resident 1's clinical record indicated Resident 1 was admitted July of 2026 with diagnoses which included acute on chronic systolic heart failure (sudden and worsening of symptoms of heart pumping weakness) and atrial fibrillation (heart rhythm disorder). A review of Resident 1's physician's order, start date 7/13/26, indicated, CHF [congestive heart failure] Daily Weight monitoring: Weigh resident daily first thing in the morning. Notify MD [medical doctor] if weight change of 2 pounds or more in one day or 5 pounds or more in 1 week. every day shift.During a concurrent interview and record review on 8/4/26, at 9:21 a.m., with the Director of Nursing (DON), Resident 1's July 2026 EMAR (electronic medical administration record) was reviewed. The DON confirmed Resident 1 had a physician order for monitoring daily weights and to notify the physician of weight changes of two or more pounds in one day. The DON further confirmed Resident 1 had a two-pound weight gain on 7/24/26 and on 7/30/26. The DON stated the expectation was for the physician to be notified of the weight changes per the physician order and the notification communication would be documented in the communication binder. A review of Resident 42's clinical record indicated Resident 42 was admitted July of 2026 with diagnoses which included heart failure. A review of Resident 42's physician's order, start date 7/9/26, indicated, CHF Daily Weight monitoring: Weigh resident daily first thing in the morning. Notify MD if weight change of 2 pounds or more in one day. every day shift.During a concurrent interview and record review on 8/4/26, at 9:35 a.m., with the DON, Resident 42's July 2026 EMAR was reviewed. The DON confirmed Resident 42 had a physician order for monitoring daily weights and to notify the physician of weight changes of two or more pounds in one day. The DON acknowledged Resident 42 had a two-pound weight gain on 7/22/26 and the physician should have been notified. A review of Resident 2's clinical record indicated Resident 2 was admitted June of 2026 with diagnoses which included cerebral infarction (narrowed artery blocks blood flow to part of the brain), occlusion and stenosis of right carotid artery (narrowing or complete blockage of a major blood vessel), bradycardia (abnormally slow heart rate), and peripheral vascular disease (slow circulation disorder). A review of Resident 2's physician's order, start date 6/25/26, indicated, Weigh resident daily first thing in the morning. Notify MD if weight gain of 2 pounds or 5lbs [pounds] in 1 week. every day shift. During a concurrent interview and record review on 8/4/26, at 9:43 a.m., with the DON, Resident 2's July 2026 EMAR was reviewed. The DON confirmed Resident 2 had a physician order for monitoring daily weights and to notify the physician of weight changes of two or more pounds in one day. The DON acknowledged Resident 2 had a two or more-pound weight gain on 7/3/26, 7/5/26, 7/11/26, 7/16/26, 7/18/26, and 7/30/26 and the physician should have been notified.During a follow up interview on 8/4/26, at 2:20 p.m., with the DON, the DON could not provide a copy of physician communication regarding weight gains for Resident 1 and Resident 42. DON also could not provide a copy physician communication regarding weight gain for dates 7/3/26, 7/16/26, 7/18/26 and 7/30/26 for Resident 2. DON stated nursing staff will be provided with additional training for consistent documentation and physician notifications. A review of the facility's P&P titled, Physician Orders, undated, indicated, Medications and treatments are administered according to standards of clinical practice upon the written order of a person duly licensed and authorized to prescribe such medications and treatments in this state.A review of facility job description titled, LVN [licensed vocational nurse] - Job Duties and Responsibilities, revised June 2020, indicated, Perform routine charting duties as required.Consult with the resident's physician in providing the resident's care, treatment.2. A review of Resident 2's physician's order, start date 6/25/26, indicated, Lisinopril [medication to lower blood pressure and treat heart failure] Oral Tablet 10 MG [milligrams-unit of measure] (Lisinopril) Give 10 mg by mouth one time a day for HTN [hypertension] **hold for SBP [systolic blood pressure-top number in a blood pressure reading] < [less than] 100; PR [pulse rate] <60.A review of Resident 2's physician's order, start date 7/9/26, indicated, Spironolactone [medication to treat high blood pressure and heart failure] Oral Tablet 25 MG (Spironolactone) Give 12.5 mg by mouth one time a day for diuretics [reduce fluid to lower blood pressure] **hold for SBP <110.A review of Resident 2's physician's order, start date 7/14/26, indicated, Midodrine HCl [medication to treat low blood pressure] Oral Tablet 2.5 MG (Midodrine HCl) Give 5 mg by mouth three times a day for hypotension [low blood pressure] **hold for SBP > [greater than] 110.During a concurrent interview and record review on 8/4/26 at 9:43 a.m. with the DON, Resident 2's July 2026 EMAR was reviewed. The DON confirmed that Resident 2's SBP was below 110 on 7/9/26 and 7/22/26, yet lisinopril and spironolactone were administered despite physician orders requiring these medications to be held when SBP is less than 110. The DON stated that administering these medications under those conditions could further lower the resident's blood pressure. The DON also confirmed that Resident 2's SBP was greater than 110 on 7/15/26, 7/16/26, 7/30/26, and 7/31/26, and midodrine was administered despite orders requiring it to be held when SBP exceeds 110. The DON stated that administering midodrine in these circumstances could increase the resident's blood pressure.A review of the facility's P&P titled, Physician Orders, undated, indicated, Medications and treatments are administered according to standards of clinical practice upon the written order of a person duly licensed and authorized to prescribe such medications and treatments in this state.A review of facility job description titled, LVN - Job Duties and Responsibilities, revised June 2020, indicated, Prepare and administer medications as ordered by the physician.

Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications according to facility policy and procedures (P&P) and/or manufacturer specifications in two of two medication carts when: Medication Cart 1 was unlocked and unattended. This failure had the potential to result in unauthorized access, accidental ingestion, and possible resident harm. One open, undated foil pouch containing levalbuterol vials (a medication delivered in mist form to help with breathing) was found in Medication Cart 2 for Resident 61. This failure created the potential for Resident 61 to receive expired or ineffective medication. One opened levalbuterol inhaler (prescription inhaler for quick relief of wheezing and shortness of breath) without a prescription label indicating whom it was prescribed for was observed in Medication Cart 2 stored with other inhalers. This failure had the potential to result in medication errors, including wrong resident, wrong dose, and increased risk of infection. One opened, undated multidose container of glucose test strips (used to monitor blood sugar) was observed in Medication Cart 1, creating the potential for inaccurate readings if expired or ineffective strips were used. A medication cup containing two loose tablets was observed stored in Medication Cart 1, creating the potential for unidentified medication to be administered and increasing the risk of medication errors.Findings:1.During a medication pass observation on [DATE] at approximately 12:35 p.m. at Medication Cart 1 with Licensed Nurse (LN 4), LN 4 stated that the blood pressure monitor was not working and left the cart to find another device. Medication Cart 1 was observed unlocked and unattended in the hallway.During an interview on [DATE] at approximately 12:40 p.m.at the Medication Cart 1, LN 4 confirmed the cart was not locked. She acknowledged it should have been secured and stated, I got distracted.During an interview on [DATE] at 3:27 p.m. with the Director of Nursing (DON), the DON stated she expected medication carts to be locked when left unattended.A review of the facility's policy and procedure titled Medication Labeling and Storage, revision date February 2023, indicated, .Compartments (including, but not limited to, .carts) containing medications and biologicals are locked when not in use, and .carts used to transport such items are not left unattended if open or otherwise potentially available to others.2. During an inspection of Medication Cart 2 on [DATE] at 10:41 a.m., the following were identified and confirmed with Licensed Nurse (LN 1):a. One opened, undated foil pouch containing multiple individual inhalation vials of levalbuterol, 0.63 mg (milligrams, unit of strength) per 3 mL (milliliters, unit of volume) for Resident 61. A review of the manufacturer's labeling on the pouch with LN 1 indicated, Once the foil pouch is opened, the vials should be used within two weeks. LN 1 acknowledged there was no open date on the pouch and acknowledged the risk of the medication not being as effective.A review of the prescribing information (PI, manufacturer's information on the storage, handling, and dosing of medication) for Levalbuterol Inhalation Solution, revised [DATE], indicated, Storage.Keep unopened vials in the foil pouch. Once the foil pouch is opened the vials should be used within 2 weeks.b. One levalbuterol meter dose inhaler was stored outside of its box and without a prescription label, among other labeled inhalers. LN 1 confirmed the levalbuterol inhaler was stored without a pharmacy prescription label and acknowledged the inhaler should have had a label, as there was no information indicating who the medication was for.A review of the facility's policy and procedure titled Medication Labeling and Storage, revision date February 2023, indicated, .The medication label includes, at a minimum:a. Medication name (generic and/or brand);b. prescribed dose;c. strength.e. resident's name;f. route of administration; andg. appropriate instructions and precaution.Further review indicated, .if medication containers have missing . labels contact the dispensing pharmacy for instructions regarding returning or destroying these items.3. On [DATE] at approximately 12:15 p.m. at Medication Cart 1 with LN 4, LN 4 confirmed the multidose vial of glucose test strips was opened and not dated. Review of the manufacturer's labeling on the vial with LN 4 indicated, use within 60 days (3 months) of first opening. LN 4 acknowledged the vial should have been dated to ensure efficacy.4. During a medication pass observation on [DATE] at 11:55 a.m. at Medication Cart 1 with LN 4, LN 4 was observed preparing Resident 3's requested, as needed medication for pain. LN 2 poured two tablets of acetaminophen (an over-the-counter medication for pain or fever) 325 mg into a medicine cup, labeled the cup with the resident's room number, and returned the cup into the cart.On [DATE] at 12:57 p.m., LN 4 was observed removing the medication cup labeled with Resident 3's room number and preparing it for administration. During a follow up interview immediately after administration, LN 4 confirmed the poured acetaminophen had been stored in the cart for approximately 1 hour. When asked how long poured medication could be stored in the cart, LN 4 stated she was not sure and thought it could be stored within 1 hour of pouring.During an interview on [DATE] at 3:04 p.m. with the Director of Nursing (DON), the DON stated she expects medication to be administered once it is prepared and confirmed poured medication should not be stored in the medication cart.A review of the facility's policy and procedure titled Medication Administration-General Guidelines, effective date [DATE], indicated, .Medications are administered at the time they are prepared. Medications are not pre-poured.

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when insulin lispro (rapid acting insulin used to control blood sugar) was not administered according to physician orders and manufacturer requirements for four out of four residents receiving insulin (Resident 3, Resident 38, Resident 37, and Resident 29).This failure had the potential to result in uncontrolled blood glucose, including hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose), increasing the risk of serious complications such as confusion, weakness, fainting, falls, or hospitalization.Findings:A review of the Institute for Safe Medication Practices (ISMP, a nonprofit organization dedicated to preventing medication errors and promoting safe medication practices) publication High Alert Medications in Long Term Care Settings (May 2021) identified all insulin products as high alert medications. ISMP defines high alert medications as drugs that bear a heightened risk of causing significant patient or resident harm when used in error.A review of the Prescribing Information (PI, manufacturer's information for medication dosing, side effects, patient instructions, and monitoring) for Insulin Lispro (Revised December 2018) indicated that insulin lispro should be administered within fifteen (15) minutes before a meal or immediately after a meal by injection. The PI further indicated in the Warnings and Precautions section that hypoglycemia may be life threatening and directed providers to monitor blood glucose and increase monitoring frequency with changes in insulin dosage, use of glucose lowering medications, or meal patterns.A review of the facility's document titled Dietary Department Mealtimes indicated that breakfast was served from 7:15 a.m. to 8:15 a.m., lunch from 11:30 a.m. to 12:30 p.m., and dinner from 5:15 p.m. to 6:15 p.m.1.A clinical record review indicated Resident 3 was admitted on [DATE] with Type 1 diabetes mellitus (a condition in which the body cannot make insulin, causing high blood glucose) and diabetes associated with complications: polyneuropathy (nerve damage) and chronic kidney disease (long term kidney damage.)A review of Resident 3's active physician orders indicated the following medication orders:-Insulin Lispro (Humalog) injection solution, 100 units(strength) per mL (milliliter, unit volume).Administer 2.5 units subcutaneously (under the skin) with meals. [Scheduled insulin lispro is a set dose given with meals to help the body process the glucose from food eaten].Order instructions: Hold if [resident] not eating and if FSBS [finger stick blood sugar, a current measurement of glucose in the blood] was less than 90 mg/dL [milligrams per deciliter, unit of blood glucose]. Order start date 7/6/26.- Insulin Lispro (Humalog) solution 100 unit/mL sliding scale [sliding scale insulin lispro is correctional insulin, used to lower blood glucose when it is already elevated, the dose is based on the current blood glucose reading]. Inject as per sliding scale with meals for type 1 diabetes. Order start date 5/16/26.A review of Resident 3's Medication Administration Record (MAR, nursing documentation of the date, time and amount of medication administered) for August 2026 indicated the following:Insulin Lispro 2.5 units (fixed dose) ordered with meals documented administrations: 8/3/26 at 5:52 a.m. (1 hour 23 min (minutes) before breakfast) 8/4/26 at 6:05 a.m. (1 hour 10 min before breakfast) 8/5/26 at 5:50 a.m. (1 hour 25 min before breakfast) Sliding Scale (correctional insulin ordered with meals) Lispro Insulin documented administrations: 8/1/26 at 5:38 a.m. 10 units (1 hour 37 min before breakfast) 8/2/26 at 5:38 a.m. 10 units (1 hour 37 min before breakfast) 8/3/26 at 5:53 a.m. 10 units (1 hour 22 min before breakfast) 8/5/26 at 6:00 a.m. 6 units (1 hour 15 min before breakfast) 8/5/26 at 6:00 a.m. 6 units (1 hour 15 min before breakfast) 2. A clinical record review indicated Resident 38 was admitted to the facility on [DATE] with Type 2 diabetes mellitus (the body does not use insulin effectively, causing high blood glucose), diabetic polyneuropathy (nerve damage caused by diabetes), and long term (current) use of insulin.A review of Resident 38's active physician orders indicated the following medication orders:-Insulin Lispro (Humalog) injection solution, 100 unit/mLAdminister 5 units subcutaneously with meals. [three times daily] for Type 2 Diabetes [NAME]. Order start date: 6/30/26. A review of Resident 38's Medication MAR for August 2026 indicated the following:Insulin Lispro 5 units ordered with meals documented administrations: 8/2/26 at 1:14 p.m. (44 min after lunch) (scheduled 11:30 a.m.-12:30 p.m.) 8/4/26 at 6:17 a.m. (58 min before breakfast) 8/5/26 at 6:30 a.m. (45 min before breakfast)3. A clinical record review indicated Resident 37 was admitted to the facility on [DATE] with: Type 1 diabetes mellitus and diabetic neuropathy. A review of Resident 37's active physician orders indicated the following medication orders:-Insulin Lispro (Humalog) injection solution, 100 units/ mLAdminister 5 units subcutaneously with meals for Type 1 DiabetesOrder start date 7/18/26.-Insulin Lispro (Humalog) solution 100 unit/mL sliding scale Inject as per sliding scale with meals for type 1 diabetes. Order start date 7/18/26.A review of Resident 37's Medication MAR for August 2026 indicated the following:Insulin Lispro 5 units ordered with meals documented administrations: 8/3/26 at 1:22 p.m. (52 minutes after lunch) Sliding Scale (correctional insulin ordered with meals), Insulin lispro documented administrations: 8/1/26 at 6:44 a.m. 2 units (31 min before breakfast) 8/2/26 at 5:42 a.m. 8 units (1 hour 33 min before breakfast) 8/4/26 at 6:13 a.m. 2 units (1 hour 2 min before breakfast) 8/5/26 at 6:02 a.m. 2 units (1 hour 13 min before breakfast) 4. A clinical record review indicated Resident 29 was admitted to the facility on [DATE] with the Type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by diabetes).A review of Resident 29's active physician orders indicated the following medication order, Insulin Lispro (Humalog) solution 100 unit/mL sliding scale Inject as per sliding scale before meals for diabetes. Order start date 5/1/26.A review of Resident 29's Medication MAR for August 2026 indicated the following insulin lispro sliding scale documentation: 8/2/26 at 9:44 a.m. 1 unit (2 hours 29 minutes after breakfast) 8/2/26 at 11:41 a.m. 1 unit (given 1 hour and 57 minutes from previous insulin lispro) 8/3/26 at 10:32 a.m. 1 unit (58 minutes before lunch) During an interview on 8/4/26 at 10:23 a.m. at Medication Cart 2, Licensed Nurse (LN 5) stated blood glucose checks are performed before meals and explained that the electronic system opens insulin orders an hour early, causing some doses to appear on the prior shift. She acknowledged this can lead to insulin being given before meals. LN 5 stated Resident 29's sliding scale lunch dose appears at 10:30 a.m., an hour before the scheduled 11:30 a.m. meal, and noted she tries to administer insulin closer to mealtime, stating, I don't want to give insulin 1.5 hours before his meals.During an interview on 8/4/26 at 10:39 a.m. at Medication Cart 1, Licensed Nurse (LN 3) stated that blood sugar checks and sliding scale insulin should be administered with meals. She explained that insulin may be given within one hour before the scheduled time. After reviewing Resident 3's record, LN 3 confirmed the scheduled insulin lispro dose was administered at 6:05 a.m. by the night shift nurse and acknowledged breakfast was served at approximately 7:40 a.m., confirming the insulin was not given with the meal.During an interview and record review on 8/4/26 at approximately 10:45 a.m. at Medication Cart 1 with Licensed Nurse (LN 3), the Nurse Practitioner (NP) stated that insulin lispro begins working within about 15 minutes and must be administered with meals as ordered. After reviewing Resident 3's clinical record, the NP confirmed the scheduled insulin lispro dose was not consistently given with meals and stated that administering scheduled or sliding scale insulin outside mealtimes increases the risk for hypoglycemia.During an interview and concurrent clinical record review on 8/5/26 at 8:26 a.m., the Director of Nursing (DON) stated that fast acting insulin, such as insulin lispro, begins working within about 15 minutes and must be administered when meal trays arrive. She confirmed meal service times as 7:15 a.m. for breakfast, 11:30 a.m. for lunch, and 5:15 p.m. for dinner. The DON stated insulin should be administered as ordered, with scheduled insulin lispro covering the resident's meal and sliding scale insulin correcting elevated blood glucose. After reviewing the insulin lispro orders, blood glucose values, and MARs for Residents 3, 38, 37, and 29 for August 2026, the DON acknowledged doses were not consistently administered with meals and confirmed the risk for hypoglycemia or hyperglycemia when insulin is not given as ordered.A review of the facility's policy titled Medication Administration-General Guidelines, effective March 2018, indicated, Medications are administered within 60 minutes of a scheduled time, except before or after meal orals, which are administered based on mealtimes.

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for one out of seven sampled residents (Resident 6) when,1.Two facility staff did not wear required personal protective equipment (PPE) when performing wound care on Resident 6 who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use), and,2. for a facility census of 55, facility staff (Facility Hairdresser [FHD]) did not receive ongoing infection prevention and control training from the facility.These failures resulted in an increased risk for wound contamination, and potential exposure of Resident 6 to germs and infection and the possible spread of germs among the residents in the facility.Findings:1.A review of Resident 6's clinical record indicated Resident 4 was admitted December of 2025 and had diagnoses that included cellulitis (bacterial skin infection affecting the skin's deeper layers and underlying tissue) of right toe, and need for assistance with personal care.A review of Resident 6's active physician's order, dated 12/17/25, indicated, Resident does have the capacity to understand choices &make [sic] health care decisions.A review of Resident 6's active physician's order, dated 12/18/25, indicated, ENHANCED BARRIER PRECAUTIONS R/T [related to] CHRONIC WOUNDS every shift.A review of Resident 6's care plan, dated 12/18/25, indicated, Resident requires Enhanced Barrier Precautions r/t presence of wounds .Implement enhanced barrier precautions (gown, gloves) when providing high risk care activities .A review of the list of residents on EBP, provided by the Infection Preventionist (IP) on 12/18/25 at 12:15 p.m., indicated Resident 6 was on EBP due to having chronic wounds.During an observation on 12/18/25 at 12:31 p.m. in Resident 6's room, two facility staff were observed handling, doing wound care, and changing Resident 6's wound dressing while only wearing gloves and not wearing a gown. There was also EBP signage posted outside of Resident 6's room which indicated, ENHANCE BARRIER PRECAUTION (EBP) .ANYONE PARTICIPATING IN ANY OF THESES SIX MOMENTS MUST ALSO: [NAME] [wear] gown and gloves .Wound care .During a subsequent interview on 12/18/25 at 12:34 p.m. with Treatment Nurse (TN) 1, TN 1 confirmed that she and the wound doctor were only wearing gloves when they did the wound assessment, care, and dressing change on Resident 6's wound. TN 1 stated they should have worn gown too because of the risk of contaminating Resident 6's wound and spreading infection.During an interview on 12/18/25 at 3:15 p.m. with the IP, the IP stated that staff should be wearing both gloves and gowns when doing wound care to prevent the risk of infecting the wound.During an interview on 12/18/25 at 4:35 p.m. with the Director of Nursing (DON), the DON stated that EBP should be practiced and observed properly by staff when doing wound care on chronic wounds to prevent the spread of germs and infection to the resident's wounds.A review of the facility's policies and procedures (P&P) titled, Enhanced Barrier Precautions, revised 12/2024, indicated, 2. Enhanced barrier precautions apply when: .b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained .7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) .8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .j. wound care (any skin opening requiring a dressing) .2.During an interview on 12/18/25 at 11:50 a.m. with the Social Services Director (SSD), the SSD stated the facility has a hairdresser who does the haircuts of the residents as needed.During an interview on 12/18/25 at 12:01 p.m. with the Facility Hairdresser (FHD), in the Beauty Shop, the FHD stated she provides services to residents from the Skilled Nursing Facility (SNF) per a schedule. The FHD also stated she would usually go take the residents from their room and sometimes would wheel them back to their room when the haircut or beauty shop services are done. The FHD further stated she already did four residents from the SNF since this morning.During an observation on 12/18/25 at 12:17 p.m., in the SNF lobby, a resident was observed being wheeled by a facility staff to the beauty shop for her hair appointment.During an interview on 12/18/25 at 2:05 p.m. with the FHD, in the Beauty Shop, the FHD stated she was a contracted employee of the facility. The FHD further stated she has no ongoing training for infection prevention and control and also, she does not join in-service trainings from the facility.During an interview on 12/18/25 at 3:15 p.m. with the IP, the IP stated she has checked her records and the FHD has never attended any of the infection control in-services training in the facility. The IP also stated she thinks the FHD should be attending the facility's in-services training for infection control so the FHD would be aware and have an ongoing training for infection control practices of the facility. The IP further stated the FHD should have an ongoing infection prevention and control training to prevent possible spread of infections to residents receiving services from her.During an interview on 12/18/25 at 4:35 p.m. with the Director of Nursing (DON), the DON stated the infection prevention and control program should be followed to prevent the spread infections among residents.A review of the facility document titled, Independent Contractor Agreement, dated 3/1/24, indicated, 5. Infection Control. Contractor will follow infection control policies, including hand hygiene, tool disinfection, PPE use, and illness reporting. The Document was signed by the Facility Administrator (ADM)and the FHD.A review of the facility's policies and procedures (P&P) titled, Infection Prevention and Control Program (IPCP), revised 12/2023, indicated, .3. The IPCP is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. 4. The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement.A review of the facility's P&P titled, Employees or Other Employers, Infection Prevention, revised 1/2024, indicated, Employees of other employers performing work on our premises shall cooperate fully with the facility's infection prevention and control practices.

Based on interview and record review, the facility failed to protect one out of seven sampled residents' (Resident 1) right to be free from physical abuse by a resident (Resident 2) when Resident 2 placed her hand over Resident 1's mouth and grabbed and squeezed Resident 1's wrist.This failure resulted in Resident 1 getting hurt and had the potential for Resident 1 and all residents in the facility to experience physical and/or psychosocial harm.Findings:A review of Resident 1's clinical record indicated Resident 1 was admitted August of 2025 and had diagnoses that included dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities) with agitation, and cerebral atherosclerosis (hardening and narrowing of arteries in the brain due to plaque buildup, restricting blood flow and oxygen to brain regions).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 11/5/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 0 out of 15 which indicated Resident 1 had a severely impaired cognition (mental process of acquiring knowledge and understanding).A review of Resident 2's clinical record indicated Resident 2 was admitted September of 2025 and had diagnoses that included malnutrition (state of poor nutrition that occurs when the body does not receive enough or the right nutrients to function properly), adult failure to thrive (a decline in older adults characterized by frailty, weight loss, reduced appetite, and cognitive and functional challenges), and muscle weakness.A review of Resident 2's MDS Cognitive Patterns, dated 10/6/25, indicated Resident 2 had a BIMS score of 15 out of 15 which indicated Resident 2 had an intact cognition.A review of Resident 2's progress notes, dated 11/11/25, indicated, CNA [Certified Nurse Assistant] reported to nurse about [Resident 2]'s behavior towards her roommate. She claims she keeps going over roommates side of the room. Taking her pillows, trying to reposition her. CNA and nurse went into the room and resident is back to [the] roommates side of the room [and] taking [the] roommates pillow saying she needs to be reposition and is snoring too loud. Nurse lets her know that she cannot be in her roommate side and cannot be touching her roommate .Resident appears to be aggressive after being told .A review of Resident 2's progress notes, dated 11/22/24, indicated, notified by CNA that [Resident 2] is refusing to wear brief. resident [Resident 2] is sitting on roommates beds without brief on. roommates ask [Resident 2] to stop and resident becomes hostile with roommates. [Resident 2] is taking clothes from roommates. CNA and nurse attemptedmultiple [sic] times to assist resident to own bed and retrieve roommates belongings, unsuccessful and resident became combative with CNA and nurse when asked to stay on her own bed.A review of Resident 2's progress notes, dated 11/23/24, indicated, Approximately around 0510 [5:10 a.m.] CNA notified nurse that while CNA was changing roommate [Resident 1] she kept yelling which made [Resident 2] walk towards roommate's bed. [Resident 2] told roommate [Resident 1] to let CNA change her [Resident 1] and suddenly grabbed her [Resident 1] wrist and covered her [Resident 1] mouth with her [Resident 2] hand .A review of Resident 2's Care Plan, dated 11/23/24, indicated, .Per staff resident [Resident 2] was witnessed trying to calm resident [Resident 1] because she [Resident 1] was yelling [then she] put her [Resident 2] hand to her [Resident 1] mouth and her [Resident 1] wrist.During an interview on 12/18/25 at 12:38 p.m. with CNA 1, CNA 1 stated Resident 2 has been moved to different rooms a lot of times already because she has been an issue with her roommates. CNA 1 then stated Resident 2 was recently moved to Resident 1's room when the incident happened. CNA 1 also stated that Resident 2 was known to make her roommates uncomfortable, that's why she has been moved a lot. CNA 1 further stated there was one time when Resident 2 was caught putting a pillow over her roommate's head that's why she was moved to a different room and then the new roommate was also disturbed too and did not like Resident 2 in their room, so she was moved to a different room again.During an interview on 12/18/25 at 1:08 p.m. with Resident 2's new roommate, (Resident 5), Resident 5 pointed at Resident 2 when she was asked if any resident is bothering or treating her badly. Resident 5 stated Resident 2 wanted her to always be quiet and would always get mad at her when she makes noise. Resident 5 also stated she does not feel comfortable and free in her own room anymore and she felt like she cannot do the things she wanted to do. Resident 5 further stated she likes to watch television, but she cannot watch normally like before anymore.During an interview on 12/18/25 at 1:12 p.m. with CNA 2, CNA 2 stated Resident 2 would get agitated and would yell when the TV gets loud or her surrounding gets noisy, and she would also get mad easily when a resident does things she does not like. CNA 2 also stated Resident 2 has a history of being aggressive towards staff where she grabs, pulls in, and jolts the staff's hand when she's mad or refusing care. CNA 2 further stated, .if she [Resident 2] can do it [being verbally and physically aggressive] to us [staff], I would think she would be able to do it to other residents .During an interview on 12/18/25 at 1:21 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 2 was mostly verbally aggressive but sometimes would also be physically aggressive with other residents. LN 1 also stated Resident 2 has history of refusing care a lot. LN 1 further stated Resident 2 does not like it and would get upset when her surrounding gets loud. During an interview on 12/18/25 at 4:14 p.m. with CNA 3, CNA 3 stated she was giving care to Resident 1 that morning and Resident 1 was agitated and was screaming, and Resident 2 was trying to calm her down and was caressing Resident 1's hair first. CNA 3 then stated she stepped out of the room to give time for Resident 1 to calm down and when she got back, she saw Resident 2 grab Resident 1 by the wrist and covered Resident 1's mouth with her other hand. CNA 3 further stated Resident 1 was complaining of pain when Resident 2 was grabbing her wrist because Resident 2 was really squeezing her hand.During an interview on 12/18/24 at 4:35 p.m. with the Director of Nursing (DON), the DON stated their priority is safety of all residents. The DON further stated that all residents should feel safe and be safe and free from abuse.A review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 2/2021, indicated, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to: .c. be free from abuse .A review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 4/2021, indicated, 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including but not necessarily limited to: .b. other residents .7. Implement measures to address factors that may lead to abusive situations .

Based on observation and interview, the facility failed to store and prepare food in accordance with professional standards of food safety for a census of 54 when several food items were not labeled and several food items were not disposed of once past their use-by date.These failures present a potential risk of foodborne illnesses for residents eating facility prepared meals. Findings:During the initial kitchen tour on 9/7/25 beginning at 8:03 a.m., with [NAME] 1 for confirmation (CK 1), the following items were observed to be past their use-by date: a container of apple sauce, four containers of prepared pudding, a bag of vanilla pudding mix and a container of fajita seasoning. Additionally, the following items were not labeled with a use-by date: a container of coleslaw, two trays of sour cream, one tray of peaches, one tray of custard dessert, and three pudding cups.During an interview on 9/9/25 at 12:10 p.m., with the Registered Dietitian (RD), the RD indicated that food items should be labeled with a date and should be tossed once they are past their use-by date to ensure food safety.During a review of the facility policy and procedure (P&P) titled, Food Receiving and Storage, revised 11/22, the P&P indicated, All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.

Based on observation, interview, and record review, the facility failed to properly label medications for a census of 54 when four eye drops were not labeled with resident names.This failure increased the potential for residents to receive medication that did not belong to them and for cross-contamination and infection.Findings:During a concurrent observation and interview on 9/8/25 with Licensed Nurse (LN1) of the number two medication cart, four eye drops in the top drawer were labeled only with a room number. LN 1 confirmed the findings and stated the eye drops should have the resident name on them. In case they move rooms.you don't want to give the medications to the wrong person.you don't want to mix them up, someone may be allergic.During an interview on 9/9/25 with the Director of Nursing (DON), the DON was shown a picture of the eyedrops. She confirmed the only identifier was a room number. The DON stated medications should be labeled with the resident names because residents could move rooms.During a review of the facility policy and procedures (P&P) titled, Labeling of Medication Containers, dated 4/19, the P&P indicated, All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations.Labels for individual resident medications include all necessary information, such as.the resident's name.

Based on observations and interviews, the facility failed to follow proper infection control practices for three of 14 sampled residents (Resident 9, Resident 11, and Resident 43) when:1. Resident 9's oxygen tubing and humidifier container (a small container of water connected to oxygen tubing used to moisten the air) were not changed after seven days,2. Resident 11's oxygen tubing and humidifier container were not labeled with a date, and3. A staff member did not put on a gown while providing care to Resident 43 who was on Enhanced Barrier Precautions (EBP, precautions taken to prevent the spread of disease and require the use of a gown and gloves).These failures had the potential to increase the spread of infection.Findings:1. Resident 9 was admitted to the facility in July of 2025 with diagnoses that included chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing).A review of Resident 9's Order Details (OD), dated 7/10/25, indicated, CHANGE HUMIDIFIER BOTTLE (if empty), O2 [oxygen] TUBING, and clean filter by washing with water and soap, then rinse and squeeze dry. Must me (sic) done weekly and PRN [as needed] every night shift every Fri [Friday].During a concurrent interview and observation on 9/7/25 at 9:07 a.m., with Certified Nursing Assistant 1 (CNA 1), Resident 9's oxygen tubing and humidifier container were found to be over seven days old. CNA 1 verbally confirmed that Resident 9's oxygen tubing had a date of 8/30/25.2. Resident 11 was admitted to the facility in September of 2025 with diagnoses that included acute respiratory failure with hypoxia (low levels of oxygen).During a concurrent interview and observation on 9/7/25 at 9:07 a.m., with CNA 1, Resident 11's oxygen tubing and humidifier container were not labeled with a date. CNA 1 verbally confirmed the findings.During an interview on 9/8/25 at 2:08 p.m. with the Infection Preventionist (IP), the IP indicated that oxygen tubing and humidifier container should be replaced every 7 days to prevent the buildup of pathogens.3. Resident 43 was admitted to the facility in August of 2025 with diagnoses that included benign prostatic hyperplasia (enlarged prostate).A review of Resident 43's OD, dated 8/13/25, the OD indicated, ENHANCED BARRIER PRECAUTIONS R/T [related to] indwelling catheters every shift.During a concurrent observation and interview, on 9/9/25 at 8:18 a.m., with the Director of Rehabilitation (DOR), the DOR was observed handling Resident 43's urinary catheter tubing with gloved hands but no gown. The DOR indicated that wearing a gown would be required to provide direct care to Resident 43 since he was on EBP.During an interview on 9/9/25 at 10:27 a.m. with the IP, the IP indicated that staff should be wearing a gown if staff will be providing high contact care to residents placed on EBP to prevent the spread of pathogens.During an interview on 9/9/25 at 3:20 p.m. with the Director of Nursing (DON), the DON indicated that she expected her staff to put on a gown and gloves when providing care to residents on EBP. The DON further indicated standards of practice suggest replacing oxygen tubing and humidifier container often and as needed.During a review of the facility's policy and procedure (P&P) titled Respiratory Therapy - Prevention of Infection, revised 8/15, the P&P indicated, Infection Control Considerations Related to Oxygen Administration.Mark the bottle with date and initials upon opening and discard when empty.Change the oxygen cannula [medical device that delivers supplemental oxygen to a patient through two prongs that fit into their nostrils] and tubing every seven (7) days, or as needed.During a review of the facility's P&P titled Enhanced Barrier Precautions, revised 12/24, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include.device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.).)

Based on interview, and record review the facility failed to maintain an infection control program for a census of 55 residents when: 1. Facility staff were observed not performing hand sanitation when entering and exiting resident's rooms; 2. Soiled linens were processed without adequate use of Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses); and, 3. The washing machine's water temperature was not monitored. These failures decreased the facility's potential to prevent the spread of disease and infections among residents. Findings: 1. During an observation and concurrent interview with Environmental Service 1 (EVS 1) on 7/18/24 10:32 a.m., the EVS 1 was observed entering and exiting resident rooms 24, 25, 12, and 13 without performing hand sanitation. The EVS 1 was observed to push her cart near room [ROOM NUMBER], entered room [ROOM NUMBER] with gloved hands without sanitizing her hands. The EVS 1 was observed to exit room [ROOM NUMBER], removed her gloves, and donned a new pair of disposable gloves without sanitizing her hands with the intention of entering room [ROOM NUMBER]. The EVS 1 confirmed she had been trained in handwashing and hand sanitation practices, but was rushing and trying to save time to complete her work. During an observation and concurrent interview on 7/18/24 at 11:05 a.m., the EVS 2 was observed to exit room [ROOM NUMBER] holding towels with ungloved hands. The EVS 2 proceeded to open the lid of the hamper with her bare hands and tossed the dirty towels into the linen hamper. The EVS 2 immediately re-entered room [ROOM NUMBER] without sanitizing her hands. The EVS 2 then touched the resident's clean blanket and began to rearrange it. The EVS 2 stated the towels were from the patient's bathroom sink in and confirmed the towels were dirty and needed to be placed in the dirty laundry hamper. The EVS 2 she confirmed she should have worn gloves. The EVS 2 stated she was in a hurry. The EVS 2 also confirmed she should have washed her hands before going into the resident's room and tidying up the resident's blanket. During an observation and concurrent interview on 7/18/24 11:20 a.m., the Certified Nursing Assistant 3 (CNA 3) was observed to enter and exit rooms [ROOM NUMBER] without using any of the alcohol-based hand sanitizers located throughout the hallway to sanitize her hands. The CNA 3 confirmed she had not sanitized her hands and should have done so before entering the residents' rooms. During an observation on 7/18/24 at 11:25 a.m. resident rooms [ROOM NUMBER] were observed to have faucets and sinks with soap dispensers available for use to wash hands. 2. During an inspection of the facility laundry department was performed on 7/19/24 at 9:12 a.m. accompanied by the Infection Preventionist (IP). The laundry department was divided into two sections: one room for storage of dirty linens and the other room was for storage of clean linens. The dirty linens section was observed to have one box of disposable gloves but no other PPE equipment was accessible in the dirty linens room. During an observation of the clean linens section of the laundry room on 7/19/24 at 9:15 a.m. the Linen Room Technician (LRT) was observed folding clothes and linens. In a concurrent interview the LRT stated she was folding the washed and clean linens. The LRT was asked to demonstrate how she processed the dirty linens to be washed. The LRT entered the dirty linens room and stated she donned disposable gloves. The LRT stated she transported the dirty linen hamper into the laundry room and the dirty linens were placed into the washing machines to be washed. The LRT stated she would then remove the disposable gloves from her hands and would sanitize her hands. The LRT confirmed she had never worn a cover gown or faceshield when processing dirty linens, she wore only disposable gloves. The LRT further stated she had not been trained to use a gown or face shield when processing dirty linens. In an interview with the IP on 7/19/24 at 9:30 a.m., the IP confirmed there were no other PPE in the dirty linens room except for the gloves. Concurrent interview the IP, she stated the LRT staff should be wearing gloves, a gown, and face shield when processing and handling dirty linens. In a further tour of the clean linen section of the laundry department with the IP and LRT on 7/19/24 at 9:45 a.m., the LRT confirmed there were two washing machines and two dryers in the department. The LRT stated she did not know if the washing machines or dryers were high or low temperature machines. The LRT further stated she did not knowwhat the water temperatures should be in the the washing machines, nor what the dryer machine temperatures were supposed to be when drying the clothes. The LRT stated she had not been monitoring temperatures for either the washing or dryer machines. The only log she kept was for cleaning the lint screens of the dryers. The LRT further indicated the washing machines were supplied from a dedicated hot water line. She pointed to a tankless water heater and had a digital readout which indicated 131 degrees Fahrenheit (a unit of measurement that is used to measure temperature). The LRT was not aware of what the minimum temperatures should be when washing the dirty linens. In an interview with the Maintenance Supervisor (MS) on 7/19/24 at 9:50 a.m., the dryer temperature was checked with a heat gun and indicated 139 degrees Fahrenheit (F). The MS stated he did not know what the optimal temperature range the dryers and the washing machines were supposed to operate within. The MS confirmed he was in charge of the Laundry Department. The MS stated the hot water supply for the washing machines came from a tankless water heater and the temperature reading from a digital thermometer was 131 degrees F. The MS stated he was unaware the temperatures were needed to be monitored on the washing machines and the dryers. There were no other temperature measuring tools to indicate how hot the water temperatures gets with the washing cycles, nor the dryers temperature when in operation. A review of an electronic mail addressed to the MS by the laundry company dated 7/19/24 at 11:46 a.m. indicated, .The washer does not have an internal water heater. However water temps [temperatures] on a Hot fill setting should be around 150 degrees F .The dryers are as follows .Low heat temp= 140 degrees, Medium heat temp= 160 degrees, High heat temp= 185-190 degrees . A review of the facility policy and procedure titled Laundry and Bedding soiled revised September 2022 indicated, .Soiled laundry/bedding shall be handled, transported and processed according to the best practices for infection prevention and control. Handling .All used laundry is handled as potentially contaminated using standard precautions (e.g. gloves and gowns when sorting .Onsite Laundry Processing .Laundry processed in hot water temperatures is 160 degrees F for 25 minutes. A review of an undated facility procedure titled Isolation Laundry Procedures indicated, .Procedures .Wear rubber gloves and gown/apron .Set booster water heater according to instructions to highest setting .

Based on observations, interviews and record reviews the facility failed to develop and implement person-centered comprehensive care plans for four (4) residents (Resident 2, Resident 36, Resident 10, and Resident 56,) of 15 sampled residents when: 1. Resident 2 and Resident 36 did not have a care plan for the use of psychotropic (medication that affects the brain associated with mental processes and behavior) medications; 2. Resident 10 did not have a care plan for the use of a Wander/Elopement Alarm (WEA, a wearable device that alerts when the wearer wanders or elopes out of the building); 3. Nursing staff did not implement Resident 56's care plan when there was no WEA on him. These failures decreased the facility's potential to provide appropriate interventions and person-centered care. Findings: 1. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility in February 2024 with diagnoses which included dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 2's Order Summary Report (OSR, physician orders), the OSR indicated Resident 2 was prescribed sertraline (a psychotropic medication) for depression manifested by feelings of sadness and loneliness. During a review of Resident 2's care plans on 7/17/24, there was no care plan for the use of Resident 2's psychotropic medication, sertraline. A review of Resident 36's admission record indicated Resident 36 was admitted to the facility in March 2024 with diagnoses including chronic kidney disease (a gradual loss of kidney function over time) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 36's OSR, the OSR indicated Resident 36 was prescribed seroquel (a psychotropic medication used to treat schizophrenia, bipolar disorder, and depression). During a review of Resident 36's care plans on 7/17/24, there was no care plan for the use of Resident 36's psychotropic medication, seroquel. 2. A review of Resident 10's admission record indicated Resident 10 was admitted to the facility in February 2024 with diagnoses including dementia without behavioral disturbance or anxiety (a group of thinking and social symptoms that interferes with daily functioning) and recurrent depressive disorders (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 10's OSR, the OSR indicated Resident 10 had an order for a WEA. A review of Resident 10's care plans on 7/17/24, there was no care plan for the use of Resident 10's WEA. During a concurrent interview and record review on 7/18/24 at 8:51 a.m. with the DON (Director of Nursing), Resident 2's and Resident 36's care plans were reviewed. The DON confirmed there were no care plans for Resident 2's and Resident 36's psychotropic medications. Resident 10's care plan was also reviewed, and the DON confirmed there was no care plan for the use of Resident 10's WEA. The DON stated comprehensive person-centered care plans should be completed within 21 days and are reviewed or updated as applicable and they should include specific orders from the physician. 34328 3. Resident 56's admission record was reviewed and indicated the resident was admitted to the facility with diagnoses of disorientation, apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked), history of falling, and dementia. In an observation on 7/16/24 at 8:45 a.m., Resident 56 was in bed asleep and had bruises around the right eye and face. A WEA was wrapped around her right ankle. During an interview with the Licensed Nurse 3 (LN 3) on 7/16/24 at 8:37 a.m. the LN 3 stated Resident 56 fell last week and sustained bruising to her face and right eye. The LN 3 confirmed Resident 56 had a WEA on her right ankle. During a review of Resident 56's care plans indicated there were no comprehensive care plans written for the use of a WEA device. During an interview and record review with the DCO on 7/18 at 8:33 a.m., the DCO reviewed Resident 56's care plans and confirmed there were no care plans for the use of use of a WEA. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, revised March 2019, the P&P stated, If identified as a risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised December 2016, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs is developed and implemented for each resident.

Based on observations, interviews, and record review the facility failed to provide care and services in accordance with acceptable professional standards of quality for seven residents (Residents 2, 36, 19, 10, 34, 56, and 110) out of 15 sampled residents when: 1. Psychotropic medications (medication that affects the brain associated with mental processes and behavior) were prescribed for Resident 2 and 36 without appropriate indications, manifestations or monitoring of behaviors. 2. Resident 19, 14 and 110 nasal cannulas (a plastic tube that delivers extra oxygen into your nose) and humidifiers (devices used to humidify supplemental oxygen) were not labeled or dated, and oxygen was not provided per the physician order. 3. Resident 10 and Resident 34 had incomplete monitoring orders for a Wander/Elopement Alarm (WEA, a wearable device that alerts when the wearer wanders or elopes out of the building) 4. Resident 56 had a WEA on without a physician's order. These failures decreased the facility's potential to prevent worsening of the residents' clinical condition. Findings: 1. A review of Resident 2's admission record indicated Resident 2 was admitted to the facility in February 2024 with diagnoses which included dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Resident 2's Order Summary Report (OSR, physician orders), Resident 2 had an order for sertraline (a psychotropic medication) for depression manifested by feelings of sadness and loneliness. There was not an order for the monitoring of Resident 2's feelings of sadness or loneliness noted on the OSR. A review of Resident 36's admission record indicated Resident 36 was admitted to the facility in March 2024 with diagnoses including chronic kidney disease (a gradual loss of kidney function over time) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 36's OSR, the OSR indicated Resident 36 was prescribed quetiapine (a psychotropic medication used to treat schizophrenia, bipolar disorder, and depression) for depression. The OSR for these psychotropic medications did not include indications, manifestations of behaviors for the use of these medications or orders to monitor behaviors identified. During an interview on 7/18/24 at 9:24 a.m. with the Director of Nursing (DON), the DON stated, Orders for psychotropic medications need to identify the specific indication or behavior for the use of the medication for the resident .there needs to be an order to monitor those behaviors. A review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022, indicated, Psychotropic medication management includes: indications for use, dose, duration, adequate monitoring for efficacy and adverse consequences, and preventing, identifying and responding to adverse consequences .Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. 2. A review of Resident 19's admission record indicated admission to the facility in June 2024 with diagnoses including acute respiratory failure (not enough oxygen in the tissues in your body) and chronic bronchitis (long term inflammation of the airways that carry air to the lungs). During an observation on 7/16/24 at 8:47 a.m. in Resident 19's room, Resident 19 was observed laying in bed with oxygen running at 2 L (liters, a unit of measurement) per minute through a nasal cannula connected to a concentrator (a machine that takes air from your surroundings, extracts oxygen and filters it into purified oxygen for you to breathe) with a humidifier. The nasal cannula and humidifier were not dated and initialed. During a concurrent observation, interview and record review on 7/16/24 at 11:11 a.m. with Licensed Nurse 4 (LN 4), in Resident 19's room, the LN 4 confirmed Resident 19's humidifier was not labeled with an open date and time and the nasal cannula was not labeled or dated. Resident 19's OSR was reviewed, the oxygen order indicated continuous oxygen due to chronic respiratory failure at 1 L per minute through a nasal cannula. The LN 4 confirmed Resident 19's oxygen was running at 2 L per minute instead of 1 L. The LN 4 acknowledged the importance of following physician orders, and the goal was to wean Resident 19 off from the supplemental oxygen. During a record review of Resident 14's facesheet, indicated Resident 14 was admitted with diagnoses of Idiopathic (relating to or denoting any disease or condition which arises spontaneously or for which the cause is unknown) Sleep Related Non-Obstructive Alveolar (the the tiny air sacs in the lungs), Asthma (chronic lung disease caused by inflammation and muscle tightening around the airways, which makes it harder to breathe). During the initial pool tour 7/16/24 at 9:44 a.m., Resident 14 was observed in her room and was receiving oxygen at 2 LPM nasal cannula via an oxygen concentrator machine. In an During an interview with the LN3 on, 07/16/24 at 9:44 a.m., he confirmed the Resident 14 was on oxygen and the oxygen cannula did not have a date when it was applied. The LN3 stated the facility practice and expectations were all oxygen tubings must be labeled and the oxygen tubing changed once every week on Friday. The LN3 stated the nasal cannula had no date on the tubing and the humidifier that would indicate when it was first used and when it was due to be changed. The LN 3 stated he will label and change the oxygen NC tubing now. Review of Resident 14's SRO indicated on 1/16/24: . Supplemental oxygen via NC (Nasal Cannula) or oxymask to keep SpO2 (blood oxygen level above or equal 90% . A review of Resident 110's admission record indicated she was admitted to the facility with diagnoses of chronic respiratory failure with hypoxia (Insufficient oxygen level at the tissue level), chronic respiratory failure with hypercapnea (excessive carbon dioxide in the bloodstream, typically caused by inadequate respiration), and unspecified asthma (a long-term condition that affects the airways in the lungs). During an observation and interview on 7/16/24 at 9:44 a.m. the LN 3 confirmed Resident 110 was receiving oxygen via oxygen concentrator. Further observation by LN3, he stated the oxygen cannula was not dated when it was applied. The LN 3 stated the facility practice was all oxygen tubes must be labeled and per protocol the cannula was changed once every week on Friday. The LN3 stated he will label and change the oxygen cannula now. During a record review of Resident 110's OSR dated 7/9/24 indicated : .Change humidifier bottle and O2 (oxygen) tubing q FRI (every Friday) on noc (night shift) and PRN (abbreviation for as necessary) every night shift every Friday . During an interview on 7/16/24 at 5:06 p.m. with the Director of Nursing (DON) and the Director of Clinical Operations (DCO), the DON and DCO both stated the oxygen tubing and the humidifier should be labeled with the date and time it was applied. The DCO confirmed the expectations were that all oxygen tubings would be labeled and changed every Friday. A review of the facility's P&P titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011, indicated, Distilled water used in respiratory therapy must be dated and initialed when opened and discarded after twenty-four (24) hours. 3. A review of Resident 10's admission record indicated admission to the facility with diagnoses including dementia without behavioral disturbance or anxiety (a group of thinking and social symptoms that interferes with daily functioning) and recurrent depressive disorders (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During an observation on 7/16/24 at 11:27 a.m. in the dining room, Resident 10 was observed sitting in her wheelchair. During an observation on 7/17/24 at 9:29 a.m. in the hallway, Resident 10 was observed sitting in her wheelchair. During concurrent observation and attempted interview on 7/18/24 at 11:57 a.m. in the dining room with Resident 10, Resident 10 was observed wearing a WEA on the left ankle. Resident 10 did not engage in conversation about the WEA. During a review of Resident 10's OSR, the OSR indicated Resident 10 had an order for a WEA with a start date of 4/10/24. There were no orders to monitor the placement, functional status or behaviors that would warrant the use of a WEA. A review of Resident 34's admission record, indicated Resident 34 was admitted to the facility in August 2023 with diagnoses that included adjustment disorder (emotional or behavioral reaction to change) with anxiety (worry and fear). A review of Resident 34's Minimum Data Set (MDS, an assessment tool), dated 4/23/24, indicated Resident 34 has severe memory problems, used a wheelchair independently, and used a WEA. A review of Resident 34's OSR, dated 7/19/24 indicated an active order for [WEA] to R [right] side of wheelchair to alert staff of attempts to leave building unassisted . with a start date of 3/1/24. The OSR did not indicate any orders for monitoring placement or functional status of the WEA. During an interview on 7/18/24 at 2:37 p.m., the DON stated, Prior to the placement of a [WEA] staff would need to contact the physician to discuss if the [WEA] is appropriate and there should be a lot of documented attempts to exit the building. During an interview on 7/19/24 at 10:10 a.m. with the DON and DCO, the DON and DCO confirmed orders for WEAs should include monitoring the placement and function of the WEA. During a review of the P&P titled, Wandering and Elopements, revised March 2019, the P&P stated, If identified as a risk for wandering, elopement or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A P&P for the use of wander/elopement alarms was requested on 7/19/24 at 10:10 a.m. from the DON and DCO. The facility was unable to provide a P&P for the use of WEAs. 34328 4. Resident 56 facesheet was reviewed and indicated the resident was admitted to the facility with diagnoses of disorientation, apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked), history of falling, and dementia. Resident 56 was seen on 7/16/24 at 8:45 a.m. during an initial pool tour of the facility. The Resident was in bed asleep and observed that Resident 56 has bruising around her right eye and face. Resident 56 was observed to have a WEA in place on her right ankle. During an interview with the LVN 3 on 07/16/24 at 8:37 a.m. he indicated the resident dad a fall last week and sustained bruising on her face and right eye. The LVN 3 confirmed that the resident has a WEA on her right ankle. The LN3 stated the resident was confused and was exit seeking from the building when she fell . The Resident's bed was observed to be in a low position and a falls mat was in place at the bedside. Review of Resident 56's nursing notes 7/12/24 indicated the resident fell and sustained bruises and a laceration by the right eye. Neuro checks were on going. Further review of the nursing notes from 7/12/24 through 7/18/24, there were no notation that indicated a WEA was applied to the resident's right ankle. Further review of Resident 56's OSR dated 7/16/24, there were no physician's orders obtained for the use of a WEA. During a record review of the resident 56's clinical records indicated there were no care plans in place for the use and monitor of a WEA. During an interview with the Director of Clinical Operations (DCO) on 7/18 at 8:33 a.m. The DCO stated after reviewing the clinical record, that Resident 56 wore a WEA and there were no physician's orders nor care plans in place for the use of a WEA. The DCO stated the MD must be notified and must order for the use of a WEA. During a record review of the facility policy and procedure Wandering and Elopements revised March 2019 indicated: .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .1. If identified at risk for wandering, elopement, or other safety issues, the resident's care plan will include startegies and interventions to maintain the resident's safety. During a record review of facility policy Goals and Objectives, Care Plans revised April 2009 indicated: .Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence .1. Care plan goals and objectives are defined as the desired outcome for a specific reisdent problem .3. Care plan goals and objectives are derived fro information contained in the resident's comprehensive assessment and: a. are resident oriented b. are behaviorally stated c. are measurable, and d. contain timetable to meet the resident's needs in accordance with the comprehensive assessment . 5. Goals and objectives are reviewed and/or revised: a. whne there has been a significant change in the resident's condition. b. when the desired outcome has not been achieved c. when the resident has been readmitted to the facility from a hospital/rehabilitatioon stay; and d. at least quarterly .

Based on observation, interview and record review, the facility failed to ensure the Dietary Supervisor (DS) met the state's education qualification requirements, as required per federal regulation, to be the DS to carry out the functions of the food and nutrition services. In addition, the facility failed to ensure the Registered Dietitian (RD) provided frequently scheduled consultations with the DS to include overseeing food safety and sanitation, food preparation, meal service and food storage. As a result, there were lapses in the delivery of food and nutrition services associated with meal distribution accuracy (cross reference F803), modified food texture accuracy (cross reference F805), and safe food handling and sanitation (cross reference F812), which lacked the benefit of a qualified DS responsible for the day-to-day food service operation for the skilled nursing facility. In addition, the facility lacked the benefit of the expertise of the RD input when there was not sufficient oversight over the food service operations via frequently scheduled consultation to the DS by the RD, when the job description and the contract of the RD was essentially based on clinical nutrition. There was a total of 53 out of 55 residents receiving meals from the facility kitchen. Findings: During the annual recertifications survey from 7/16/24 to 7/19/24, multiple issues surrounding the delivery of dietetic services were identified: 1. Meal distribution accuracy - the menu/spreadsheet (a tool helps the kitchen staff to identify food items, portion sizes and utensils (such as scoops, ladles, etc.) for different therapeutic diets) were not followed, and the portion size of food items were not served correctly; 2. Puree food texture was not prepared appropriately to meet residents' needs, and 3. Safe food handling and sanitation: a. Cooked chicken leftovers were found without temperature monitoring before being stored in the refrigerator for the cool down procedure; b .A cook did not practice ambient (room temperature) food cool down procedures when preparing ambient foods (such as tuna salad, egg salad, chicken salad, etc.); c. Bags of bread (English muffins and raisin bread) passed the used-by date were not discarded; d. Several sizes metal pans were found stacked wet, and few metal pans with brown and white substances on the food contact surfaces were stored at the clean and ready-to-use storage areas; e. The interior of the microwave was found dirty with food debris and liquid splashes; f. Several cutting boards were found with deep gouges, black substances and strong rancid odor; g. Employee's personal beverage containers were found at the resident's food/beverage preparation area, and h. The ice machines located in the kitchen and nourishment room (at nurse station) were not clean. During an initial kitchen tour and concurrent interview with the Dietary Supervisor (DS) on 7/16/24, at 9:13 a.m., the DS stated she started the position since in September last year (2023). She stated she was not certified as a Dietary Services Supervisor (DSS) or Certified Dietary Manager (CDM), and she added she was still taking courses to be a CDM. She stated there were two Registered Dietitians (RD) contracted to the facility and they visited the facility around 16 hours per week. The DS stated the RDs were responsible for clinical and monthly kitchen sanitation audit, but no in-services for the kitchen staff. She stated she was responsible for the in-services for the staff, but she only did one so far since she started working in the facility. During an interview with the Regional Operations Director (ROD) on 7/17/24, at 2:14 p.m., he was aware the DS was not qualified for the current position. A concurrent review of the federal regulations with the ROD indicated the qualified personnel for the Dietary Manager position should meet one of the criteria from the state standards, Health and Safety Code 1265.4. The ROD acknowledged the requirements after he reviewed the state standards. During an interview with the RD on 7/17/24, at 2:45 p.m., she stated she and the other dietitian visited the facility twice per week (around 16 hours per week) per contract. She stated she and the other dietitian were majorly responsible for clinical work (such as nutrition assessments, monitoring resident's weight and attending weight meeting, and consultations) and monthly kitchen sanitation audit. She stated she usually spent one to two hours for the kitchen sanitation audit monthly. She stated she did some meal tray monitoring and in-services for the staff last year but did not do any this year. She stated she spent approximately 80 percent of her visit time for clinical and 20 percent for foodservice operation (kitchen). During a follow up interview with the RD on 7/18/24, at 10:30 a.m., she stated she was not aware the DS was not qualified for the position and did not meet the state standards. She stated she was aware that the DS still taking the courses to be CDM certified. RD stated she and the other dietitian covered the full-time position due to the previous dietary supervisor not being qualified. She stated the dietitians' hours cut back to part time since the new company took over and the new supervisor, DS, was on board for the position. A review of the DS's employee file indicated the DS was hired by the facility on 3/22/24 for the full-time position as Dietary Manager. The file indicated DS had three associate degrees with management, business management and recreational management but no indication of any type of professional registration nor certification. The file included ServSafe certification (a certification provided after the completion of training and an examination of the knowledge of safe food handling), but this certification was not one of the requirements of the state standards. A review of DS's job description (JD) provided by the facility, revised 6/2020, it did not indicate any education and experience requirements for the dietary supervisor position. A review of the state's qualifying pathways to be a dietary manager as listed in the Health and Safety Code (H & SC) 1265.4, 72035. Dietetic Service Supervisor. Dietetic service supervisor means a person who has completed the training requirements specified in section 1265.4(b) of the Health and Safety Code. A review of the RD's JD, revised 11/2017, it indicated the RD majorly was responsible for clinical work for the facility. A review of the facility-RD contract titled, [Consulting Company Name] - Consulting Agreement, contracted started 4/1/2024, it indicated the scope of the RD's duties as consultant basis and responsible for clinical work for the facility. It also indicated the RD or RDs were contracted to work in the facility and did not exceed a maximum of 20 hours per week. The contract also indicated work days and hours were flexible and allowed the RD or RDs to be complete remotely for documentation and charting through the electronic medical record system 50 percent of the time.

Based on interview and record review the facility failed to develop, implement, and monitor an infection control program with the use of antibiotics when: 1. The Infection Prevention and Control Program (IPCP) failed to monitor the laboratory indications on the use of antibiotics. 2. There were inadequate tracking tools in use for tracking of residents on antibiotics and the indications for the use of antibiotics 3. There were inadequate infection control inservices for the facility staff on handwashing. These failures had the potential for residents to be exposed and acquire infectious diseases causing illness. Findings: 1. During an interview with the Infection Preventionist (IP) on 7/18/24 02:35 PM the IP was asked to provide the tracking tool she used to monitor residents who were using antibiotics. The IP was further asked aside from the tracking tool she used what were the clinical indications for the use of the antibiotics. The IP provided a map of the facility which she stated she used to monitor residents that were having Urinary Tract infections (UTI) which were rooms 11, 23, 24, 25, 26. The IP was asked how she verified and confirmed the specific residents in rooms 11, 23, 24, 25, 26 who had a UTI. The IP was not able to answer who were the specific residents in the room that had UTI, nor the confirming laboratory indicators of a urinalysis (a test of your urine. It is often done to check for a urinary tract infections, kidney problems, or diabetes), urine culture and sensitivity (C/S A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection and antibiotics that the germs may be resistant). She was not using any other tool to track antibiotic use. The IP was asked who were the current residents she had that were on antibiotic treatment. The IP state for Resident 35 (3 A), the Medical Doctor (MD) prescribed Ciprofloxacin, an antibiotic for the treatment of UTI. The IP was asked what was the laboratory indication for the use of the antibiotic, she stated she had not checked for the urinalysis and the C/S indication. She was asked to check the lab of Resident 35 and the culture result dated 7/18/24 result was urogenital flora (normal). Concurrent interview with the Director of Clinical Operations she was was asked to verify the laboratory findings, and she stated it was normal and the resident had no indications for use of the antibiotic. The DCO stated she will clarify with the MD if not to discontinue the medication. Further interview with the IP on 7/18/24 at 2:55 p.m. the IP was asked to verify if Resident 29 in room [ROOM NUMBER] was on antibiotics. The IP was not aware if resident 29 was on antibiotics. The MD orders were reviewed with the IP and she confirmed that Resident 29 was on antibiotic Cephalexin 250 mg (milligrams, a dosage) by mouth was ordered on 5/31/24. Further interview with the IP she stated the Cephalexin was ordered to be given 1 capsule once a day for Prophylaxis (preventative) related to Urinary Tract infection. The IP was asked to verify if the resident had any urinalysis or culture and sensitivity labs done to indicate the Resident had any UTI. The IP confirmed there were no laboratory examinations ordered. Further interview with the IP the antibiotic Cephalexin was started on 5/31/24 and as of 7/18/24 Resident 29 had been on antibiotics a total of 48 days for the prevention of UTI. Concurrent interview with the DCO she stated the used of Cephalexin antibiotic for UTI prophylaxis was not normal clinical indications for usage. The DCO stated she will clarify with the MD if not discontinue the medication. 2. During an interview with the Infection Preventionist (IP) on 7/18/24 02:35 PM the IP was asked to provide the tracking tool she used to monitor residents who were using antibiotics. The IP was further asked aside from the tracking tool she used what were the clinical indications for the use of the antibiotics. The IP provided a map of the facility which she stated she used to monitor residents that were having Urinary Tract infections (UTI). The IP was asked how she verified and confirmed the rooms 11, 23, 24, 25, 26 had UTI. The IP was not able to answer who were the residents in the room that had UTI nor the confirming laboratory indicators of a urinalysis (a test of your urine. It is often done to check for a urinary tract infections, kidney problems, or diabetes), urine culture and sensitivity (C/S A culture is a test to find germs (such as bacteria or a fungus) that can cause an infection and antibiotics that the germs may be resistant). She was not using any other tool to track antibiotic use. Concurrent interview with the DCO she stated there were tracking tools for the IP to use in the Electronic Health Records (EHR). The DCO stated it was still in development and not yet active. The DCO confirmed there were no other tools in used for monitoring infections and for the use of antibiotics. 3. During an interview with the IP on 07/18/24 at 2:42 PM The IP was asked about staff infection control in-services specifically hand washing. The IP was made aware of observations made on staff who were not performing hand hygiene when going in and out of residents rooms. The IP stated in-services were done on handwashing, and she confirmed all employees whether they are clinical or non clinical employees are expected to attend handwashing inservices. The IP was asked to provide the staff in-services attendance sheets on handwashing from January 2024 to current date of 7/18 /24. The IP stated that ALL staff must attend handwashing in-services whether they are clinical or non-clinical employees. The IP stated and verified total number of employees were 82. The breakdown were Fulltime employees were 59, Part time were 15, on call were eight (8). The IP provided the In-service Training attendance on Handwashing and the sign in attendance sheets dated 2/6/24 for in-service times of 6:30 a.m. and 2:10 p.m. total staff who attended were six (6) staff members. The IP confirmed that was all the inservices she had on file. Review of some of the Infection Prevention Nurse job description indicated: .Plan, develop, organize, implement evaluate, coordinate, and direct our infection control program in accordance with the current rules, regulations, and guidelines that govern such requirement .Interpret infection control policies and procedures as necessary .Assist the supervisor of laundry services in developing infection control procedures for the handling of clean and soiled laundry and linen, equipment cleaning .Ensure that all nursing service personnel follow established isolation precautions to include standard/universal precautions .

Based on observation, interview, and record review, the facility failed to ensure one Certified Nursing Assistant (CNA), CNA 2, of five sampled CNAs had a valid CNA license. This failure had the potential to result in all 55 residents in the facility to receive care from an unqualified person. Findings: During a concurrent interview and record review on [DATE] at 11:44 a.m. with the Director of Nursing (DON), the CNA 2's license verification was reviewed. The DON confirmed CNA 2's license verification indicated an expiration date on [DATE]. The DON stated she expected CNAs who worked at the facility to have a valid CNA license. During a concurrent observation and interview on [DATE] at 11:48 a.m. with the Director of Staff Development (DSD) in the facility's dining room, CNA 2 was assisting residents with their lunch meal. The DSD stated she was aware CNA 2's license was getting close to expiration, CNA 2 had not yet submitted an updated CNA license and confirmed CNA 2 was currently working a CNA shift. An interview on [DATE] at 11:53 a.m., CNA 2 confirmed she has not received a CNA license renewal yet and her CNA license was expired. A review of the facility's policy and procedure titled Competency of Nursing Staff revised [DATE], indicated, .all nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law . A review of California Health and Safety Code, Division 2. Licensing Provisions, Chapter 2. Health Facilities Article 9, Section 1337.6, effective date [DATE], indicated, .The department shall give written notice to a certificate holder 90 days in advance of the renewal date and, 90 days in advance of the expiration of the fourth year that a renewal application has not been submitted, and shall give written notice informing the certificate holder, in general terms, of the provisions of this article. Nonreceipt of the renewal notice does not relieve the certificate holder of the obligation to make a timely renewal. Failure to make a timely renewal shall result in expiration of the certificate

Based on observation and interview, the facility failed to provide a clean environment for the residents and visitors when one of one garbage dumpster, located outside the facility, was not closed securely due to deformed dumpster lids. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During a concurrent observation and interview on 7/16/24, at 10:52 a.m., it was observed one out of one outside dumpster was covered with its two lids. However, the dumpster lids were bowed away from the midline where they converged, leaving a two-inch gap in between. The deformed lids lacked the integrity to securely cover the bin. The Dietary Supervisor (DS) confirmed the condition of the dumpster lids and agreed that either the lids needed to be fixed or the facility needed a new trash bin. During an interview with the Director of Clinical Operations (DCO) on 7/19/24, at 9:35 a.m., she stated the facility did not have a policy and procedure regarding dumpster conditions. The DCO stated the maintenance department called a waste management company and had to purchase new lids for the dumpsters. According to the Food and Drug Administration (FDA) Food Code 2022, Section 5-501.15 Outside Receptacle, referenced 7/23/24, (A) Receptacles and waste handling units for refuse .used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.

Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1) Cool down process was not performed for meat leftovers (any food that was prepared for service but was not served), 2) Procedure for cooling down method for ambient (room temperature) food was not being followed, 3) Metal serving pans had brown and white substances on the inside surface; serving pans were found stacked wet, 4) Expired bread had not been discarded, 5) Microwave had food debris on upper interior surface, 6) Several cutting boards had gouges, black smudges, and rancid odor, 7) Employees' beverage containers were stored in residents' food and drink preparation area, and 8) Ice machines in kitchen and nourishment rooms were not clean. These failures had the potential to lead to foodborne illness for a total of 53 out of 55 residents who received facility prepared foods. Findings: 1. During an inspection in the walk-in refrigerator on [DATE], at 10:28 a.m., a bucket of cooked leftover chicken breasts (cooked on [DATE]) was found that did not have temperature monitoring and without the cool down process done before being stored in the refrigerator. In a concurrent interview with the Dietary Supervisor (DS), she reviewed the weekly menu for the week and stated the chicken was prepared for the Asian Chicken salad for dinner on [DATE]. When the DS was asked whether the cook performed a cool down process for the chicken pieces, she reviewed the Food Cooling Log and stated there was no entry for the chicken breasts for [DATE]. She stated the cook who placed the chicken breasts in the refrigerator would return to work on [DATE]. During a follow up interview on [DATE], at 9:05 a.m. with the DS, she stated [NAME] (C) 2 was the one who cooked the chicken in the walk-in refrigerator, and he would be in to work that morning at 10:30 a.m. During an interview with C 2 on [DATE], at 10:54 a.m., he stated someone else cooked the chicken breasts, but he was the one who put them in the refrigerator that evening ([DATE]) without taking the temperature of the chicken or following the cool down process. He stated, It was a mistake, and specified that because he didn't perform the cooling down method, he wouldn't know whether the temperature of the food was within safe food parameters. During an interview with the Registered Dietitian (RD) on [DATE], at 10:30 a.m., she stated the cook should have done the cool down procedure for the leftovers before storing them in the refrigerator for food safety. She said, We need to do the in-service, and we need to get a log for the process. A review of facility's Food Preparation and Service, revised Nov. 2022, it showed, .Potentially hazardous food (PHF) including meats, poultry .Rapid Cooling: PHF are cooled rapidly. This is defined as cooling from 135 degrees Fahrenheit (F) to 70 F within two hours and then to a temperature of 41 F or below within the next 4 hours. The total cooling time between 135 F and 41 F is not to exceed 6 hours . A review of facility policy and procedure titled, Use of Leftovers (2013), it showed, Leftovers must be cooled to 70 F within 2 hours and then down to 41 F within another 4 hours . 2. During a concurrent observation and interview on [DATE] at 3:55 p.m., C 2 was preparing chicken salad for the evening meal, chicken salad sandwiches. C 2 stated there was no system for cooling ambient foods, nor was he practicing it. He verbalized the process of ambient food (such as tuna or egg salad) cool down with prompting. He stated he would put the made salads in the refrigerator but not take any temperature nor using the cool down log for monitoring. C 2 also stated he never practiced or had been told to do the ambient food temperature monitoring and cool down process. During an interview with the DS on [DATE], at 2:55 p.m., she stated the kitchen did not have a policy and procedure for ambient foods, and the kitchen staff were not practicing the ambient cool down process. During a follow up interview with the DS on [DATE], at 9:12 a.m., she changed her answer and stated the kitchen had a cool down process for ambient foods. However, she stated the staff were not monitoring the temperature after the cold salads were prepared. She confirmed that the staff should be monitoring the temperature and practicing the ambient food cooling down process. A review of undated facility's policy and procedure titled, Addendum to Food Preparation, it showed, Ambient food being used for cold food preparation will be pulled from the shelf 24 hours in advance and placed in the refrigerator. Once pulled from the refrigerator, and opened, food items will be temped [temperature taken] to assure temperatures are 41 degrees or below. Once the preparation of the food is completed, the item will then be temped again to assure food temperature has not exceeded 41 degrees .Ambient food prepared using ingredients from room temperature items for cold production must be cooled to 41 degrees within four hours .Will maintain cooling logs for ambient food. 3. During a concurrent observation and interview on [DATE], at 9:53 a.m. and 10:12 a.m., there were several metal pans found having issues stored in the clean and ready-to-use areas as follows: -9 of ,d+[DATE] sheet pans (stacked wet) -3 of ,d+[DATE] sheet pans (stacked wet) -4 of full sheet pans (stacked wet) -2 of full sheet pans (had brown and white substances on the inside surfaces) The Assistant Dietary Supervisor (ADS) stated the pans should be dried. She also stated the pans should be clean and the staff should check them before being stored away. During an interview with the RD on [DATE], at 10:30 a.m., she stated the pans should be fully dried and clean before being stored away. The RD stated she would talk with the dishwasher about completely air drying the pans. A review of facility's policy and procedure titled, Sanitation: Dish Machine Usage and Testing, dated [DATE], it showed, .Air dry: Place equipment or utensils onto a clean surface to air dry. Do not dry with a towel or other method .Return to storage: Once equipment and utensils are completely air dried, they can be returned to storage . A review of the facility's policy and procedure titled, Sanitation, dated ,d+[DATE], it indicated all food contact surfaces and utensils must be washed to remove the soil completely before manual or machine wash, then sanitized. 4. During a concurrent observation and interview on [DATE], at 10:18 a.m., there was a tray of four bags of English Muffins with a label written, Pulled [DATE], Use by [DATE]. There was another tray of three bags of raisin bread with a label written, Pulled [DATE], Use by [DATE]. The ADS confirmed and stated those breads were past the use by date and should be discarded. She added the breads stored in the freezer are pulled out for thawing at room temperature. She stated it was everybody's responsibility to check the bread. During an interview on [DATE], at 9:05 a.m. with the DS, she stated the bread was received frozen from the supplier and kept in the walk-in freezer. She stated the kitchen followed the dry storage guidelines for the bread, which could keep for five to seven days unopened or opened on the shelf. A concurrent review of facility policy and procedure, Food Receiving and Storage Policy and Procedure, dated ,d+[DATE], with the DS, under the Refrigerated/Frozen Storage section, which stated that refrigerated foods should be eaten by their 'use by' date, or else need to be frozen or discarded. The DS confirmed that she would follow that section of the guidance for the dry foods which would be discarded if past the use by date. During an interview with the RD on [DATE], at 10:30 a.m., she stated the kitchen staff need more training. She stated she planned to talk to the staff more about putting correct dates on labels. The RD stated, There's no excuse. They shouldn't have them (expired bread items) there. She stated she had a prior discussion with kitchen staff about doing a daily walkthrough of food items and discarding expired food. A review of facility's document titled, Dry Goods Storage Guidelines, dated 2023, it indicated that the bread should be stored, ,d+[DATE] days unopened on shelf XXX,d+[DATE] days opened on shelf .This storage length is to be followed unless you have manufacturer's recommendation indicating otherwise. A review of facility policy and procedure titled, Food Receiving and Storage, revised Nov. 2022, it showed, .Refrigerated/Frozen Storage: Refrigerated foods are labeled, dated and monitored so they are used by their 'use by' date, frozen or discarded . (The DS stated this guidance also applied to the dry food, which needed to be discarded when past the use-by date.) 5. An observation of the microwave oven cleanliness and concurrent interview was conducted on [DATE], at 10:09 a.m. The interior top portion of the microwave was found with food residue and liquid splash spots. Dietary Aide (DA) 1 confirmed and stated the microwave was dirty and that she cleans the oven every day. She stated the microwave was scheduled to be cleaned daily. During an interview with the RD on [DATE], at 10:30 a.m., she acknowledged and agreed the microwave should be cleaned daily. A review of facility's policy and procedure titled, Sanitization, revised ,d+[DATE], it showed, .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair . 6. A concurrent observation of the cleanliness of cutting boards and interview was conducted with the ADS on [DATE], at 9:24 a.m. There were seven plastic cutting boards found with deep gouges, dark brownish black splotches on the surfaces, and a rancid odor. The ADS confirmed and stated the cutting boards were in bad condition and agreed they smelled. She also stated she would discard them. During an interview with the RD on [DATE], at 10:30 a.m., she stated she was aware of the issues with the cutting boards. She stated she recommended they do a chorine wash, and she had also instructed the staff to discard marred or stained cutting boards. She stated the cutting boards should have smooth surfaces to be easily cleaned. A review of the facility's policy and procedure titled, Sanitization, revised ,d+[DATE], it showed, .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/chemical sanitizing solutions .Cutting boards (acrylic or hardwood) will be washed and sanitized between uses . 7. During an initial kitchen tour on [DATE], at 9:00 a.m., an observation of the food preparation area and interview was conducted with the ASD. There were personal beverage containers found on the resident's food and drink preparation area. The ASD confirmed the beverage containers belonged to the kitchen staff. She stated there was no designated area for the staff's drink containers. In a follow up interview with the DS at 9:20 a.m., she confirmed that staff's drinks were in the food preparation area and agreed there should be a designated area for staff's belongings. During an interview with the RD on [DATE], at 10:30 a.m., she stated staff's personal items and drinks were not allowed in the food/beverage prep area and these items should be in a designated area. A review of the undated facility's policy and procedure titled, Employee Health and Hygiene: Personal Items, Food and Drink, it showed, .Designate area within the facility for associates to store beverages-ideally 3 feet from any food preparation or storage area. Beverages should not be stored in and around cook areas or utility rooms .Observe food preparation areas to ensure no food, drink .are stored outside of their designated area . 8. During an inspection of the ice machine in the kitchen on [DATE], at 11:20 a.m., the Dietary Aide (DA) 2 stated he was responsible for the monthly cleaning and sanitizing for the ice storage bin. He dissembled the top part (machinery part) of the ice machine. DA 2 stated he was also responsible for rinsing the water curtain (a plastic cover rest on the ice making panel of the top machinery component, the function is to prevent ice shooting out and redirect the ice to the ice storage bin) and the water trough (a component that holds the water before it is frozen during the ice making process) with hot water only. He stated he did not touch anything else other than the ice storage bin, water curtain and water trough. During an interview with the Maintenance Supervisor (MS) on [DATE], at 11:40 a.m., he stated that the facility hired outside vendor and sent their technician to the facility and performed the deep clean (clean and sanitize the machinery part (top part) of the machine and the ice storage bin with the chemical solutions) of the ice machine every six months. Upon removing the ice machine's top access panel, the water curtain and the water trough, there were pink and slimy substances found. This was covering some portion outside of the water curtain and inside of the water trough and was easily removed when wiping with paper towel. There were significant black substances found at the bottom of the evaporator unit (a part where the water condenses and makes ice) and was easily wiped off with the paper towel. The MS stated the last deep clean was done on [DATE] and the water filter would be changed every year with the last change on [DATE]. The MS confirmed the pink and black substances and stated maybe the ice machine was not scrubbed enough. During an inspection of the ice machine in the nourishment room located at the nurse station on [DATE], at 11:43 a.m., the MS stated he was responsible to clean the ice storage bin and rinse the water curtain and water trough with hot water and clean the ice dispenser nostril monthly. When the MS removed the top access of the machinery part of the ice machine, there were pink slimy substances found on the water curtain and inside the water trough, and on the top and bottom rims of the ice making panel. The pink slimy substances were easily wiped off with paper towel. In addition, there were significant black substances found on the bottom of the evaporator unit and the black substances were easily wiped of with paper towel and felt the surface was not smooth when touched. The MS stated the outside vendor was responsible to do deep clean for the ice machine every six months and the last service was done on [DATE]. The MS confirmed the pink and black substances were found and stated maybe the outside vendor technician did not scrub enough when cleaning the ice machine. During an interview with the outside vender technician (OVT) on [DATE], at 3:35 p.m., he stated the previous technician may not be scrubbing the parts of the ice machine enough and the calcium deposits accumulated for both ice machines (kitchen and nourishment room). He stated the calcium deposits took times to be soften and clean better. During an interview with the Registered Dietitian (RD) on [DATE], at 10:30 a.m., she stated the ice machine should be clean. She stated she checked the ice machine monthly during the monthly kitchen sanitation audit, but she did not check the top (machinery) part. A review of the facility policy and procedure titled, Sanitization, revised [DATE], indicated, The food service area shall be maintained in a clean and sanitary manner . ice machine and ice storage containers will be drained, cleaned and sanitizer per manufacturer's instructions . A review of the undated kitchen ice machine manual titled, [Manufacturer's brand] Ice Machines Installation, Operation and Maintenance Manual, indicated, .You are responsible for maintaining the ice machine in accordance with the instructions in this manual. CLEANING/SANITIZING PROCEDURE This procedure must be performed a minimum of once every six months. The ice machine and bin must be disassembled, cleaned and sanitized . Removes mineral deposits from areas or surfaces that are in direct contact with water. PREVENTATIVE MAINTENANCE CLEANING PROCEDURE . This procedure cleans all components in the water flow path, and is used to clean the ice machine between the bi-yearly cleaning/sanitizing procedure without removing the ice from the bin/dispenser . A review of the undated nourishment room ice machine manual titled, [Manufacturer's brand] Dispensers Installation, Use & Care Manual, indicated all removable and disassembled parts of the ice machine should be clean and sanitize with the cleaning and sanitizing solutions monthly. According to 2022 FDA (Food and Drug Administration) Food Code, on section ,d+[DATE].11 Equipment Food-Contact Surface and Utensils, it stated equipment like ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms (a living thing that is so small it must be viewed with a microscope, such as bacteria or algae). In addition, on Section ,d+[DATE].11 Food-Contact Surfaces, it stated, .The purpose of the requirements for multiuse food-contact surfaces is to ensure that such surfaces are capable of being easily cleaned and accessible for cleaning. Food-contact surfaces that do not meet these requirements provide a potential harbor for foodborne pathogenic organisms. Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts . and .Multiuse Food-Contact Surfaces shall be: 1. Smooth; 2. Free of breaks, open seams, cracks, chips, inclusions, pits .

Based on staff interview and review of facility documents, the facility failed to: 1. Report all allegations of abuse within 24 hours, and report the results of all abuse investigations to the Department within 5 working days for 5 of 5 Random Resident's (RR 18, 21, 19, 20, and 17), and one sampled resident (8). These failures had the potential to place all residents at risk for abuse in an unsafe environment, for a census of 55 residents. An Immediate Jeopardy (IJ - a situation in which the provider's non compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident.) was identified by the Department on 5/10/17 at 1:35 p.m., for the facility's failure to: 1. Ensure all abuse allegations were reported to the Department; and 2. Submit completed investigations of alleged abuse to the Department. The facility's Administrator (ADM) and the Director of Nursing (DON) were informed of the IJ on 5/10/17 at 1:58 p.m. The immediacy of the IJ was removed on 5/10/17 at 5:13 p.m., based on acceptance and implementation of the facility's immediate plan of correction. Findings: 1. a. Random Resident 21 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Review of an abuse allegation form, dated 7/5/16, revealed Random Resident 21 reported his roommate grabbed him, and later told the wound doctor that he had a skin tear. Review of Interdisciplinary Team Progress Notes dated 7/6/16 stated, Spoke with (Random Resident 21) regarding the skin tear at the (left) forearm today (doing investigation for incident report). Asking him how (skin tear) occurred, he stated, 'I don't know, blood was coming down my arm' There was no documented evidence about Random Resident 21's welfare, feelings about the alleged abuse, or fears for safety. Review of facility document titled, Resident Abuse Investigation Form, dated 7/6/16 stated the Social Services Director (SSD), called Random Resident 21's family member and stated a possibility for a private room would be a Board and Care. We only have one room and it is occupied. There was no documented evidence of asking Random Resident 21 about his welfare, or fears of staying in the room, nor were steps taken to remove or separate Random Resident 21 from his roommate. 1. b. Random Resident 19 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Resident 8 was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Review of an abuse allegation form, dated 9/9/16, revealed a nursing assistant witnessed Random Resident 19 striking Resident 8's shoulder with a clothing protector. Resident 8 cried out and got the attention of a nursing assistant. When approached by the nursing assistant, Random Resident 19 was about to strike Resident 8 again. A review of records showed there was no documented evidence of a formal investigation involving other resident or staff witnesses. 1. c. Random Resident 15 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. Random Resident 20 was admitted to the facility in 2016 with [DIAGNOSES REDACTED]. Review of an abuse allegation form, dated 12/8/16, revealed a nursing assistant had witnessed Random Resident 15 telling Random Resident 20 to stop rocking in her wheelchair. After an exchange of words, Random Resident 15 subsequently slapped Random Resident 20 on the left cheek (of the face). Nursing notes dated 12/7/16 at 10 p.m., stated, I also saw another (resident) protecting herself from getting hit. There was no documented evidence the allegation of abuse was reported to the Department. 1. d. Random Resident 17 was admitted to the facility 2014 with [DIAGNOSES REDACTED]. Random Resident 18 was admitted to the facility in 2015. Review of an abuse allegation form, dated 9/9/16 revealed a licensed nurse reported Random Resident 18 was standing in the doorway of Random Resident 17's room. Random Resident 18 refused to move, grabbed the doorway and kicked both Random Resident 17 and Random Resident 17's family member. There was no documented evidence the allegation of abuse was reported to the Department. Review of facility policy and procedure titled, Abuse Neglect Exploitation, dated 2/25/15, defined abuse as, the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The document defined physical abuse as including, hitting, slapping, pinching, pulling, and kicking. In an interview with the ADM and DON on 5/11/17 at 11:17 a.m., the ADM stated he did not think a slap on the face was abuse, nor was hitting or slapping on the arm. The DON stated she believed that a slap on the face would be considered abuse. Review of facility policy titled, General Abuse Policy, revised 8/25/16, directed, All abuse concerns, questions, allegations, and incidents shall be reported immediately according to (facility) policies, state and federal law and regulations . Review of facility policy titled, Abuse Reporting, dated 10/23/03, stated, External Reporting by Employees .Employees may contact the applicable government agency(ies) either prior to or after reporting the concern internally. See attached table to identify the appropriate state agency(ies) that employees must report abuse concerns to, the information to be provided, reporting time frames, and any other additional reporting requirements . Review of the Abuse Reporting table stated, The facility shall immediately report all known, suspected, or witnessed incidents of abuse/neglect in any form to ALL of the following agencies: 1. The local Ombudsman OR 2. The local policy department/sheriff's office. PLUS FOR INCIDENTS INVOLVING SNF RESIDENTS: Contact the local office of the California State Department of Health (DHS) as follows: Within 24 hours by phone AND Confirmed in writing within 2 working days using the Report of Suspected and Dependent Adult/Elder Abuse form . Review of facility policy titled, Abuse Reporting, dated 10/23/03 read, All applicable documents shall be completed and submitted to the appropriate government agency(ies) within the prescribed time frames. During an interview on 5/9/17 at 11:20 a.m., the ADM stated he received direction of reporting abuse incidents from the facility's corporate office. He considered the 5 abuse allegations that occurred over the past year as incidents perpetrated by a resident with a [DIAGNOSES REDACTED]. He stated he reported these incidents to the local ombudsman. During an interview with the ADM and SSD on 5/10/17 at 8:50 a.m., the ADM confirmed he did not report the abuse allegations, or submit documentation of a formal investigation to the Department for Random Residents' 18, 21, 19, 20, 17, and one sampled resident (8).