Every finding on record at Bridgewood Post Acute

Based on interview and record review the facility failed to ensure necessary respiratory care was provided to one of one sampled resident (Resident 1) when: the facility did not have evidence they applied Bipap (Bilevel Positive Airway Pressure, a non-invasive form of ventilation that delivers pressurized air through a mask to help you breathe) oxygen therapy to Resident 1 as needed.This failure had the potential to worsen Resident 1's chronic respiratory illnesses.A review of Resident 1's facesheet (demographic information) indicated multiple diagnoses including Pneumonia, Chronic Obstructive Pulmonary Disease (COPD, a progressive lung condition that causes obstruction of airflow and breathing difficulties), acute and chronic respiratory failure with hypercapnia (occurs when the lungs cannot adequately remove carbon dioxide (CO , the gas that we breathe out), leading to a dangerous buildup in the blood -hypercapnia), asthma, morbid obesity with alveolar hypoventilation (condition that occurs when excess body weight creates mechanical breathing difficulties, leading to chronically low oxygen and high carbon dioxide levels in the bloodstream), obstructive sleep apnea (OSA, a disorder where your throat muscles relax and repeatedly block your airway during sleep).A review of Resident 1's medical record indicated he was admitted to the facility on [DATE].A review of Resident 1's Skilled Nursing Facility admission Orders from the acute care hospital he was admitted from dated 10/24/24 indicated, Active hospital problems Diagnosis acute on chronic hypercapnic respiratory failure.CHF [congestive heart failure, a condition where the heart does not adequately pump blood to the body] exacerbation.asthma.adult obstructive sleep apnea, severe, obesity hypoventilation syndrome.Oxygen orders: Nightly BPAP [Bipap], pt [patient] may use his home machine [bipap settings to be used].A review of Resident 1's Baseline Care Plan dated 10/24/24 indicated, Special Treatment 1. BIPAP.A review of Resident 1's Order Summary Report dated 10/24/24-11/21/24 indicated, no order for the use of a Bipap machine.A review of Resident 1's Medication Administration Record (MAR) dated, October 2024, indicated no documentation for the application of a Bipap machine.A review of Resident 1's MAR dated, November 2024, indicated no documentation for the application of a Bipap machine.A review of Resident 1's comprehensive care plan during admission to the facility indicated, no care plan or interventions for the use of a bipap machine.During a concurrent interview and record review on 7/10/26, at 2:02 p.m., with Director of Nursing (DON), Resident 1's medical record was reviewed. Resident 1's medical record indicated, Resident 1 did not have an order to use Bipap while at the facility. Record indicated, no evidence for the use of Bipap on the MAR for October 2024 or November 2024. The DON stated that he did not see an order for Bipap, and Resident 1 should have had an order since it was ordered from the hospital in the admission orders. The DON further stated that there was no documentation the facility applied Bipap to Resident 1 on the MAR for October or November 2024. The DON stated the interdisciplinary team should have seen the admission order and made sure there was a care plan and order to instruct staff to apply Bipap and chart on the MAR that it was completed. The DON stated if Resident 1 did not use the Bipap there is a concern for worsening of his shortness of breath.A review of the facility's policy and procedure titled, CPAP/BiPAP Support dated 2015 indicated, Purpose 1. To provide the spontaneously breathing resident with continuous positive airway with or without supplemental oxygen. 2. To improve arterial oxygenation (Pa02) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety.Documentation Document the following in the resident's medical record: 1. General assessment .2.Time CPAP [Bipap] was started and duration of the therapy.

Based on interviews, and record review, the facility failed to protect two of five sampled residents' (Resident 3 and Resident 4) right to be free from physical abuse by another resident when:Resident 1 punched Resident 4, andResident 2 punched Resident 3 in his right eye.These failures had the potential to cause physical/mental harm to Resident 3 and Resident 4.Findings:1. Resident 1 was admitted to the facility in August of 2024 with diagnoses that included schizophrenia (a mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior).A review of Resident 1's Minimum Data Set (a standardized assessment tool used in nursing homes), dated 12/5/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 10 indicating Resident 1 had moderate mental and cognitive impairments.Resident 4 was admitted to the facility in February of 2025 with diagnoses that included Parkison's disease (a movement disorder of the nervous system that worsens over time).A review of Resident 4's MDS, dated [DATE], indicated Resident 4 had a BIMS score of 10 indicating Resident 4 had moderate mental and cognitive impairments.A review of Resident 4's Nurses Progress Note (NPN), dated 1/8/26, indicated, At approximately 0650, the nurse observed Resident [Resident 4] and male peer [Resident 1] in an altercation in the Resident's [Resident 4] room.During an interview on 1/28/26 at 10:58 a.m. with Licensed Nurse 3 (LN 3), LN 3 confirmed he witnessed the altercation between Resident 1 and Resident 4. LN 3 indicated that when he walked into Resident 4's room for medication administration, he observed Resident 1 punching Resident 4. LN 3 indicated that during the altercation, Resident 1 stood over Resident 4, who was lying in his bed. LN 3 confirmed Resident 1's punches made physical contact with Resident 4's body but was unable to state exact locations.2. Resident 2 was admitted to the facility in July of 2024 with diagnoses that included schizoaffective disorder (a chronic mental health condition characterized by a combination of schizophrenia symptoms and a mood disorder).A review of Resident 2's MDS, dated [DATE], indicated Resident 2 had a BIMS score of 7 indicating Resident 7 had severe cognitive impairments.Resident 3 was admitted to the facility in October of 2025 with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body).A review of Resident 3's MDS, dated [DATE], indicated Resident 3 had a BIMS score of 13 indicating Resident 3 was cognitively intact.A review of Resident 3's NPN, dated 1/4/26, indicated, [Resident 2] turned toward [Resident 3] and made kin contact with [Resident 3] in the left eye (sic).During an interview on 1/28/26 at 9:52 a.m., with LN 1, LN 1 confirmed she witnessed the altercation between Resident 2 and Resident 3. LN 1 stated, [Resident 3] was in a wheelchair. [Resident 2] was standing up. [Resident 2] was on the phone with his mom. I was charting during this. [Resident 2] then swung around. [Resident 2] used his right arm and struck [Resident 3] in the right eye. It was a punch like motion.[Resident 2] was on the phone with his mom and that is what might have triggered him. LN 1 then indicated that residents have the right to be free from abuse.During an interview on 1/28/26 at 10:01 a.m., with LN 2, LN 2 indicated she was present during the altercation between Resident 2 and Resident 3. LN 2 indicated she witnessed Resident 2 talking on the phone with his mom, when he suddenly hung up and turned towards Resident 3. LN 2 indicated Resident 3 then stated, He hit me.During an interview on 1/28/26 at 11:42 a.m., with the Social Services Director (SSD), the SSD stated that physical abuse could, affect residents' mental, physical, social, and overall wellbeing. The SSD indicated residents in the facility have the right to not be physically abused.During a review of the facility's policy and procedures (P&P) titled, Abuse Prevention Program, revised 12/2016, the P&P indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.These findings represent past noncompliance with this regulatory requirement. Observations, interviews and record review confirmed the residents were separated immediately, the residents were assessed, the residents' providers and responsible parties were notified, the residents' care plans were updated, and sitter staff were assigned to each resident to closely supervise them. There was sufficient evidence that the facility corrected the violation as of 1/8/26, and no other occurrences of noncompliance were identified. At the time of the visit, the facility was in substantial compliance with this regulatory requirement, and therefore, this violation does not require a plan of correction.

Based on observation, interview, and record review, the facility failed to provide supervision for two of three sampled residents (Resident 1, Resident 2) when Resident 2 pushed Resident 1's wheelchair from behind causing Resident 1 to react impulsively and strike Resident 2 on the hand.This failure had potential to cause harm and psychosocial distress. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in October 2025 with multiple diagnoses including schizoaffective disorder (mental condition that is characterized by symptoms of schizophrenia, including delusions and hallucinations, with mood disorder symptoms such as depression or mania), borderline personality disorder (mental health condition causing unstable emotions characterized by impulsivity and difficulty regulating feelings), and bipolar disorder (mental health condition causing extreme mood swings from manic highs to depressive lows).A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 10/6/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 1 was cognitively intact. A review of Resident 1's Change of Condition Assessment, dated 11/14/25, indicated . [Resident 1] was sitting in her chair in the hallway when another resident was trying to pass her but was not able to due to not having enough space. The other resident states she reached to move [Resident 1's] wheelchair over so she could pass and alleged that [Resident 1] made contact with her left arm. Staff member immediately stepped in between and separated them. Both residents assessed and no injuries noted .A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in April 2025 with multiple diagnoses including encephalopathy (disorder that alters brain structure causing confusion and personality changes), sepsis (body responds improperly to infection causing organ damage), and dementia (disease characterized by memory loss and decline in judgment that interferes with daily life). A review of Resident 2's MDS, Cognitive Patterns, dated 10/29/25, indicated Resident 2 had a BIMS score of 13 out of 15 that indicated Resident 2 was cognitively intact. A review of Resident 2's Change of Condition Assessment, dated 11/14/25, indicated .alleged altercation with another resident in the hallway .A review of Resident 2's Progress Note, dated 11/14/25, indicated . [Resident 2] was mobilizing in her wheelchair in the hallway and was making an attempt to pass another resident but that residents chair was blocking her ability to pass so she stated that she reached out in an attempt to move the other resident's wheelchair so she could pass her when that resident made contact with her left arm. Staff member immediately stepped in between the and separated them. Both residents assessed and no injuries noted .During an interview on 12/30/25 at 12:29 p.m. with the Director of Staff Development (DSD), the DSD stated Resident 1 was in the front lobby by the nursing station in her wheelchair when Resident 2 pushed her wheelchair forward and Resident 1 reacted by reaching back making contact with Resident 2. Resident 1 said, Hey, don't do that. The DSD stated Resident 1 was startled when her wheelchair was moved. The DSD stated the residents were separated. The DSD stated the residents had no prior incidents with each other or any other residents. During an interview on 12/30/25 at 12:42 p.m. with the Administrator (ADM), the ADM stated Resident 1 and Resident 2 were in wheelchairs in front of the nursing station when Resident 2 was trying to go around Resident 1 and moved her wheelchair. The ADM stated Resident 1 was startled and swung her arm and made contact with Resident 2's arm. The ADM stated he spoke with Resident 1 who stated she did not mean to hurt her but was startled. The ADM stated a staff member witnessed the incident and separated the residents. The ADM stated there were no injuries to either resident. The ADM stated both residents are in the behavioral program and they are monitored for behavioral needs and have not had any previous incidents with each other or other residents. During a telephone interview on 12/30/25 at 12:58 p.m. with the Director of Rehab (DOR), the DOR stated she was a witness to the incident between Resident 1 and Resident 2 on 11/14/25. The DOR stated she saw both residents in their wheelchairs by the nursing station. The DOR stated Resident 2 wanted to get by and pushed Resident 1's wheelchair forward. The DOR stated Resident 1 reached back and swiped Resident 2's left hand. The DOR stated Resident 1 was upset because her wheelchair was moved and said, Don't push me. The DOR stated the residents were separated and then assessed by nursing. During a concurrent observation and interview on 12/30/25 at 2:34 p.m. with Resident 2, observed Resident 2 with frequent mouth and jaw movements and folding blanket over and over. Resident 2 stated she was hit by a man in a wheelchair but did not recall any altercation with a woman. Resident 2 then indicated she did not want to talk any further.During an interview on 12/30/25 at 2:36 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was not aware of any incident between Resident 1 and Resident 2, but she had not seen any physically aggressive behaviors from Resident 1 or Resident 2. During an interview on 12/30/25 at 2:39 p.m. with Resident 1, Resident 1 stated a resident pushed her from the back and said, Get out of my way. Resident 1 stated she did not try to hit her and stated, Please do not push me. Resident 1 stated she was startled when pushed. During an interview on 12/30/25 at 2:50 p.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 1 has auditory hallucinations and is mostly quiet in her wheelchair but will yell and get upset. LN 1 stated Resident 2 has hallucinations and can be verbally aggressive but has not seen any physical aggression.A review of the facility's Policy and Procedure (P&P) titled Safety and Supervision of Residents, not dated, indicated . Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents and facility-wide priorities .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment .The type and frequency of resident supervision may vary among residents and over time for the same resident .

Based on observation, interview, and record review, the facility failed to provide supervision to prevent two of three sampled residents (Resident 1 and Resident 2) from having a physical altercation when Resident 2 bumped Resident 1 with his wheelchair and Resident 1 struck Resident 2. This failure resulted in Resident 1 experiencing frustration and Resident 2 experiencing physical injury to his face. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in June 2025 with multiple diagnoses including malignant neoplasm of the tonsil (tonsil cancer), dysphagia (difficulty swallowing foods or liquids), and severe protein calorie malnutrition (inadequate intake of calories and protein to maintain nutritional status).A review of Resident 1's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 6/16/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 12 out of 15 that indicated Resident 1 had moderate cognitive impairment. A review of Resident 1's Change in Condition Evaluation, dated 7/21/25, indicated . while speaking to staff about discharge, resident stated that over the weekend, male peer repeatedly bumped into him with his wheelchair on purpose and that he responded by striking male peer .A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in December 2024 with multiple diagnoses including right femur (thighbone) fracture, diabetes (too much glucose in the blood), and vascular dementia (decline in thinking skills caused by decreased or blocked blood flow to the brain). A review of Resident 2's MDS, Cognitive Patterns, dated 4/24/25, indicated Resident 2 had a BIMS score of 6 out of 15 that indicated Resident 2 had severe cognitive impairment. A review of Resident 2's MDS, Functional Abilities, dated 4/24/25 indicated Resident 2 used a motorized wheelchair and was able to wheel himself 150 feet with supervision. A review of Resident 2's Change in Condition Evaluation, dated 7/21/25, indicated .On 7/21/25 at around 10:10 am, during male peers discharge he reported that over the weekend resident was repeatedly bumped into him w/ his wheelchair on purpose and that he responded by striking resident . Resident assessed with superficial abrasion 0.4 cm [centimeters] L [long] x 0.2 cm W [wide] and mild discoloration of his left eye previously identified as an unwitnessed fall . A review of Resident 3's clinical record indicated Resident 3 was admitted to the facility in July 2025 for multiple diagnoses including anemia (blood does not have enough red blood cells and hemoglobin to carry oxygen throughout the body), gastrointestinal hemorrhage (bleeding in the digestive tract), and alcoholic cirrhosis of liver (scarring and damage to the liver from chronic alcohol abuse). Further review of the clinical record indicated that Resident 3 was alert and oriented. A review of the facility's Resident Abuse Investigation Report Form, dated 7/24/25, indicated .On 7/21/25 at approximately 10:10 AM, while speaking with staff regarding his upcoming discharge, [Resident 1] reported that over the weekend, [Resident 2] repeatedly bumped into him with his wheelchair in what her [sic] perceived to be an intentional manner, despite being asked to stop. In response, [Resident 1] stated he struck [Resident 2] . During an interview on 7/24/25 at 10:20 a.m. with the Administrator (ADM), the ADM stated when Resident 1 was being discharged on 7/21/25 he reported to the Social Services Director (SSD) that on 7/19/25 he was bothered by Resident 2 who had been bumping into him with his wheelchair. The ADM stated Resident 1 reported he was annoyed with Resident 2, so he hit him. The ADM reported Resident 1 stated, He was pestering me the other day, so I hit him. The ADM stated once incident was identified as abuse on 7/21/25, it was reported to the ombudsman, The Department, and law enforcement. The ADM stated Resident 2 had dark bruising around eyes and bleeding from nose. The ADM acknowledged that Resident 1 was annoyed with Resident 1, so he deliberately hit Resident 2.During an interview on 7/24/25 at 11:09 a.m. with the SSD, the SSD stated she met with Resident 1 on 7/21/25 to review discharge plan. SSD stated Resident 1 reported Resident 2 kept running into him intentionally with his wheelchair and Resident 1 reported that on 7/19/25 he struck Resident 2. The SSD stated Resident 1 did not have any injuries, but Resident 2 had bruising across the bridge of his nose. During a concurrent observation and interview on 7/24/25 at 11:30 a.m. with Resident 2, observed dark blue discoloration under left eye extending to cheek, yellow discoloration to left side of eye, and red scabbed abrasion across the bridge of the nose. When asked what happened to his eye and nose, Resident 2 stated he did not know. When asked if anyone had hit him, Resident 2 stated Maybe tried to hit him, then he tried to hit me. During an interview on 7/24/25 at 11:54 a.m. with Resident 3, Resident 3 stated Resident 2 causes problems because he goes into different rooms in his wheelchair. Resident 3 stated he has heard Resident 2 bumps into things and is trying to hurt others.During an interview on 7/24/25 at 11:57 a.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 2 reported to staff that he had an altercation with another resident. LN 1 stated Resident 2 stated that someone hit him, that man, and he hit someone back. LN 1 stated Resident 2 did not indicate any person specifically. LN 1 stated Resident 2 had an abrasion to his left eye. LN 1 stated Resident 2 bumps into people and things with his wheelchair and is not aware of his surroundings. During an interview on 7/24/25 at 12:04 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she had seen Resident 2 bump into people or things with his wheelchair, but not on purpose. A telephone call was placed to Resident 1 on 7/24/25 at 4:45 p.m. Surveyor did not receive return call.A review of the facility's Policy and Procedure (P&P0 titled Resident-to-Resident Altercations, revised 9/22, indicated .All altercations, including those that may represent resident-to-resident abuse, are investigated . Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents .Behaviors that may provoke a reaction by residents or others include .physically aggressive behavior .wandering into others' rooms/space .If two residents are involved in an altercation, staff .identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation .A review of the facility's P&P titled Abuse Prevention Policy, dated 3/17/25, indicated .Residents have the right to be free from all forms of abuse. This includes .Freedom from physical abuse .Certification of Abuse .Occurrences, patterns, and trends will be assessed by administrative staff, licensed staff, and the interdisciplinary team (IDT) to determine the corrective action based on the results of the investigation . The facility will ensure that all residents are protected from physical and psychosocial harm during and after investigation .Increase supervision of the alleged victim and other residents as necessary .

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for three of six sampled residents from Medication Administration (Resident 25, 37, and 447), when; 1. For Resident 25, a licensed nurse did not administer resident's prescribed haloperidol (medication used to treat nervous, emotional, and mental conditions) as it was prescribed by the doctor. 2. For Resident 37, a licensed nurse did not follow the instructions on the medication label for resident's divalproex sodium (medication used to treat certain types of seizures). 3(a). For Resident 447, a licensed nurse did not follow the instructions on the medication label for resident's mycophenolate (medication used to prevent organ transplant rejection), and (b). For Resident 447, a licensed nurse did not administer resident's prescribed Aspirin (medication used for pain or inflammation) as it was prescribed by the doctor. As a result, 4 errors were identified out of 27 opportunities for error during the observation of medication administration; the facility medication error rate was 14.81%. Findings: 1. During an observation of medication administration on 6/3/25 at 7:41 a.m., Licensed Nurse 4 (LN 4) was observed to prepare Resident 25's morning medications which included a full haloperidol 5 mg (milligram, unit of measure) tablet instead of 2.5 mg (1/2 tablet). During an interview on 6/3/25 at 7:41 a.m., with LN 4, LN 4 stated, I cannot administer resident's medication without clarifying it. there is a discrepancy with the ordered dose and the available dose in the medication blister pack. LN 4 further stated that the haloperidol order was changed, but the new dosage was not delivered to the facility from the pharmacy. Reconciliation of the observed medication administration for Resident 25's current Physician Orders, dated 6/2/25, indicated, haloperidol oral tablet, 5 mg, give 0.5 tablet by mouth one time a day for schizophrenia (a type of chronic mental disorder) 0.5 tab =2.5mg). During an interview on 6/3/25 at 8:01 with the Director of Nursing (DON), the DON stated a new verbal order for haloperidol was documented by a licensed nurse at 8:44 a.m., a day before, on 6/2/25 and was signed by the doctor on 6/3/25 at 1:11 a.m. The DON stated, the expectation was for the doctor to sign the order as soon as possible for the pharmacy to fill the prescription. Furthermore, the DON stated, since the current available dose of medication is not the same as the doctor's order, we will call the pharmacy to ask how we can use the current available medication until the new medication dose arrives. The DON confirmed the medication dose should have been available for the morning medication administration. During a review of the facility policy and procedure (P&P), titled, Administering Medications, revised April 2019, the P&P indicated, Ensure that the six rights of medication administration are followed . Right dose .Compare medication source (bubble pack .) with MAR to verify . dose . administer medication as ordered in accordance with manufacturer specifications . 2. During an observation of medication administration on 6/4/25 at 7:05 a.m., LN 5 was observed to prepare and administer Resident 37's morning medications which included divalproex sodium, without wearing gloves. During an interview on 6/4/25 at 07:13 a.m. with LN 5, LN 5 confirmed the medication label for divalproex sodium indicated to use gloves to handle. LN 5 stated the purpose of using gloves was due to the medication being a hazardous (the state or condition of being dangerous or involving risk) medication. LN 5 acknowledged gloves should have been worn. Reconciliation of the observation of medication administration with Resident 37's current Physician Orders for divalproex sodium dated 4/23/25, indicated, divalproex sodium 250 mg. Give 3 tablet by mouth two times a day for Epilepsy (a neurological disorder characterized by recurrent seizures, which are abnormal electrical activity in the brain). Use gloves to handle. During a review of Resident 37's Medication Administration Record (MAR), dated 4/23/25, the MAR indicated to use gloves to handle divalproex sodium. During a review of the facility policy and procedure (P&P), titled, Administering Medications, revised April 2019, the P&P indicated, Compare medication source (bubble pack .) with MAR . administer medication as ordered in accordance with manufacturer specifications . 3 (a). During an observation of medication administration on 6/4/25 at 7:44 a.m., LN 1 was observed to prepare and administer Resident 447's morning medications which included two mycophenolate tablets without wearing gloves. During an interview on 6/4/25 at 7:28 a.m. with LN 1, LN 1 confirmed the medication label for mycophenolate indicated to use gloves when handling. LN 1 acknowledged the reason was due to the resident being a transplant recipient. LN 1 acknowledged gloves should have been worn. Reconciliation of the observation of medication administration with Resident 447's current Physician Orders dated 3/26/25, indicated, mycophenolate mofetil 500 mg. Give 2 tablets by mouth two times a day to prevent and treat rejection after transplant. Use gloves to handle. During a review of Resident 447's Medication Administration Record (MAR), dated 5/19/25, the MAR indicated to use gloves to handle mycophenolate. During an interview on 6/4/25 at 7:48 a.m. with the DON, the DON acknowledged the nurse should have worn gloves when she administered mycophenolate and divalproex. He further stated, in addition to the pharmacy label on the blister packs, even the physician order indicates to wear gloves. 3 (b). During an observation on 6/4/25 at 7:14 a.m. of medication administration, LN 1, was observed preparing and administering Resident 447's morning medications which included only 2 tablets of mycophenolate. LN 1 confirmed 2 pills were being administered prior to administration. Reconciliation of the observation of medication administration with Resident 447's current Physician Orders dated 3/27/25, indicated, aspirin oral 81 mg by mouth one time a day for PPX DVT (deep vein thrombosis prophylaxis), which was not administered during the morning medication pass observation. During an interview and concurrent record review on 6/4/25 at 10:14 a.m. with LN 1, LN stated Resident 447's aspirin was given later that day during the second medication pass observation at 8:07a.m.; however, after reviewing the Electronic Medication Administration Record (e-MAR), LN 1 acknowledged being confused about the aspirin administration and believed it was given early in the morning at 7:24 a.m. during the first morning medication pass. LN 1 was unable to explain why only two mycophenolate tablets were dispensed during the first morning medication pass observation as the number of pills were confirmed by her prior to the administration of Resident 447's morning medications. During an interview on 6/4/25 at 11:02 a.m. with the DON, the DON stated, it is expected the nurses follow the e-MAR and doctors' orders and aspirin should have been administered as ordered by the doctor. During a review of the facility policy and procedure (P&P), titled, Administering Medications, revised April 2019, the P&P indicated, Ensure that the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route. e. Right time, f. Right documentation .Review MAR to identify medication to be administered .Administer medication as ordered .

Based on observation, interview, and record review, the facility failed to ensure medications were stored properly, when unlabeled loose pills and labeled pharmaceutical products were found behind the drawers and in the back of medication cart A. These failures had the potential for medication error, misuse and drug diversion. Findings: During an inspection of the Medication Cart A on 6/2/25 at 9:31 a.m., four unlabeled loose pills and four labeled pharmaceutical products were found behind the drawers and in the back of medication cart A. During an interview on 6/2/24 at 9:48 a.m. with Licensed Nurse 1 (LN 1), LN 1 removed the pills found on the bottom of the drawer and confirmed there were 4 loose pills. LN 1 also confirmed there were 4 labeled medications found at the back of the cart behind the drawers. LN 1 stated the loose pills or the misplaced medication blister packs in the back can lead to a mediation error. LN 1 stated, the cart should have been checked every day to make sure medications did not fall in the back. During an interview on 6/2/25 at 11:41 a.m. with the Director of Nursing (DON), the DON confirmed medications should not be loose in the drawers and labeled medication should not be at the back of the cart behind the drawers. The DON stated, the medication carts should be checked thoroughly, cleaned and sanitized daily. During a review of the facility Policy and Procedure (P&P), titled, Medication Labeling and Storage, revised February 2023, the P&P indicated, Medications and biologicals are stored in the packaging, containers .which they are received .The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner .Medications are stored in an orderly manner in cabinets, drawers, carts .Each resident's medications are assigned to an individual cubicle, drawer, .to prevent the possibility of mixing medications of several residents.

Based on observation, interview and record review, the facility failed to ensure four dietary staff had the appropriate skill set to safely perform the daily operations of the food and nutrition services department when: 1. Two Dietary Aides were not able to verbalize the process of manual dishwashing with 3-compartment sink (cross refer to F812, #8), and 2. Two Cooks did not perform handwashing before touching the clean dishes at the clean side of the dishwashing machine (cross refer to F812, #9) These failures had the potential to place 45 out of 47 highly susceptible residents who consumed food from the facility kitchen at risk for food borne illness. Findings: 1. During an interview on 6/2/25 at 10:06 a.m. with Dietary Aide (DA) 1, DA 1 verbalized the manual dishwashing procedure by using the 3-compartment sink. He stated he would switch to manual dishwashing when the dishwashing machine was not working. He explained the kitchen had a 2-compartment sink for wash and rinse, and used an extra tub for the sanitize step as a third compartment. DA 1 was unable to answer the immersion time for dishes and pans into the sanitizer. A concurrent confirmation with Dietary Supervisor (DS), DS stated the immersion time should be 20-60 seconds. During an interview on 6/3/25 with DA 3, DA 3 verbalized the process of the manual dishwashing with the 3-compartment sink. DA 3 stated the steps involved wash, rinse, sanitize and air dried. She stated the wash and rinse water temperature should be 130 degrees Fahrenheit (F), and the immersion time for the dishes in the sanitizer should be one minute and the concentration of the sanitizer (quaternary ammonium) should be 100 ppm (parts per million, a measurement unit for concentration of solution). During an interview on 6/4/25 at 12:41 p.m. with Registered Dietitian (RD), RD stated, she expects staff to know about the procedure in case of an emergency. RD stated if sanitation was not performed properly, it may cause cross-contamination. A review of the facility P&P titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated, .washing .fill the first compartment with detergent .and hot water (110-120 degrees F) .rinsing .fill the second compartment with .hot water, (110-120 degrees F) .sanitizer solution must read 200 ppm .immerse all washed items for 60 seconds. A review of DA 1's employee file, it indicated their date of hire was on Spring 2023 for dietary aide position. DA 1 had an updated food handler certificate with issue date of 6/4/25. A review of DA 3's employee file, it indicated their date of hire was Winter 2010 for dietary aide position. DA 3's had a food handler certificate with expiration date of 6/3/2028. A review of facility documents titled, Verification of Job Competency Demonstration- Dietary Aids, for DA 1 and DA 3, both completed for the year 2024 by DS, it indicated that DA 1 and DA 3 were competent on Emergency dish washing procedure and when to use it. A review of departmental documents titled, Food & Nutrition Services In-Service, Topic: Low Temp Dish Machine and 3-Compartment Sinks,, completed on 4/20/24 and given by DS and indicated DA 1 and DA 3 attended in-services. The In-services explained about the proper steps, temperature requirements, sanitizer used and testing and the policies and procedures for three-compartment sink methods. 2. During an observation of the handwashing practice on 6/3/25 at 8:59 a.m., [NAME] (CK) 1 used the same gloved hands to touch the handle of refrigerator, clothing pocket, and then used the same gloved hands to touch and put away the clean dishes at the clean side of the dishwashing machine. During an observation of the handwashing practice on 6/3/25 at 11:20 a.m., CK 2 placed her bare hands on the whipped cream package then on the soiled plates. CK 2 used the same bare hands to pull up the handle of dishwasher panel (the dishwashing machine completed the dishwashing cycles) and pulled out the clean dish rack and then touched and rearranged the clean dishes and utensils. During an interview with DS on 6/3/25 at 12:42 p.m., DS acknowledged the handwashing issue above and she stated CK 1 and CK 2 should perform handwashing before touching the clean dishes. DS further stated the staff should wash their hands and don gloves between tasks. During an interview on 6/4/25 at 12:41 p.m. with RD, RD stated the dietary staff should perform hand hygiene every time in the kitchen before touching food, food contact surfaces and between tasks. RD further stated handwashing before touching the clean dishes should be done to prevent cross-contamination. A review of facility P&P titled, Dishwashing Machine Use, dated 2010, indicated, The following guidelines will be followed when dishwashing .a. Wash hands .frequently during the process . A review of the undated facility P&P titled, Dietary Employee Personal Hygiene, indicated, .Hands and fingernails .must always be washed .before putting on gloves, after removing gloves, and after engaging in other activities that contaminated the hands .Employees should never use bare hands contact any foods .or otherwise .Gloves are to be worn and changes appropriately to reduce the spread of infection . A review of CK 1's employee file, it indicated their date of hire was on Spring 2023 for [NAME] position. CK 1's had a food handler certificate with expiration date of 7/27/2026. A review of CK 2's employee file, it indicated their date of hire was on Fall 2023 for [NAME] position. CK 2's had a food handler certificate with expiration date of 9/24/2026. A review of facility documents titled, Verification of Job Competency Demonstration - Cooks, for CK 1 and CK 2, both were completed for the year of 2024 by DS. Both documents indicated CK 1 and CK 2 were competent on Hand washing procedure and Glove use in food preparation and service A review of facility document titled, Dietary In-Service, Topic: Proper Glove Use and Hand Washing, completed on 11/30/24 and given by DS, indicated CK 1 and CK 2 attended. The in-service explained about importance of hand washing, FDA food code, techniques, P&P of glove use and hand washing. A review of undated facility job description (JD) titled, Dietary Aide, it stated, .Essential Job Functions .ensure all dietary procedures are followed in accordance with established policies .attend trainings, in-services, and meetings .prepare, serve, and store food, etc., in accordance with sanitary regulations and established policies and procedures . A review of undated facility JD titled, Cook/Kitchen Staff, it stated, .Safey and Sanitation Functions .Follow established infection prevention and control policies and procedures when performing daily task .Prepare food in accordance with sanitary regulations as well as established facility policies and procedures. A review of facility JD titled, Certified Dietary Manager, revised 10/2020, it stated, .administrative functions .assume .responsibility and accountability of supervising the food and nutrition services department .Duties and Responsibilities .standardizing the methods in which tasks will be performed .assist staff in the development and use of departmental procedures governing activities .ensure staff is aware of and follows established facility policies .make daily rounds to assure that personnel are performing required duties and to assure that appropriate procedures are being rendered to meet the needs of the facility .ensure that food and nutrition services personnel follow established infection prevention and control procedures . It showed the DS should have an effective in-service and monitoring programs for the dietary staff to understand the established policies and procedures to be competent to perform their job duties and functions described.

Based on observation, interview and record review, the facility failed to ensure the menu was followed for the therapeutic diet during lunch meal on 6/3/25 when: 1. One resident (Resident 26) with a diet of mechanical soft (MS) texture diets (a diet consisting of soft, moist foods for people who have chewing and/or swallowing difficulties) and small portions received the wrong portion for the meat. 2. One resident (Resident 13) with diet of MS, CCHO (diet where number of sugars and starches are controlled), and Renal (special diet to avoid foods that can be harmful to kidneys) received brown rice instead of wheat pasta. 3. One resident (Resident 22) with MS diet received parsley sprig for garnish instead of parsley flakes 4. Six residents (Resident 12, 34, 35, 37, 38, and 43) did not receive parsley sprig garnishes with their lunch meals. These failures had the potential to result in compromising the medical and nutrition status of nine out 45 residents who received food from the facility kitchen. The census was 47. Findings: During the lunch meal distribution on 6/3/25 beginning at 11:46 a.m., it was noted as follows: 1. Resident 26 with a diet of mechanical soft and small portions received 1/3 cup (#12 scoop) instead of 3/8 cup (#10 scoop) of meatball. A concurrent review of facility spreadsheet (a menu excel sheet that indicates what items and portions to be served for each prescribed diet) titled, Summer Menus, Week 1 Tuesday, indicated that MS texture and small portion diet should receive 3/8 cup (#10 scoop). 2. Resident 13 with a diet of MS, CCHO, and Renal received brown rice instead of wheat pasta for starch. A concurrent review of facility spreadsheet titled, Summer Menus, Week 1 Tuesday, indicated that MS, CCHO, and Renal diet should receive 1/2 cup of wheat pasta with margarine. 3. Resident 22 with mechanical soft diet received parsley sprig for garnish instead of parsley sprig flakes. A concurrent review of facility spreadsheet titled, Summer Menus, Week 1 Tuesday, indicated that MS diet should receive parsley sprig flakes. 4. Residents 12, 34, 35, 37, 38, and 43 did not receive parsley garnish with their lunch meal. A concurrent review of the facility spreadsheet titled, Summer Menus, Week 1 Tuesday, indicated that all diets on the spreadsheet should have received garnish. During an interview with Dietary Supervisor (DS) on 6/3/25 at 12:40 p.m., DS confirmed CK 1 used the incorrect scoop size to serve the MS soft small portion. DS stated Renal CCHO diet should get wheat pasta instead of brown rice. DS confirmed wheat pasta was in stock. DS stated she expected the dietary staff to follow the spreadsheet during meal distribution. During an interview with Registered Dietitian (RD) on 6/4/25 at 12:41 p.m., RD stated she expected the dietary staff to follow the spreadsheet and scoop size. RD confirmed renal/CCHO diet should not be replaced without notifying her to evaluate the replacement. RD further explained the garnishes were provided for appealing presentation. She stated if giving a whole garnish to MS diet instead of flakes may cause choking. A review of the job description (JD) titled, Certified Dietary Manager, dated October 2020, indicated, .Duties and Responsibilities .assure that personnel are performing required duties and to assure that appropriate procedures are being rendered . A review of the JD titled, Cook/Kitchen Staff, dated October 2020, indicated, .Food Service Functions .Prepare food in accordance with standardized recipe, planned menus, and special diet orders .serve meals that are appetizing in appearance .serve food in accordance with established portion control procedures . A review of the JD titled, Dietary Aide, undated, indicated, .Dietary Service .Assist in preparing food for therapeutic and texture modified diets in accordance with planned menus with established portion control procedures . Assist in preparing an .appetizing meal in accordance with planned menus . A review of the JD titled Registered Dietitian, dated October 2020, indicated, .Assist in planning regular and special diet menus as prescribed by the attending physician .evaluate .therapeutic diets.

Based on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service in a safe manner when: 1. The ice machine was not clean. 2. Found pans stacked wet and had food debris stored at the clean and ready-to-use storage area. 3. Found opened packaged food products with improper labeling and dating procedure in the reach-in refrigerator and reach-in freezer. 4. Found food products that stated, keep frozen, stored in the dry storage area. 5. Found produces were not fresh stored in dry storge area. 6. Found personal belonging stored in dry storage area. 7. One Dietary Aide used a mask to replace the beard net and not covered the facial hair completely. 8. Two Dietary Aides were not able to verbalize the process of manual dishwashing with 3-compartment sink correctly. 9. Two Cooks did not perform handwashing before touching the clean dishes at the clean side of the dishwashing machine. 10. There were issues found in the resident's food refrigerator at the ice room: a. One food item was expired and was not discarded b. Few food items did not have labels with residents' names and date they were received. These failures had the potential to cause food-borne illness which could cause illness in 45 out of 45 medically vulnerable residents who consumed food from the facility kitchen and food from outside. The census was 47. Findings: 1. During a concurrent observation and interview on [DATE] at 10:48 a.m. with Maintenance Supervisor (MS) in the ice machine room. MS stated the maintenance department was responsible for the deep cleaning (cleaning and sanitizing the machinery parts on the top section of the ice machine and ice storage bin on the bottom section of the machine with chemical solutions designed to remove lime scale and mineral deposits and to remove algae and slime, then sanitize with chemical agent) of the ice machine monthly. A concurrent review of the undated facility's document titled, Ice Machine Cleaning Log, indicated the last deep cleaning was completed on [DATE]. A white chalky substance was observed on the motor unit (unit that plumbs water to the evaporator unit) upon the mechanical (top) part of the ice machine dissembled. MS confirmed it was calcium deposit (white mineral buildup), and he needed to clean it with water and a brush. There were significant black gelatinous substances found on the bottom evaporator unit (a part where the condensation occurs to make ice). The black substances were sticky and rough to touch, and hard to remove with a paper towel. MS confirmed the findings and agreed the ice machine was not clean. MS explained the process of deep cleaning the ice machine, he stated he would dissemble the parts that could be removed which included the hose, water curtain, water trough) and put in the dishwashing machine for cleaning and sanitizing. Then he would use the descaler to clean and use the sanitizer to sanitize the areas inside the machine and the ice storage bin. The removed parts done with cleaning and sanitizing, he would assemble the parts back and turned on the water mode to drain and started to make ice, the first batch of ice would be discarded, and the second batch could be used. During an interview on [DATE] at 12:41 p.m. with Registered Dietitian (RD), RD stated, facility ice machine expected to be clean and should be clean monthly. A review of the undated facility's ice machine user manual titled, [Ice machine Brand] Instruction Manual, undated indicated, .Installation .unit must be cleaned once every other week with citric acid to remove mineral build up .Sanitizing solution- .ratio of water to vinegar or lemon juice; or .household bleach to .hot water .wipe the interior, including evaporator rods, with the solution .run the ice maker, discard the first two batches (ice) . A review of the facility's policy and procedure (P&P) titled, Sanitation, dated [DATE], the P&P indicated, ice machines and ice storage containers are drained, cleaned and sanitized per manufacturer's instructions. 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). 2. During an observation on [DATE] at 8:48 a.m. and 9:10 a.m. there were issues found in the clean and ready-to-use storage area as follows: - one full sheet metal pan (stacked wet on top of another pan) - one metal muffin pan (with brown grainy substances) During an interview on [DATE] at 9:15 a.m. with the Dietary Supervisor (DS), the DS confirmed the metal pan was wet and the muffin pan had brown grainy substance and stated it was food particles. DS stated she expected the pans and dishes to be dried and clean before being stored away. During an interview on [DATE] at 12:41 p.m. with the RD, the RD stated the pans should be completely dried to prevent bacteria growth and contamination. RD further stated the pans should be clean before being stored away. A review of a facility P&P titled, Dishwashing Machine Use revised 2010, indicated, .After running items (dishes/utensils) through entire cycle, allowed to air-dry . According to 2022 FDA Food Code, on section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, the document indicated, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch (C) Non-food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . 3. A concurrent observation in the reach-in refrigerator and interview with the DS on [DATE] at 9.25 a.m. was conducted. There were issues found as followed: -one opened jar of mayonnaise (no opened and used by dates) -one opened jar of Italian dressing (no opened and used by dates) -one opened pack of parmesan cheese (no opened or used by dates) -one opened jar of Cesar salad dressing (no used by date) -one opened pack of shredded cheese (no used by date) -one opened pack of white shredded cheese (no used by date) DS confirmed some of food items above did not have opened and used by dates and some of them did not have used by dates. A concurrent observation in the reach-in freezer and interview with DS on [DATE] at 9:38 a.m. was conducted. There were issues found as followed: -two opened bags of frozen blueberries (no used by date) -one opened bag of frozen cream puffs (no used by date) DS confirmed the food items above without used by dates. A concurrent observation in the reach-in freezer and interview with the DS on [DATE] at 9:48 a.m. was conducted. There was one opened pack of pork sausage (no opened and used by dates). DS stated the opened pack of sausage should have an open and use by date. During an interview on [DATE] at 12:41 p.m. with the RD, the RD stated, she expected opened food in the refrigerator and freezer should be labeled with opened and use by dates. A review of the facility P&P titled, Food Receiving and Storage, date 2022 indicated, .All foods stored in the refrigerator or freezer are .labeled and dated (use by date). 4. A concurrent observation in the dry storage and interview with the DS on [DATE] at 9:38 a.m. was conducted. There were four boxes of bread items that had information on them that indicated to keep frozen (two boxes with receive date of [DATE] (Texas toast & Buns/Rolls), and two boxes with receive date of [DATE] (wheat toast & croissants). DS confirmed the boxes of bread items mentioned above were defrosting in the dry storage. During an interview on [DATE] at 12:41 p.m. with the RD, the RD stated when a package or box stated keep frozen when received from a delivery, should be kept in the freezer. She further stated the frozen food should thaw or defrost in the refrigerator not in dry storage. A review of the facility P&P titled, Food Receiving and Storage, date 2022 indicated, Frozen foods are maintained at a temperature to keep the food frozen solid. According to 2022 FDA Food Code, section ,d+[DATE].11 Frozen Food, indicated frozen foods should be maintained at a temperature that keeps the food frozen solid. 5. During a concurrent observation and interview on [DATE] at 10:23 a.m. with the DS, there were 12 out of 38 white onions found with black fuzzy substances and soggy spots. The DS confirmed the onions were not fresh. During an interview on [DATE] at 12:41 p.m. with the RD, the RD stated the dietary staff should check the produce when received and daily rounding should be done to check for freshness. A review of the facility P&P titled, Storing Produce, indicated, .check boxes of fruit and vegetables for rotten, spoiled items .Throw away all spoiled items .Remove obvious soil and debris when produce is delivered . 6. A concurrent observation in the dry storage and interview with the DS on [DATE] at 10:25 a.m. was conducted. There was a black backpack observed hanging on the rack where stored food was in the dry storage area. DS confirmed the personal belongings should not be stored in the dry storage area and expected the staff to store their items in the designated area. During an interview on [DATE] at 12:41 p.m. with the RD, the RD stated the dietary staff should store their personal belongings in designated area but not in food storing and preparation areas. RD further stated personal items stored in the food storing areas would put residents at risk for sickness. A review of the undated facility P&P titled, Dietary Employee Personal Items, indicated, .personal items from outside will not be kept in the kitchen or food storage areas. These items will be kept in the employee break room or other designated area . According to the 2022 FDA Food Code, section ,d+[DATE].110 Using Dressing Rooms and Lockers, it indicated personal items should be stored in a designated area away from food, equipment, linens, and single-service and single-use articles to prevent contamination. 7. During a kitchen inspection tour on [DATE] at 11:08 a.m., it was observed that the Dietary Aide (DA) 2 had a facemask on (without any beard net) that did not completely cover all his facial hair (mustache, beard and sideburns). Observed sides burns on left and right side of face extending outside of mask. A concurrent conformation with the DS and she agreed DA 2 was expected to wear a beard net to completely cover his facial hair and a mask was not a replacement. During an interview on [DATE] at 12:41 p.m. with the RD, the RD stated the mask cannot replace the beard net and the restraint should completely cover the facial hair. A review of the undated facility P&P titled, Dietary Employee Personal Hygiene, indicated, .all dietary staff must wear hair restraints ( .beard restraints) .to prevent hair from contacting food . According to the 2022 FDA Food Code, section ,d+[DATE].11 Hair Restraints - Effectiveness, it indicated food employees are required to wear hair restraints such as hair nets, beard nets, and other effective hair coverings to prevent hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single-service and single-use articles. 8. During an interview on [DATE] at 10:06 a.m. with DA 1, DA 1 stated if the dishwashing machine was not functioning, he would switch to manual dishwashing with 2-compartment sink with an extra tub for the sanitize step as a third compartment. DA 1 was unable to answer the immersion time for dishes and pans into the sanitizer. A concurrent confirmation with the DS, the DS stated the immersion time should be ,d+[DATE] seconds. During an interview on [DATE] with DA 3, DA 3 verbalized the process of the manual dishwashing with the 2-compartment sink. DA 3 stated the steps involved wash, rinse, sanitize and air dried. She stated the wash and rinse water temperature should be 130 degrees Fahrenheit (F), and the immersion time for the dishes in the sanitizer should be one minute and the concentration of the sanitizer (quaternary ammonium) should be 100 ppm (parts per million, a measurement unit for concentration of solution). During an interview on [DATE] at 12:41 p.m. with the RD, the RD stated the dietary staff should know about the procedure in case of an emergency. The RD stated if sanitation was not performed properly, it may cause cross-contamination. A review of the facility P&P titled, 3-Compartment Procedure for Manual Dishwashing, dated 2023, indicated, .washing .fill the first compartment with detergent .and hot water (,d+[DATE] degrees F) .rinsing .fill the second compartment with .hot water, (,d+[DATE] degrees F) .sanitizer solution must read 200 ppm .immerse all washed items for 60 seconds. 9. During an observation of the handwashing practice on [DATE] at 8:59 a.m., [NAME] (CK) 1 used the same gloved hands to touch the handle of refrigerator, clothing pocket, and then used the same gloved hands to touch and put away the clean dishes at the clean side of the dishwashing machine. During an observation of the handwashing practice on [DATE] at 11:20 a.m., CK 2 placed her bare hands on the whipped cream package then on the soiled plates. CK 2 used the same bare hands to pull up the handle of dishwasher panel (the dishwashing machine completed the dishwashing cycles) and pulled out the clean dish rack and then touched and rearranged the clean dishes and utensils. During an interview with the DS on [DATE] at 12:42 p.m., the DS acknowledged the handwashing issue above and she stated CK 1 and CK 2 should perform handwashing before touching the clean dishes. The DS further stated the staff should wash their hands and don gloves between tasks. During an interview on [DATE] at 12:41 p.m. with the RD, the RD stated the dietary staff should perform hand hygiene every time in the kitchen before touching food, food contact surfaces and between tasks. RD further stated handwashing before touching the clean dishes should be done to prevent cross-contamination. A review of the undated facility P&P titled, Dietary Employee Personal Hygiene, indicated, .Hands and fingernails .must always be washed .before putting on gloves, after removing gloves, and after engaging in other activities that contaminated the hands .Employees should never use bare hands contact any foods .or otherwise .Gloves are to be worn and changes appropriately to reduce the spread of infection . According to the 2022 FDA Food Code, section ,d+[DATE].14 When to Wash, it indicated, .food employees must wash their hands and exposed portions of their arms at specific times to prevent contamination. This includes: . Before working with food or clean equipment. After handling soiled equipment or utensils .After touching bare human body parts other than clean hands and arms .After engaging in other activities that contaminate the hands . 10. During an observation in the resident's food refrigerator located in the ice room on [DATE] at 8:53 a.m., there were issues found as followed: -one pack of expired tortillas (expiration date of [DATE] and no resident's name) was not discarded -two packages of tortillas (without a resident's name and received date) -one popsicle in the freezer compartment (without a resident's name and received date) During an interview on [DATE] at 3:53 p.m. and 4:07 p.m. with the Infection Preventionist/Director of Staff Development (IP/DSD), he confirmed the tortillas with expiration date of [DATE] was expired and should be discarded and confirmed other food items mentioned above did not have a resident's name and received date. The IP/DSD stated the food needed to be labeled with a resident's name and received date. The IP/DSD further stated there was a designated person to check and discard the outdated food, and stated the food could only be kept in the resident's food refrigerator for three days. A review of the facility P&P titled, Food Brought by family/Visitors, dated 2017, indicated, .Perishable foods must be stored and labeled with the resident's name, the item and the data. The nursing staff will discard perishable foods on or before the use by date . A review of the facility P&P titled, Refrigerators and Freezers, revised ,d+[DATE], indicated, .all food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates .will be marked on cases .Supervisors will be responsible for ensuring food items in pantry, refrigerators and freezers are not expired or past perish date .

Based on observation, interview, and record review, the facility failed to ensure a safe, functional, and comfortable environment for a census of 47 when: 1. rooms [ROOM NUMBER] had broken/missing wardrobe drawers. 2. room [ROOM NUMBER] had a cracked toilet seat and a broken call light in the bathroom. 3. room [ROOM NUMBER] and 115 had missing call lights in the bathrooms. 4. room [ROOM NUMBER] had a broken windowsill lying on the floor with nails sticking up. These failures resulted in non-functional rooms and an unsafe environment. Findings: 1. During a concurrent observation and interview with the Contractor on 6/4/25 at 11:32 a.m., the Contractor verified and confirmed room [ROOM NUMBER] had a broken wardrobe drawer (2nd bottom drawer from the left) and room [ROOM NUMBER] had a broken, misaligned, and unable to open wardrobe drawer (2nd middle drawer from the top and bottom right drawer). room [ROOM NUMBER] had the 2nd drawer from the top missing from the wardrobe. During an interview with the Contractor on 6/4/25 at 11:56 a.m., the Contractor stated, The missing drawer in room [ROOM NUMBER] still needs to be made and the other drawers should have been working. A review of Resident 20's, Admission Record indicated Resident 20 was admitted to the facility in 2024 with a diagnoses that included, cirrhosis of the liver (a chronic liver disease where healthy liver tissue is replaced by scar tissue, hindering the liver's ability to function properly). A review of Resident 20's Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive Patterns, dated 3/12/25, indicated Resident 20 had a Brief Interview for Mental Status (BIMS - a tool to assess cognition) score of 15 out of 15 which indicated Resident 20 had full understanding. During an interview with Resident 20 on 6/5/25 at 9:33 a.m., Resident 20 was asked about the broken wardrobe drawer and stated, The drawer has been like that for a while. Resident 20 further stated, I would like it fixed so that I can use it. A review of Resident 10's, Admission Record indicated Resident 10 was admitted to the facility in 2024 with a diagnoses that included a stroke (a condition that occurs when blood flow to part of the brain is disrupted). A review of Resident 10's MDS, Cognitive Patterns, dated 5/17/25, indicated Resident 10 had a BIMS score of 15 out of 15 which indicated Resident 10 had full understanding. During an interview with Resident 10 on 6/5/25 at 9:47 a.m., Resident 10 was asked about the missing drawer and stated, That drawer has been missing for 7 years. Resident 10 further stated, I would like it replaced. During an interview with Administrator 2 (ADM2) on 6/5/25 at 11:33 a.m., ADM2 stated, All wardrobe drawers should be functioning and easy to open and close. A review of the facility's policy dated 12/2009 indicated, The maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 50312 2. During an observation at 9:51 a.m., in room [ROOM NUMBER]'s bathroom the toilet seat appeared cracked, and the call light was not attached to the wall. During an observation and concurrent interview on 6/3/25 at 11:00 a.m., with the Director of Nursing (DON), the cracked toilet seat was acknowledged by the DON. The DON also stated that the call light had been repaired on 6/2/25 after the Department's initial observation of the restroom in room [ROOM NUMBER]. A review of the facility policy and procedure title Routine Bathroom Cleaning and Maintenance, dated 2/2023 indicated Employees are to report areas of mold, cracked, leaking or damaged items in need of repair. 39489 3. A review of Resident 33's Clinical Record indicated Resident 33 was admitted to the facility in April 2025 with diagnoses that included Infection and inflammatory reaction due to internal left knee prosthesis (artificial implants) and Methicillin Resistant Staphylococcus Aerus (MRSA, a serious, potentially fatal, bacterial infection [diseases that can affect your skin, lungs, brain, blood and other parts of your body]). A review of Resident 33's MDS, dated [DATE], Cognitive Patterns Section C, indicated a score of 15, meaning cognitively intact. During a concurrent observation and interview with the DON, inside the bathroom of room [ROOM NUMBER] and room [ROOM NUMBER] on 6/2/25 at 10:55 a.m., the DON confirmed there was no call light inside the bathroom of room [ROOM NUMBER] and room [ROOM NUMBER]. The DON acknowledged there should be a call light inside the bathroom. During a concurrent observation and interview with the Maintenance Supervisor (MS) inside the bathroom of room [ROOM NUMBER] and room [ROOM NUMBER] on 6/2/25 at 11:16 a.m., the MS confirmed the call light in the bathroom for room [ROOM NUMBER] and 115 was missing. The MS stated the call light had been missing for couple days ago, and he was not aware that it was missing. The MS further stated, he ordered the parts to fix the call light on 5/27/25 and was scheduled to be delivered on June 3rd or 6th. TheMS agreed that as of 6/2/25, there was no call light inside the bathroom of room [ROOM NUMBER] and room [ROOM NUMBER] for six to seven days. MS continued, it is important to have a working call light in the bathroom so the residents can call for help as needed. During a concurrent observation and interview with Resident 33, inside his bathroom, on 6/3/25 at 9:35 a.m., Resident 33 confirmed there was no call light in their bathroom. Resident 33 stated, they should have a call light inside the bathroom as it allows quick and easy to request assistance from the staff and gives us a sense of security. Resident 33 further stated residents in room [ROOM NUMBER] and room [ROOM NUMBER] shared the same bathroom with no call light. During an interview with the Certified Nursing Assistant (CNA 5) on 6/5/25 at 11 a.m., CNA 5 stated, it's important to have a call light in the bathroom to alert the staff if the residents need help and allows the staff to respond safely and quickly. 51717 4. During an observation on 6/2/25 at 9:50 a.m., of Resident 30 in his room, Resident 30 was sleeping in bed laying on his right side wearing a gown. A piece of wood from the windowsill was seen on the floor next to his bed with nails sticking up from the piece of wood. During a concurrent observation and interview on 6/2/25 at 10:24 a.m. with CNA 3, CNA 3 went in Resident 30's room to feed him. CNA 3 moved Resident 30's bed away from the wall and was standing on his right side next to the window. CNA 3 confirmed the windowsill had been broken and there was a piece of wood on the floor next to the Resident 30's bed with nails sticking up and agreed that it was a was a safety risk if the resident fell out of bed or if someone stepped on the nails. During a concurrent interview and record review on 6/3/25 at 08:54 a.m. with the MS, the MS reviewed the photographs of Resident 30's room. The MS confirmed there was a piece of wood on the floor next to Resident 30's bed and stated that this was a safety risk for staff and the resident if they stepped on the nails or if the resident fell out of the bed. Resident 30s progress notes dated 4/26/25 indicated that Resident 30 had an unwitnessed fall from bed on 4/26/25 at 7:30 p.m. During a review of the facility's policy titled. Maintenance Service, revised 2009, the policy stipulated, The Maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner,, and functions of the personnel include, Maintaining the building in good repair and free from hazards,. In a review of the facility's policy and procedure, titled, Call Lights, Answering . Procedure/Guidelines, dated, 3/17/25, indicated, . c. Staff will ensure that the call light system is plugged in, functioning and accessible to the resident. d. Any call light found to be defective will be reported to the supervisor, management, and/or the maintenance department . III. Documentation a. Facility management will periodically test call light functionality .

Based on observation, interview and record review, the facility failed to ensure one of 19 sampled residents (Resident 30) was free of unnecessary psychotropic medications (drug prescribed to affect the mind, emotions or behavior) when he was prescribed an antianxiety medication without adequate indication. This failure placed the resident at risk for unnecessary psychotropic medication use and excessive sedation. Findings: A review of Resident 30's admission record indicated he was admitted on [DATE] with the diagnoses of hemiplegia and hemiparesis (weakness and paralysis) following cerebral infarction (stroke) and dementia (a progressive state of decline in mental abilities). A review of Resident 30's Order Summary Report, dated 6/3/25, included active orders for lorazepam 1 mg, 1 tablet, twice a day for dementia with behaviors as manifested by yelling and removing clothes and to monitor Resident 30 closely for signs of significant side effects such as sedation drowsiness or confusion and to give special attention if administered with other sedatives or hypnotics. A review of Resident 30's Medication Administration Record (MAR), dated 5/25, indicated that the resident medications that were ordered included, Seroquel XR oral extended release 50 mg at bedtime for extreme physical aggression and striking out at staff, melatonin 3 mg, 2 tablets at bedtime to regulate circadian rhythm, gabapentin 600 mg 1 tablet twice a day for neuropathy pain (hold for sedation or drowsiness), lorazepam 0.5 mg, twice a day for dementia with behaviors manifested by yelling and removing clothes, fluoxetine 20 mg, 2 tablets once a day for depression. A review of Resident 30's Medication Regimen Review (MRR) completed by the Consultant Pharmacist (CP) to the Attending Physician/Prescriber, dated 4/10/25, indicated Resident 30 had been prescribed lorazepam, 0.5 mg tablet, 1 tablet, twice a day for dementia with behaviors manifested by yelling and removing clothes. The CP indicated lorazepam was being prescribed for an unapproved diagnosis of dementia and a re-evaluation of the order or rationale to support the diagnosis was needed. The MRR indicated a Physician/provider response of, Resident reviewed, and consultation behavior notes reviewed. No rationale to support the continued order was indicated on the MRR. During an interview on 6/5/25 at 1.30 p.m. with the Consultant Pharmacist (CO), the CP stated dementia was not an appropriate diagnosis for lorazepam and she had made a recommendation to the physician to re-evaluate the medication order. During a review of the facility's policy titled, Psychotropic Medication Use, undated, the policy stipulated psychotropic medications were to be used only, With a documented clinical indication for use with accepted clinical standards of practice.

Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of 16 sampled residents, Resident 33, when the Director of Nursing (DON) removed, and did not measure the length of Resident 33's Peripherally Inserted Central Catheter (PICC, thin, and long plastic tube that goes into a vein in your arm and ends in a large vein close to your heart) before throwing it in the trash can. This deficient practice had the potential risk of not removing the full length of the catheter and causing infection. Findings: A review of Resident 33's Clinical Record indicated Resident 33 was admitted to the facility in April 2025 with diagnoses that included infection and inflammatory reaction due to internal left knee prosthesis (artificial implants) and Methicillin Resistant Staphylococcus Aerus (MRSA, a serious, potentially fatal, bacterial infection [diseases that can affect your skin, lungs, brain, blood and other parts of your body]). A review of Resident 33's Minimum Data Set (MDS; an assessment tool), dated 4/28/25, Cognitive Patterns Section C, indicated a score of fifteen, meaning cognitively intact. A review of Resident 33's PICC INSERTION dated 4/24/25, indicated, . Initial internal catheter length: 42 cm . [length of thin plastic tube/catheter placed inside Resident 33's body]. A review of Resident 33's Order Summary Report, dated 6/2/25, indicated, Remove PICC line as per MD orders . During an observation inside Resident 33's room with the DON, on 6/2/25 at 11 a.m., As Resident 33 was lying on his bed, the DON pulled out the PICC line catheter from Resident 33's right upper arm and threw the catheter in the trash can beside Resident 33's bed. The DON did not measure the length of the PICC line catheter before throwing it in the trash can. During an interview with the DON on 6/5/25 at 12:35 p.m., the DON acknowledged he did not measure the length of the PICC line catheter before throwing it in the trash. The DON stated that he should have measured the length of the PICC line catheter to ensure the length of the catheter matches the pre-insertion length for residents' safety. The DON further stated the facility utilized [NAME] the PICC for PICC line insertion. A review of [NAME] the PICC's guidelines titled PICC Care & Maintenance Class, undated, indicated, . Objective Four PICC Line Removal and PICC Dressing Change Procedures . Procedure for PICC Line Removal: .8. Measure device to make sure entire catheter has been removed; check against documentation made upon device insertion. According to an article written in Medbridge (a comprehensive healthcare platform that offers both educational resources for healthcare professionals), titled PICC Line Removal: Techniques, Tips, and Troubleshooting, dated 11/5/2024, indicated, . While the removal process may seem routine, it carries risks if performed improperly . 1 These risks emphasize the importance of having the proper technique and knowledge to ensure patient safety . 4. Dressing the exit site and post-removal care . o Inspect the catheter. Always check the catheter tip to ensure it's intact and consistent with the original documented length . References 1. Medbridge PICC Line Removal: Techniques, Tips, and Troubleshooting. (November 5, 2024). https://www.medbridge.com/blog/picc-line-removal-techniques-tips-and-troubleshooting

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for one of 46 residents (Resident 25) when: Resident 25's haloperidol (medication used to treat nervous, emotional, and mental conditions) was not available to administer in the dose prescribed by the doctor. This failure had the potential for medication error and disruption of the resident's treatment plan. Findings: During an observation of medication administration on 6/3/25 at 7:41 a.m., Licensed Nurse 4 (LN 4) was observed to prepare Resident 25's morning medications which included haloperidol 5 mg (milligram, unit of measure). Reconciliation of the observed medication administration for Resident 25's current Physician Orders, dated 6/2/25, indicated, haloperidol oral tablet 5 mg. Give 0.5 tablet by mouth one time a day for schizophrenia (a chronic mental and brain disorder) . (0.5 tab =2.5 mg). During an interview on 6/3/25 at 7:41 a.m., with LN 4, LN 4 stated, I cannot administer resident's medication without clarifying it. There is a discrepancy with the ordered dose and the available dose in the medication blister pack. LN 4 further stated that the haloperidol order was changed, but the new dosage was not delivered to the facility from the pharmacy. During a review of Resident 25's Medication Administration Record (MAR), dated 6/3/25, the MAR indicated haloperidol 5 mg, give 0.5 tablet. During an interview on 6/3/25 at 8:01 a.m. with the Director of Nursing (DON), the DON stated a new verbal order for haloperidol was documented by a licensed nurse at 8:44 a.m., a day before, on 6/2/25 and was signed by the doctor on 6/3/25 at 1:11 a.m. The DON stated, the expectation was for the doctor to sign the order as soon as possible for the pharmacy to fill the prescription. Furthermore, the DON stated, since the current available dose of medication is not the same as the doctor's order, we will call the pharmacy to ask how we can use the current available medication until the new medication dose arrives. The DON confirmed the medication dose should have been available for the morning medication administration. During a follow up interview on 6/3/25 at 8:12 a.m. with the DON, the DON stated, the pharmacy said the pills are scored and can be cut in half until the new blister pack arrives at 11 p.m. tonight. During an interview on 6/3/25 at 11:47 a.m. with the DON regarding administering or dispensing a verbally ordered medication before the order is signed by a doctor, the DON stated, I am not sure if a medication can be dispensed by the pharmacy or administered by nurses after a verbal order is received and before the MD signs the order. The DON stated, he would find a policy, but policy was not provided. During a review of the facility policy and procedure (P&P), titled, Administering Medications, revised April 2019, the P&P indicated, Ensure that the six rights of medication administration are followed . Right dose .Compare medication source (bubble pack .) with MAR to verify . dose . administer medication as ordered . During a review of the facility P&P, titled, Pharmacy Services Overview, revised April 2019, the P&P indicated, .Pharmacy services are available to residents 24 hours a day, seven days a week .Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner .

Based on interview and record review, the facility failed to ensure the availability and timely administration of medications for four of 15 sampled residents (Residents 2, 3, 7, and 9) when: 1. Resident 2 did not receive a dose of Venlafaxine (A drug used to treat depression and certain anxiety disorders) and two doses of Clonazepam (a medication used to treat anxiety), 2. Resident 3 did not receive four doses of Clozapine (a medication that treats mental health conditions like schizophrenia - a mental illness that is characterized by disturbances in thought), 3. Resident 7 did not receive four doses of Haloperidol Decanoate injection (Haldol, medication used to treat schizophrenia), and 4. Resident 9 did not receive nine doses of Clozapine and three doses of Austedo (a medication used to treat movement disorders). These failures had the potential to negatively affect the residents' mental health and stability. Findings: 1. Resident 2 was admitted to the facility in October of 2024 with diagnoses that included paranoid schizophrenia, bipolar disorder, major depressive disorder. A review of Resident 2's Physician Order for Venlafaxine, dated 10/4/24, indicated, Venlafaxine HCl ER [extended release] Oral Tablet Extended Release 24 Hour 150MG [milligrams, a unit of measurement] (Venlafaxine HCl) Give 1 tablet by mouth one time a day for depression MB [manifested by] verbalization of depression ICO by MD from RP. Do not crush or chew. A review of Resident 2's Physician Order for Clonazepam, dated 2/11/25, indicated, Give 1 tablet by mouth at bedtime for Anxiety m/b inability to nocturnal restlessness. A review of Resident 2's Nurse Progress Note (NPN), dated 2/11/25, indicated Clonazepam was on order. A different NPN, dated 3/24/25, indicated Venlafaxine was not available and was await (sic) supply. During an interview on 4/29/25 at 1:48 p.m. with Licensed Nurse 2 (LN 2), LN 2 confirmed Clonazepam was not available to give for Resident 2 in February. LN 2 indicated the facility sometimes had problems ensuring medications were available for residents. LN 2 also indicated the dispensing pharmacy required blood work prior to dispensing medication for Resident 2. During a concurrent interview and record review on 4/30/25 at 1:18 p.m. with the Director of Nursing (DON), Resident 2's Medication Administration Record (MAR) for February and March were reviewed. The DON confirmed Resident 2 did not receive a dose of Venlafaxine on 3/24/25 and did not receive two doses of Clonazepam on 2/11/25 and 2/12/25. The DON also confirmed the NPNs that indicated these medications were not available to administer. 2. Resident 3 was admitted to the facility in December of 2024 with diagnoses that included suicidal ideations, schizoaffective disorder, bipolar disorder, and major depressive disorder. A review of Resident 3's Physician Order for Clozapine, dated 12/21/24, indicated, Give 1 tablet by mouth one time a day for schizophrenia MB [manifested by] visual and auditory hallucinations Take 1 tablet (200 mg total) by mouth in the morning AND 2 tablets (400 mg total) at bedtime. +50mg by mouth at bedtime = 450mg total at bedtime. A review of Resident 3's NPN, dated 1/8/25 to 1/10/25, indicated Clozapine was not available due to being on order or waiting for pharmacy. A review of Resident 3's NPN, dated 1/10/25, indicated, call pharmacy, talk to [staff] regarding clozapine, ask for CBC (a lab test usually required for the dispensing of Clozapine) LAB result, fax to her. Await supply. During a concurrent interview and record review on 4/30/25 at 1:18 p.m. with the DON, Resident 3's MAR for January was reviewed. The DON confirmed that the resident's MAR indicated that he did not receive his morning dose of Clozapine from 1/8/25 to 1/10/25 and on 1/19/25. The DON indicated that nursing staff were responsible for ensuring pharmacy had all the necessary lab results for dispensing Clozapine. The DON also indicated that he expected nursing staff to notify him regarding pharmacy not delivering medications and to notify the provider regarding missed medication doses. During an interview on 4/30/25 at 4:54 p.m. with the Pharmacist Consultant (PC), the PC indicated the pharmacy required lab results prior to dispensing Clozapine, and it was the responsibility of the facility to do so to ensure timely dispensing of the medication. 3. During a review of Resident 7's admission records, the records indicated Resident 7 was admitted in July 2024 with diagnoses that included Schizophrenia. During a review of Resident 7's physician's order, dated 7/29/24, the order indicated, Haloperidol Decanoate Intramuscular [into the muscles] Solution 100mg/mL [milligrams/milliliter, a unit of measurement] .Inject 2.5 ml intramuscularly one time a day every 28 day(s) for Schizophrenia M/B visual hallucination [seeing images that are not actually present] . During a review of Resident 7's care plan, undated, the care plan indicated, Black box warning for use of Haldol (Haloperidol) .The resident will be/remain free of drug related complications, including movement disorder .or cognitive/behavioral impairment .Administer medications as ordered . During a review of Resident 7's MAR for the month of September 2024, the MAR indicated Resident 7's Haldol was scheduled to be given on 9/23/24. The MAR indicated the dose was not administered and was coded with the number 9 which indicated to refer to progress notes. During a review of Resident 7's progress notes, dated 9/23/2024, the notes indicated .spoke with [name of staff] from pharmacy. Haloperidol dec [sic] 100 mg/ml vial not available in ekit [emergency kit]. Order refilled. Should be delivered by tonight. To be admin as soon as med arrives. There was no documented evidence that Resident 7's Haldol was delivered or administered. During a review of Resident 7's MAR for the month of December 2024, the MAR indicated Resident 7's Haldol was scheduled to be given on 12/16/24. The MAR indicated the dose was not administered and was coded with the number 9 which indicated to refer to progress notes. During a review of Resident 7's progress notes, there was no documented evidence that Resident 7's Haldol dose was administered on 12/16/25. During a review of Resident 7's MAR for the month of March 2025, the MAR indicated Resident 7's Haldol was scheduled to be given on 3/11/25. The MAR indicated the dose was not administered and was coded with the number 9 which indicated to refer to progress notes. During a review of Resident 7's progress notes, dated 3/11/2025, the notes indicated Spoke to pharmacist, faxed med order over to pharmacy, pharmacy states to deliver on next schedule drop-off. There was no documented evidence that Resident 7's Haldol was delivered or administered. During a review of Resident 7's MAR for the month of April 2024, the MAR indicated Resident 7's Haldol was scheduled to be given on 4/8/25. The MAR indicated the dose was not administered and was coded with the number 9 which indicated to refer to progress notes. During a review of Resident 7's progress notes, dated 4/8/2025, the notes indicated Await supply. Talk to [name of staff] in the pharmacy, promise to send medication later today. DON notified. During a concurrent interview and record review on 4/30/25 at 9:36 a.m. with LN 2, LN 2 confirmed Resident 7 had orders for Haloperidol Decanoate injections every 28 days since admission in July 2024. LN 2 verified there was no documented evidence that Resident 7's Haloperidol injections were given on September 2024, December 2024, March 2025, and April 2025 as ordered. LN 2 stated, Sometimes the pharmacy don't send the medication as they say they will and that nurses were supposed to refill the medication and order it as soon as they used the vial. The LN 2 added Resident 7 could lash out and behavioral symptoms could regress if Resident 7 missed haloperidol doses and stated, It is unacceptable. During a concurrent interview and record review on 4/30/25 at 1:47 p.m. with the DON, the DON verified Resident 7's Haloperidol Decanoate was not delivered by the pharmacy in September 2024, December 2024, March 2025, and April 2025, and that there was no documented evidence that Resident 7 received the injections in those months. The DON added that for April 2025, the medication was not available on the scheduled administration date, was delivered the following day, and stored in the refrigerator but still was not given because it was not delivered on time and already passed due. The DON stated, I wasn't aware, none of the nurses notified me and his expectation was that nurses should notify him and the physician about the missed doses. The DON further stated that if Haloperidol doses were missed, Resident 7's behaviors could occur. During an interview on 4/30/25 at 4:56 p.m. with the PC, the PC stated, We always tell the facility to request 3-5 days before the scheduled dose and before they run out. The PC added that if a resident missed Haldol doses, the resident could go into withdrawal and could be potentially life threatening. 4. Resident 9 was admitted to the facility in January of 2025 with diagnoses that included paranoid personality disorder, schizoaffective disorder, and auditory hallucinations. A review of Resident 9's Physician Order for Clozapine, dated 1/31/25, indicated, cloZAPine Oral Tablet 200 MG (Clozapine) Give 1 tablet by mouth at bedtime for Schizoprenia m/b delusion ICO by MD/RP. A review of Resident 9's Physician Order for Austedo, dated 1/31/25, indicated, Austedo XR Oral Tablet Extended Release 24 Hour 42 MG (Deutetrabenazine) Give 1 tablet by mouth in the morning for tardive dyskinesia [movement disorder brought on by the use of antipsychotic medications] 2/2 long term psychiatric medication use. During a concurrent interview and record review on 5/6/25 at 10:32 a.m. with the DON, Resident 9's MARs for February, March, and April were reviewed. The DON confirmed that Resident 9 missed nine consecutive doses of Clozapine starting on 2/5/25 and ending on 2/13/25, and missed three doses of Austedo on 3/9/25, 3/10/25, and 4/1/25. The DON indicated that Resident 9 was hospitalized in February due to the missed doses of Clozapine. The DON further indicated the pharmacy did not dispense these medications due to nursing staff not relaying lab results to the pharmacy in a timely manner, which nursing staff were responsible for. During a review of the facility's policy and procedure (P&P) titled Medication and Treatment Orders, revised 7/2016, the P&P indicated, .11. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available . During a review of the facility's P&P titled Pharmacy Services Overview, revised 4/2019, the P&P indicated, .Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration .7. Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice .

Based on observation, interview, and record review, the facility failed to ensure the care plan to prevent falls was implemented for one resident (Resident 1) for a census of 47. This failure increased Resident 1's risk of falling, which could result in injury. Findings: A review of the clinical record indicated Resident 1 was admitted [DATE] with diagnoses including conversion disorder (a mental health condition where psychological stress is expressed as physical symptoms) with decreased coordination or balance and episodes of involuntary muscle contractions and spasms. A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 3/13/25, indicated Resident 1 had moderate cognitive impairment with BIMS (Brief Interview for Mental Status- an assessment used to screen and identify memory, orientation, and status of the resident) score of 10 out of 15. Resident 1's functional abilities indicated she had impairment on both lower extremities and used a wheelchair for mobility device. Further review of Resident 1's clinical records indicated the following: 1. An SBAR (Situation, Background, Appearance, Review) Communication Form indicated Resident 1 had a fall on 3/16/25; 2. A care plan, dated 3/16/25, indicated Resident 1 had an unwitnessed fall and the interventions included, Maintain on low bed and fall mat on the floor. 3. An IDT (Interdisciplinary Team) note dated 3/17/25 indicated Resident 1 was found lying on floor mat (cushioned pad to help minimize injury following a fall), the bed on lowest position and there was no injury. The new interventions implemented indicated, maintained bed on lowest position, continue floor mat on floor. In an observation conducted on 4/29/25 at 10:03 a.m., Resident 1 was lying in bed with right arm covering her eyes. Resident 1's bed was not in a low position and there was no fall mat in place. A concurrent observation and interview was conducted on 4/30/25 at 10:08 a.m. in Resident 1's room. Resident 1 was lying in bed with a hooded sweatshirt. The bed was not in a low position and there was no floor mat. Resident 1 stated the staff helped her get in and out of bed. Resident 1 further stated she wanted the height of her bed in this [regular] position. In a concurrent observation and interview on 4/30/25 at 10:12 a.m., Certified Nurse Assistant 1 (CNA 1) confirmed Resident 1's height of bed was not in the lowest position and there was no fall mat. CNA 1 stated resident required a hoyer lift (a mechanical device) for transfers and was totally dependent on staff for her care. CNA 1 further stated she positioned the bed in the lowest position earlier today and resident adjusted the height of the bed. CNA 1 added Resident 1 indicated she did not like her bed to be in low position. In an observation and interview on 4/30/25 at 1:23 p.m., Licensed Nurse 1 (LN 1) and CNA 1 were unable to find Resident 1's floor mat inside her room. LN 1 stated there was no fall mat and CNA 1 stated she did not see a fall mat when she came in this morning. LN 1 further stated she thought Resident 1 had a fall before and the height of her bed was lowered because [Resident 1] was high risk for falls. A concurrent interview and record review was conducted with the Director of Nursing (DON) on 4/30/25 at 3:23 p.m. Resident 1's clinical record including SBAR, IDT note and care plan was reviewed with the DON. The DON stated his expectation was for staff to fulfill the interventions to keep the bed at the lowest position and to have a fall mat in place. The DON further stated whenever resident was in bed, the bed should be in the lowest position and if resident preferred the height of the bed in a regular position, it should be documented. A review of the facility's policy revised March 2018 and titled, Falls and Fall Risk, Managing indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .Environmental factors that contribute to the risk of falls include: .Incorrect bed height .Resident conditions that may contribute to the risk of falls include: .other cognitive impairment .functional impairments .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of four sampled residents (Resident 2) when Resident 1 threw a plate on Resident 2's face. This failure resulted in Resident 2 sustaining a laceration on the right eyebrow. Findings: During a review of Resident 1's admission record, the record indicated Resident 1 was admitted in October 2024 with diagnoses that included schizophrenia (a mental illness that is characterized by disturbances in thought), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), anxiety disorder (significant and uncontrollable feelings of anxiety and fear), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), dementia (a progressive state of decline in mental abilities), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 1 had moderate cognitive impairment and did not exhibit physical or verbal behaviors toward self or others. During a review of Resident 1's Change in Condition notes, dated 1/19/25 at 6:37 a.m., the notes indicated, [Resident 1] elicits an altered mental status. [Resident 1] exhibits physical and verbal aggression towards staff. Knocking over items on purpose. [Resident 1] has not slept in a single minute all night long. [Resident 1] has been naked the entire time. Urinating and bowel movements in the hallway. Not able to follow commands .Recommendations: Send out for further evaluation and treatment . During a review of Resident 1's Change in Condition notes, dated 1/19/25 at 12:27 p.m., the notes indicated, .observed [Resident 1] standing over another resident [Resident 2] and throwing items at him [Resident 2]. [Resident 1] also threw items at staff members, spit on staff, and uncontrolled aggressive behavior .Recommendations: Sent to ER [emergency room ]. During a review of Resident 1's Nurses Progress Notes, dated 1/19/25, the notes indicated, .observed [Resident 1] standing over another resident [Resident 2] and throwing items at him [Resident 2]. [Resident 1] also threw items at staff members, spit on staff, and uncontrolled aggressive behavior. Attempted to redirect [Resident 1] by multiple staff members. Other residents advised to go in their rooms, doors closed . During a review of Resident 1's Social Services Progress Notes, dated 1/22/25, the notes indicated, .[Resident 1] had witnessed altercation [with Resident 2] .Per order, [Resident 1] has capacity to make own decisions . During a review of Resident 2's admission record, the record indicated Resident 2 was admitted in October 2024 with diagnoses that included low vision on right eye, blindness on left eye, muscle weakness, and dementia. Resident 2's MDS indicated Resident 2 had intact cognition and did not exhibit physical or verbal behaviors toward self or others. During a review of Resident 2's Change in Condition notes, dated 1/19/25 at 12:26 p.m., the notes indicated, .heard [Resident 2] crying and screaming from room, observed another [Resident 1] standing over [Resident 2] and throwing items at him. [Resident 2] bleeding from cheek .nurse did skin assessment, noted right Eyebrow Skin tear . During a review of Resident 2's Skin/Wound Note, dated 1/19/25, the note indicated, Noted laceration to top right forehead measuring approximated 2x2cm [centimeters, a unit of measurement] with no skin flap . During an interview on 1/23/25 at 10:19 a.m. with Licensed Nurse 1 (LN 1), LN 1 stated that on 1/19/25, staff saw Resident 1 throwing stuff and were telling him to calm down. LN 1 stated staff were outside and they heard a lot of cry from Resident 2's room. LN 1 further stated Resident 1 was seen standing in front of Resident 2 who was bleeding. LN 1 stated, [Resident 1] used to be very calm .he started getting more agitated .[Resident 1] Started to become agitated not too long ago, staff tried redirecting him .At that time, we couldn't get close to him .anybody who tried, he will try to hit During an interview on 1/23/25 at 11:04 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated, [Resident 1] was wandering a lot that day [1/19/25], throwing things, not listening or cooperating with us, just disrupted .He was throwing stuff in the hallway from the nurses cart, throwing pillows, anything he can see . CNA 1 stated Resident 1 went back to his room and the staff heard crying from the room. CNA 1 stated, [Resident 1] was by [Resident 2's] side of the bed .all the food was all over [Resident 2], there was a lot of blood . During an interview on 1/23/25 at 11:16 a.m. with LN 2, LN 2 stated Resident 1 was sent out on 1/19/25 (at 6:30 a.m.) to the hospital during the night shift for his behavior and altered level of consciousness and stated, [Resident 1] was acting a little different the day before [1/18/25] .it was very difficult to redirect him . LN 2 stated Resident 1 came back from the hospital on the same day, 1/19/25 (at 10:20 a.m.), and still had the same behavior. LN 2 stated, .I don't know what happened but he got very very angry and uncontrollable .he was breaking plates and trying to hurt us . LN 2 stated Resident 1 took himself to his bed and LN 2 stated, Then we heard wailing from the room, it was [Resident 2], [Resident 1] was throwing things to him from his food tray .we saw [Resident 1] threw [Resident 2's] plate into his face .I was very scared, [Resident 1] broke [Resident 2's] face open LN 2 further stated, We saw [Resident 1] throwing items on [Resident 2's] face .[Resident 2] was bleeding .had a cut on his eyebrow .I saw [Resident 1] standing over [Resident 2] and throwing items .it was really traumatizing . LN 2 further stated Resident 2 was in shock and was crying at that moment and was able to express anger after he was moved on the other end of the facility. LN 2 added that on the following day (1/20/25) after the incident, Resident 2 was still upset and told the CNA, He [Resident 1] is not coming back, right? LN 2 stated, I would say that's a sign of fear. During an interview on 1/23/25 at 11:55 a.m. with the Director of Nursing (DON), the DON stated, On 1/19/25, staff on the floor witnessed [Resident 1] was throwing items. When they went in the room, they saw [Resident 1] standing by [Resident 2's] bed .[Resident 2] was bleeding from right upper eyebrow . The DON stated Resident 1 was sent out (to the hospital on 1/19/25 at 6:30 a.m.) for altered mental status and came back from the hospital on the same day (1/19/25 at 10:20 a.m.) without new orders. The DON further stated, He was disoriented and started throwing things .It happened very quickly, he was stabilized in his bed and suddenly he got up .He woke up and he was agitated .it was witnessed that [Resident 1] was throwing stuff on [Resident 2]. During an interview on 1/23/25 at 12:53 p.m. with the Administrator (ADM), the ADM stated, .[Resident 2] had a little skin tear above his eye .The ADM stated he spoke with LN 2 about what happened, and LN 2 told him that LN 2 saw Resident 1 holding the plate on 1/19/25. The ADM stated, This was the first time, [Resident 1] had been confused before, and we redirect him .We had increased supervision making sure staff was with him [Resident 1] and it was in between the checks when it happened. The ADM further stated, When [Resident 1] came back [from the hospital on 1/19/25 at 10:20 a.m.], he settled down, laying down on bed, it was sudden agitation. For precaution, they [staff] closed the doors for other residents. During a concurrent observation and interview on 1/23/25 at 2:16 p.m. with Resident 2 in his room, translated by Housekeeping Staff (HS), Resident 2 was observed alert and calm, sitting on a wheelchair on the side of his bed, bandage was observed on his right eyebrow. When asked about what caused the wound on his right eyebrow, Resident 2 stated that somebody threw a plate with food and hit him with the plate. Resident 2 stated he was not able to remember who it was because he was blind and that he felt very bad. Resident 2 further stated that at that time, he felt too much pain on his head and that he can still feel the pain. Resident 2 added that he was hoping Resident 1 does not come back. During a review of the facility's policy and procedure (P&P) titled Resident-to-Resident Altercations Policy, dated 10/2023, the P&P indicated, 1. Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents, family members, visitors, or to the staff .2. Behaviors that may provoke a reaction by residents or others include: b. physically aggressive behavior, such as hitting, kicking, grabbing .threatening gestures, throwing objects . During a review of the facility's P&P titled Abuse, Neglect and Exploitation Prevention, dated 6/2023, the P&P indicated, It is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .8. Prevention of Abuse, Neglect and Exploitation .B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur .D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect .

Based on interview and record review, the facility failed to develop a specific care plan for weight loss and pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one resident (Resident 1) out three sampled residents, that included measurable objectives and timeframes. This failure had the potential to compromise the nutritional and health status for Resident 1. Findings: Resident 1 was admitted to the facility in early 2024 with diagnoses which included sepsis (a life-threatening blood infection), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), hypertensive heart (high blood pressure) and chronic kidney disease. A review of Resident 1's Interdisciplinary team (IDT) note dated 9/23/24, indicated there was a weight change of 5.7%. A review of Resident 1's Order Summary Report (OSR), dated 9/12/24, indicated, Sacrococcyx, stage 4 PU (pressure ulcer)-cleanse with NS/Vashe (normal saline moistened gauze), pat dry. Apply scant medihoney and cal alginate, lightly pack with 4x4 gauze; cover with foam dressing . During a concurrent observation and interview on 10/8/24 at 10:08 a.m. with the License Nurse (LN), the LN confirmed there were no care plans for Resident 1's weight loss or pressure ulcer/injury and stated, The nurses and the interdisciplinary team do the care plans. During an interview on 10/8/24 at 1:50 p.m. with the Director of Nursing (DON), the DON stated, My expectation are that care plans are implemented right away when orders are written. Upon Request, the facility was not able to provide the facility's policy and procedure (P&P) for care plans.

Based on interview and record review, the facility failed to implement policies and procedures (P&P) for the prohibition and prevention of abuse for a census of 48 residents when two out of five sampled facility staff (Certified Nurse Assistant [CNA] 1 and CNA 2) were actively working in the facility without an initial background check (a formal process that verifies an upcoming employee's personal and professional information such as identity, work history, criminal record, and any other relevant information) done. This failure placed all the residents in the facility at risk for possible serious physical and/or psychosocial harm and decreased the facility' ability to protect residents from exposure to an employee with a criminal history of abuse, neglect, and/or exploitation. Findings: During an interview on 9/3/24 at 1:12 p.m. with CNA 1, CNA 1 stated she has been working as a CNA (provides vital support to both residents and nurses which includes assisting, transporting, bathing, and feeding patients, stocking medical supplies, and logging patient information) in the facility for more than 1 year now. During an interview on 9/3/24 at 1:15 p.m. with the Director of Nursing (DON), the DON stated they would conduct an employee background check during the hiring process and then every 2 years. During an interview on 9/3/24 at 1:18 p.m. with CNA 2, CNA 2 stated she started working as a CNA in the facility last December of 2023. During a phone interview on 9/16/24 at 11:15 a.m. with the DON, the DON confirmed that they could not find the initial background checks for CNA 1 and CNA 2. During a concurrent phone interview and employee record review on 9/16/24 at 11:38 a.m. with Human Resources (HR), CNA 1 and CNA 2's employee files were reviewed. The HR confirmed that CNA 1 was hired as a part time (an employee who is scheduled to work and who does work a schedule of anything under 32 hours per week) CNA on 8/9/23. The HR also confirmed that CNA 2 was hired as a full time (an employee who is scheduled to work and who does work a schedule of anything above 32 hours per week) CNA on 12/17/23. The HR further confirmed that there were no initial background checks done for CNA 1 and CNA 2 and stated, .They [facility] never did them [CNA 1 and CNA 2's initial background checks] . The HR further stated that the facility's policy is to conduct initial background checks for all employees being hired so she would expect that the background checks for CNA 1 and CNA 2 should have been done. A review of the facility's P&P titled, Abuse, Neglect and Exploitation Prevention, dated 6/1/23, indicated, 4. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background .checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants . 3. The facility will maintain documentation of proof that the screening occurred. A review of the facility's P&P titled, Background Investigation Policy, dated 3/1/24, indicated, .criminal conviction record checks are conducted on all employees . 1. The Human Resource department will conduct all applicable background investigation(s) on each individual candidate for employment as appropriate for the position in which the individual has applied.

Based on observation, interview, and record review, the facility failed to ensure that a safe, clean, comfortable and homelike environment was provided for seven of 18 sampled residents (Resident 9, Resident 18, Resident 153, Resident 253, Resident 254, Resident 255, and Resident 256), when a cabinet and closet drawers were in disrepair, with chipped paint, and the walls were empty and bare inside the residents' rooms. This failure had the potential to result in the residents not attaining their highest practicable level of well-being. Findings: Resident 9 was admitted in late 2011 and readmitted in early 2022 with diagnoses which included stroke and weakness. During a review of Resident 9's Minimum Data Set (MDS, an assessment tool), dated 6/19/24, the MDS indicated Resident 9 had mild memory impairment and required extensive assistance with activities of daily living (ADLs). During a concurrent observation and interview on 7/9/24 at 8:35 a.m. in Resident 9's room, the cabinet drawers and closet doors were noted to be in disrepair, and the walls with chipped and had stained paint. Resident 9 was up in the wheelchair, awake and alert and verbally responsive and stated, Those cabinet drawers and doors don't close properly and they have been like that for a long time. The paint is wearing off. I don't know why they are not fixing them. It is very annoying. Resident 18 was admitted to the facility in early 2024 with diagnoses which included chronic lung disease and pneumonia (lung infection). During a concurrent observation and interview on 7/8/24 at 9:24 a.m. in Resident 18's room, the cabinet drawers were noted to be in disrepair and there was chipped and stained paint on the walls. The Administrative Assistant/Clerk (AA/C) verified the finding and stated, It is not homelike. It is not good for the residents. Resident 153 was admitted to the facility in late 2023 with diagnoses which included stroke, difficulty walking, muscle weakness, difficulty swallowing, and expressive language disorder. During an observation on 7/8/24 at 9:41 a.m. in Resident 153's room, Resident 153 was found asleep. The immediate environment and the walls were bare and no belongings were found in the bedside area except a urinal on top of the nightstand. During a concurrent observation and interview on 7/8/24 at 9:49 a.m. with Certified Nursing Assistant 5 (CNA 5) in Resident 153's room, CNA 5 verified the walls were empty and bare and stated, The room is not homelike. There are no pictures, like something from home, to provide dignity. During a concurrent observation and interview on 7/8/24 at 9:51 a.m. with CNA 6 in Resident 153's room, Resident 153's closet drawers did not close properly, with parts of the drawers unevenly protruding outward. Additionally the paint was noted to be chipped and stained. CNA 6 verified the findings and stated, The drawers are not safe. The residents in this room are ambulatory (out of bed and mobile) and may trip and can cause accidents and injuries to the residents. During a concurrent observation and interview on 7/8/24 at 9:54 a.m. with the Director of Nursing (DON) in Resident 153's room, the DON verified the cabinet drawers were in disrepair and the walls were bare and stated, The drawers here are not closing properly and somebody can trip and can cause some accident .Whenever we have an admission, we try to ask them, like what kind of preferences do they have, and if they don't have anything, we are going to, like pay for something (sic) to put something in the room. During a concurrent observation and interview on 7/8/24 at 10:07 a.m. with CNA 7, when asked about the cabinet drawers in Resident 153's room, CNA 7 stated, The drawers are not closing too well. It has been like that for a while. CNA 7 tried to close the drawers and stated, No. It's like sinking and not closing properly. I just don't like it if somebody can trip and fall. The residents here are walking and that's little unsafe for me. We don't want anybody to get hurt. During an interview on 7/8/24 at 10:09 a.m. with the Maintenance Supervisor (MS), when asked about the cabinet drawers and the chipped paint on the wall, the MS stated, So many of that (sic) because it's like a lot of things needs to be fixed .I think the broken drawers are not safe for the ambulatory residents .I mean, when you trip on those you can fall. 48175 Resident 253 was admitted to the facility in mid-2024 with diagnoses which included need for assistance with personal care. During an observation on 7/8/24 at 8:30 a.m., Resident 253 was lying in bed with an empty bedside table and nightstand, and the walls around the bed were bare. There were no personal belongings in Resident 253's immediate environment. During a review of Resident 253's MDS, dated [DATE], the MDS indicated Resident 253 had moderate memory impairment and required extensive assistance with ADLs. Resident 254 was admitted to the facility in mid-2024 with diagnoses that included dementia (a group of symptoms affecting memory, thinking, and social abilities), and need for assistance with personal care. During a review of Resident 254's MDS, dated [DATE], the MDS indicated Resident 254 had severe memory impairment and required extensive assistance with ADLs. During an observation on 7/8/24 at 8:45 a.m., Resident 254 was lying in bed, the bedside table and nightstand were empty, and the walls around the bed were bare. There were no personal belongings in the immediate environment. Resident 255 was admitted to the facility in mid-2024 with diagnoses that included encephalopathy (damage or disease that affects the brain), and need for assistance with personal care. During a review of Resident 255's MDS dated [DATE], the MDS indicated Resident 255 had severe memory impairment and required extensive assistance with ADLs. During an observation on 7/8/24 at 8:45 a.m. Resident 255 was lying in bed, the bedside table and nightstand were empty, and the walls around the bed were bare. There were no personal belongings in the immediate environment. Resident 256 was admitted to the facility in mid-2024 with diagnoses that included major depressive disorder and need for assistance with personal care. During a review of Resident 256's MDS, dated [DATE], the MDS indicated Resident 256 required extensive assistance with ADLs. During a concurrent observation and interview on 7/8/24 at 8:45 a.m., Resident 256 was lying in bed, awake, alert, and verbally responsive. Resident 256's bedside table and nightstand were empty, and the walls around the bed were bare. There were no personal belongings in the immediate environment. Resident 256 stated, It would be nice to have some images on the wall. During an interview on 7/8/24 at 11:50 a.m. with CNA 1, CNA 1 confirmed Residents 253, 254, 255, and 256's rooms had bare walls without any personal belongings. CNA 1 stated, I have been here since December [2023], and I have not seen any personal items belonging to the residents. I mentioned the bare walls to the activity department and asked if any pictures could be placed on the walls or something to brighten the rooms. So far, nothing has been done. During a concurrent observation and interview on 7/8/24 at 11:55 a.m. with Licensed Nurse 4 (LN 4), LN 4 confirmed Residents 253, 254, 255, and 256's rooms had bare walls and contained no personal belongings. During an interview on 7/9/24 at 7:54 a.m. with Resident 253 regarding having some personal items in the surrounding environment, Resident 253 stated, I would like pictures of my family. I have two daughters and three granddaughters. During an interview on 7/9/24 at 9:30 a.m. with the Activity Director (AD), the AD confirmed Residents 253, 254, 255, and 256's walls were bare. During a review of the facility's policy and procedure (P&P) titled, Safe and Homelike Environment, dated 3/23, the P&P indicated, The facility will create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting. a. The facility will allow residents to use their personal belongings, including furnishings and clothing (as space permits) to assist in creating and maintaining a homelike environment .the social service designee, or another designated staff member, will encourage residents and their families to bring in personal belongings (within space constraints) to personalize residents' rooms .the facility will honor and document a resident's choice not to personalize his/her room . During a review of the facility's P&P titled, Resident Rights, dated 3/23, the P&P indicated, The resident has a right to a safe, clean, comfortable and homelike environment .

Based on interview and record review, the facility failed to develop and implement comprehensive, documented care plans for four of 18 sampled residents (Resident 18, Resident 15, Resident 204, and Resident 19), when: 1. Resident 18 had no documented care plan for the isolation precautions; 2. Resident 15 had no documented care plan for skin integrity; 3. Resident 204 had no documented care plan for the use of dentures; and 4. Resident 19 had no documented care plan for medication combined with other medications. These failures had the potential to put the residents at risk for unmet needs and as well as the potential to negatively impact their highest practicable level of well-being. Findings: 1. Resident 18 was admitted to the facility in early 2024 with diagnoses which included chronic lung disease and pneumonia (lung infection). During a review of Resident 18's Minimum Data Set (MDS, an assessment tool), dated 4/21/24, the MDS indicated Resident 18 had no memory impairment and required extensive assistance with activities of daily living (bathing, dressing, toileting). During a review of Resident 18's Nursing Care Plans (NCP), the medical record indicated there was no documented evidence a care plan was developed and implemented for contact/droplet isolation precautions. During a review of Resident 18's Baseline Care Plan (BCP), dated 4/16/24, the BCP indicated, Special Treatment: Contact/droplet isolation. During a review of Resident 18's Physician's Orders (PO), dated 4/17/24, the PO indicated, Contact/Droplet Precautions d/t [due to] MRSA [methicillin resistant staphylococcus aureus, an infectious bacteria]/nares [nostrils] & ESBL [extended spectrum beta-lactamase, enzyme produce by infectious bacteria causing resistance to antibiotics]/urine - (staff to wear gown and gloves when providing care to resident). During an observation on 7/8/24 at 9:11 a.m. outside Resident 18's room, the room door was closed with signs posted which indicated, Contact Precautions, and other guidelines to follow before entering room. There was no sign posted for Droplet Precautions. During a concurrent observation and interview on 7/8/24 at 9:12 a.m. in Resident 18's room, Certified Nursing Assistant 6 (CNA 6) opened the room door while not wearing a face mask, indicated the room was on isolation precautions, and stated, [Resident 18] has ESBL in urine and MRSA in nostrils .Not all of them in this room are on isolation. The one on isolation is just [Resident 18]. During a concurrent observation and interview on 7/8/24 at 9:18 a.m. in Resident 18's room, Resident 18 was in bed, awake, alert and verbally responsive. Resident 18 had an oxygen (O2) tubing connected to an O2 concentrator, and stated, It's not good here .They have not done a chest x-ray I requested. I have been having difficulty breathing. During a concurrent observation and interview on 7/9/24 at 8:45 a.m. with Licensed Nurse 2 (LN 2), LN 2 stated, [Resident 18] is on droplet precautions. The LN verified there was no sign for droplet precautions, and stated, [Resident 18] has MRSA nares and ESBL urine. So, when I go in there, I usually wear face masks because of the droplet . During an interview on 7/9/24 at 11:38 a.m. with LN 4, LN 4 stated, [Resident 18] has ESBL in urine and MRSA in the nostrils. LN 4 verified the listed diagnoses did not indicate ESBL and MRSA but the physician's order indicated what type of isolation precautions, and stated, There should be diagnosis. The order indicates contact and droplet precautions. During an interview on 7/9/24 at 11:40 a.m. with LN 4, LN 4 verified the physician's order for contact/droplet precautions was dated 4/17/34, and stated, It has been three months. There should have been a diagnosis. There should have been a posted sign about the droplet precautions .I'm not sure if [staff] know about the droplet precautions. The LN confirmed there was no posted sign for droplet precautions on the Resident 18's door, and stated, I am not sure if [staff] know about the droplet precautions. The roommates are not on isolation .I think it's not safe for the other residents. During an interview on 7/9/24 at 11:41 a.m. with LN 4, when asked if the isolation precautions were in the nursing care plan, LN 4 verified there was no care plan created in the Resident 18's electronic medical record, and stated, The isolation precautions should be documented in the care plan. I don't find any care plan for the isolation [precautions]. I tried to find it but I can't find [the isolation care plan]. During an interview on 7/9/24 at 11:42 a.m. with the Director of Nursing (DON) at the nurse's station, the DON verified and confirmed there was no posted sign for droplet precautions in Resident 18's room door, and stated, When the [Resident 18] came from the hospital, she was admitted with the droplet infection. During an interview on 7/11/24 at 11:40 a.m. with the Director of Nursing (DON), the DON stated, The nurses need to develop and implement a care plan for any problem the residents have and the care plan needs to be revised and updated and documented. 42255 2. Resident 15 was admitted in mid-2023 with diagnoses which included diabetes (uncontrolled blood sugar), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), dependence on renal dialysis, acute kidney failure (a disorder of the urinary tract that occurs when urine cannot filter the waste from the blood). A review of Resident 15's clinical record did not include the following documents: a care plan with interventions for a skin assessment, repositioning, monitoring, offloading, heel protectors and/or hygiene/shower. During a concurrent observation and interview on 7/9/24 at 12:10 p.m., with Administrative Assistant/Clerk (AA/C), the AA/C agreed with the observation that Resident 15's right heel which had a slight odor and an open wound the size of a half dollar. Additionally, the wound bed had a dark black hard crust in the center, with flakes of dry skin surrounding the outside. The AA/C stated, This is not right, I'll have to check to see what going on, it should at least be offloaded. During a concurrent interview and record review on 7/9/24 at 12:20 p.m. with LN 5, LN 5 stated, I just saw that wound and received orders for treatment. Every day I check the left foot but not the right. LN 5 confirmed that there was no care plan with interventions for Resident 15's right heel, and stated, I don't have one [care plan] for skin protection . During an interview on 7/10/24 at 9:16 a.m. with the DON, the DON stated, There should be an available care plan for the risk of the development of PU/PI [pressure ulcer/pressure injury] . There should always be care plans in place to assist the staff in the care of resident. 46995 3. Resident 204 was admitted to the facility in mid-2024 with diagnoses which included adult failure-to-thrive (weight loss, decreased appetite, and physical inactivity), need for assistance with personal care, and Alzheimer's disease (progressive memory loss). During a review of Resident 204's NCP, the medical record indicated there was no documented evidence a care plan was developed and implemented for Resident 204's use of dentures. During an observation on 7/9/24 at 12:33 p.m. of Resident 204's lunch tray, Resident 204 was served a whole piece of chicken and zucchini. He was not wearing any dentures. During an interview on 7/9/24 at 12:47 p.m. with CNA 7, CNA 7 was asked why Resident 204 was not wearing dentures. CNA 7 stated, I did not know he had dentures, I should have checked before his meal. During a concurrent observation and interview on 7/10/24 at 9:53 a.m. with CNA 8 of Resident 204, CNA 8 agreed that Resident 204 was lying in bed without dentures. CNA 8 was asked if Resident 204 wore dentures while eating, and stated, I don't know. I did not know he had dentures . During an interview on 7/10/24 at 9:59 a.m. with the DON, the DON was asked how a CNA would know if a resident needed dentures. The DON stated he would expect CNAs to look at [medical record] before providing care. During an interview on 7/10/24 at 12:49 p.m. with the Infection Preventionist/Director of Staff Development (IP/DSD), the IP/DSD was asked if the use of dentures were to be care planned. The IP/DSD stated, Yes. The IP/DSD confirmed there were no care plan in place for Resident 204's dentures. When asked why the care plans were important, the DSD stated, It is important so staff can give care. 48860 4. Resident 19 was admitted to the facility in late 2022 with diagnoses which included heart failure, diabetes mellitus (condition in which the body has trouble controlling blood sugar), chronic kidney disease (impaired kidney function), pain in leg, neuralgia (severe, sharp, and often shock-like nerve pain) and neuritis (nerve inflammation). During a review of Resident 19's Medication Review Report (MRR), the MRR indicated, .Norco Tablet 5-325 MG (milligrams, a unit of measurement) (Hydrocodone-Acetaminophen, narcotic pain reliever) Give 1 tablet by mouth every 6 hours as needed for mod [moderate] to severe pain ., Amitriptyline HCL Tablet 25 MG Give 1 tablet by mouth at bedtime for neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet) .and Gabapentin Oral Capsule 100 MG (Gabapentin, for nerve pain) Give 1 capsule by mouth two times a day for neuropathic pain. During a review of the Resident 19's Care Plan History there were no care plans indicated for gabapentin administration and monitoring. During a review of Residents 19's Physician's Progress Notes/Psychological Evaluation, dated 5/30/24, the progress notes indicated, .No specific psychiatric diagnoses. Continue Amitriptyline for Neuropathy. During a review of Residents 19's Medical Doctor Notes [MDN] dated 6/24/24, the MDN indicated, .Physician's Response: 1. Continue Amitriptyline as written, 2. Add Gabapentin 100 MG 1 tablet BID [Twice a day]. During a review of Resident 19's Medication Administration Review (MAR) for June to July 2024, the MAR indicated Resident 19 received Gabapentin 100 MG in the morning and evening since 6/27/24 and Amitriptyline HCL 25 MG during bedtime since 6/1/24. During a concurrent interview and record review on 7/10/24 at 11:50 a.m. with LN 2, LN 2 stated, Gabapentin can cause drowsiness, sleepiness, tiredness, and sedation and these effects are worsened if the patient was taking other medications that has the same effects. LN 2 confirmed Resident 19 did not have gabapentin monitoring on MAR and a care plan. LN 2 added that care plan was important to have for gabapentin, and stated, So nurses know what to do and what to monitor before giving the medication because of the patient's other medication like amitriptyline. During a concurrent interview and record review on 7/10/24 at 1:51 p.m. with the MDS Coordinator (MDSC), the MDSC indicated that nurses needed to have monitoring before administering a medication that could cause drowsiness and sedation especially for multiple medications that had the same effects. The MDSC confirmed that there was no care plan for gabapentin administration for Resident 19. During a concurrent interview and record review on 7/10/24 at 1:15 p.m. with the DON, the DON stated that, Gabapentin should have a care plan and monitoring before administration of the medication. The DON confirmed that there was no care plan for gabapentin monitoring for Resident 19. The DON confirmed that gabapentin could cause sedation and drowsiness and if given with amitriptyline, could exacerbate the effects. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans, dated 3/23, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record .The comprehensive care plan will describe, at a minimum, the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on record review and interview, the facility failed to ensure a smooth and safe discharge back to the community when Resident 1 was dropped off at a shelter during a period of extreme heat without secured lodging after being exposed to COVID-19 by facility staff. This failure resulted in Resident 1 being readmitted to the hospital. Findings: A review of an admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included shortness of breath, abnormalities of gait and mobility, and urinary retention. A review of a Minimum Data Set (MDS, an assessment tool) dated 8/8/22, indicated Resident 1 had no memory problems, inattention, nor disorganized thinking. A review of a care plan, created on 8/15/22, indicated, The [Resident 1] wishes to discharge to the Community when goals have been met .Interventions .Make arrangements with required community resources to support independence post-discharge . A review of a progress note, dated 9/1/22 at 3:42 p.m. indicated, COVID 19 [a virus which causes mild to severe respiratory infections] Possible Exposure .spoke with resident today regarding his possible exposure to the virus, as a staff member tested positive this morning .informed resident that he is now in a yellow zone, and he should not attend group activities. Resident acknowledged and had no questions. A review of Resident 1's Medication Review Report indicated there was a physician's order for staff to monitor for signs and symptoms of COVID-19 every shift for 10 days starting on 9/1/22. A review of a notice of proposed discharge, dated 9/2/22, indicated Resident 1 was notified on 9/2/22 of his discharge to a community shelter on 9/7/22 because his health had improved sufficiently so he no longer required services provided by the facility. The document also indicated Resident 1 refused to sign the document. A review of Resident 1's nurses progress note, dated 9/7/22 at 1:21 a.m. indicated, .continue on isolation precaution for covid exposure . A review of Resident 1's nurses progress notes, dated 9/7/22 at 1:56 p.m. indicated, Discharge instructions given to resident verbalized/ expressed understanding. discharged to home with current medications. Picked up at [1:50 p.m.] via white cab. A review of Resident 1's social services progress note, dated 9/7/22 at 4:14 p.m. indicated, [Resident 1] has completed goals and is safe to discharge. [Resident 1] requested to Discharge to Homeless Shelter. SSD arranged transport to the Homeless Shelter that Resident requested to DC [discharge] to. A review of Resident 1's progress notes, created between 8/7/22 and 9/7/22, indicated one social service note in which discharge planning had been discussed. A review of a social services progress note, created on 9/15/22 at 2:51 p.m., with an effective date of 9/2/22 at 2:47 p.m. indicated, SSD [Social Service Director] and Assistant Administrator met with [Resident 1] and discussed Discharge Plan. Resident has completed goals and is safe to DC to the Community on 9/7/22. Resident states he prefers to go to a Homeless Shelter .Resident is scheduled to DC 9/7/22. In an interview on 12/19/22 at 1:14 p.m., the SSD stated her responsibility in the process of a resident discharge was to ensure a smooth and safe discharge to home or another facility. The SSD stated she called the community shelter and was told beds were available, but they were on a first-come, first-served basis. The SSD also stated she did not document what date she called the community shelter nor whom she spoke with. In an interview on 12/19/22 at 1:35 p.m., the Assistant Administrator (AA) stated he expected staff to document when, who, and what was discussed when staff contacted other facilities during the discharge process. The AA also stated he expected facility staff to ensure Resident 1 got a bed at the shelter. In an interview on 12/19/22 at 1:50 p.m., Resident 1 stated the facility staff told him he had been exposed to COVID-19 by a staff member, but the next day was told he had to leave. Resident 1 stated when he arrived at the shelter, the shelter staff told him they had no idea who he was and denied they spoke to anyone to secure him a bed because, that was not how it was done. Resident 1 confirmed he refused to sign the discharge paperwork and was not provided a copy of the paperwork until the day he was discharged . Resident 1 stated he wanted to appeal but was given the instructions on how to appeal an hour before transportation came to pick him up. Resident 1 stated the SSD told him she would make arrangements for him to secure a bed at the shelter. Resident 1 also stated because he did not have a bed at the shelter, he ended up living on the streets for three weeks during a heat wave before he passed out and was sent back to the hospital. In an interview with a representative at 2-1-1 Sacramento (a free confidential information and referral service provided to the public within the Sacramento area) on 12/19/22 at 3:25 p.m., the Referral Specialist 1 (RS 1) stated a shelter survey must be completed when a person plans to discharge from a skilled nursing facility to a shelter. The RS 1 stated the shelter survey assesses the needs and accommodations required for a placement to the appropriate shelter. Once the survey is completed, the person is placed in a queue for placement. The typical timeframe for the shelter survey and placement into a shelter is three months. The RS 1 also stated, There is a zero percent chance a person from a nursing facility can call a shelter directly and get a guaranteed bed on the spot. The shelter survey is required and can only be accessed via the Homeless Management Information System database. There are only three shelters in Sacramento which allow for overnight-stays. These shelters are on a first-come, first-served basis. Two of the shelters open at 7 p.m. and the other opens at 8 p.m. The RS 1 stated, In order to get a good chance at securing a bed, most people must get in line at least one hour before doors open. In event of extreme weather, Sacramento also has day-shelter locations, but these are only open during the day and are offered temporarily during times of extreme weather. In an interview on 12/19/22 at 4:17 p.m., the Transportation Service Representative (TSR) confirmed the SSD called the transportation company to schedule a ride for Resident 1 at approximately 3 p.m. The TSR stated Resident 1 was picked up at 4:10 p.m. and was dropped off to a predetermined location at approximately 4:30 p.m. A review of the National Weather Service's climatological data for the Sacramento area indicated: -On 9/6/22, Sacramento had a maximum temperature of 114 degrees Fahrenheit (F, a measure of temperature) and a minimum temperature of 73 F; -On 9/7/22, a maximum temperature of 107 F and a minimum temperature of 73 F; and, -On 9/8/22, a maximum temperature of 112 F and a minimum temperature of 68 F. A review of the facility's policy and procedure titled Discharging the Resident, revised December 2016, indicated, .Preparation .The resident should be consulted about the discharge .Discharges can be frightening to the resident. Approach the discharge in a positive manner .Assess and document resident's condition at discharge .if medical condition allows .The following information should be recorded in the resident's medical record .If the resident refused the discharge, the reason(s) why and the intervention taken . A review of the facility's document titled Notice of Proposed Transfer/ discharge date d 9/2/22 indicated, .If you believe that the proposed transfer/ discharge is inappropriate in your case, and is involuntary, you have the right to appeal .If you intend to file an appeal .it is suggested that you do so within (10) ten calendar days of being notified. The decision regarding an appeal will normally by made within thirty (30) working days from the date you were formally notified .You should be aware that the decision to transfer/ discharge may be upheld; if this is the case, you should be prepared to transfer/ discharge at the end of the (30) days from the date you were formally notified.

Based on interview and record review, the facility failed to identify the development of multiple pressure ulcers (damage to the skin and underlying tissue due to localized pressure) for one (Resident 1) of three sampled residents. This failure resulted in Resident 1 not receiving wound care for multiple pressure wounds which had the potential to cause wound infection or [CONDITION(S)]. Findings: A review of Resident 1's Admission Record, indicated Resident 1 was admitted in 2016 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS) (an assessment tool)- Section C- Cognitive Patterns, dated [DATE], indicated Resident 1 had a Brief Interview for Mental Status (BIMS) (a cognitive assessment tool) score of 6 out of 15 which indicated that he was severely cognitively impaired. A review of Resident 1's MDS-Functional Status, dated [DATE], indicated Resident 1 required extensive assistance with bed mobility and had limited range of motion in his lower extremities (legs). A review of Resident 1's MDS-Skin Conditions, dated [DATE], indicated Resident 1 did not have any unhealed pressure ulcers (PU), but was at risk of developing pressure ulcers or injures. During an interview on [DATE] at 2:50 p.m. with the MDS coordinator (MDS), he stated Resident 1 was admitted to an acute care hospital on [DATE] due to altered mental status (change in cognition). He was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was readmitted to the facility on [DATE] for comfort care measures (end of life medical care) after the acute hospital stay. Resident 1 died at the facility on [DATE]. During an interview on [DATE] at 1:47 p.m. with Licensed Nurse (LN) 1, he stated that they used to have a specific wound treatment nurse, but due to the COVID-19 outbreak that nurse was performing a regular nursing role. He stated all the nurses were providing wound care. During an interview on [DATE] at 12:55 p.m. with the Director of Nursing (DON), she stated there is currently a wound care nurse (WCN) working at the facility. Residents are referred to the WCN and wound care physician (WCP) upon admit and as needed. Resident 1 was being followed by the WCN and WCP. The DON stated Resident 1's skin condition worsened daily because he was at the end of life and was not eating or drinking. During an interview on [DATE] at 1:05 p.m. with the WCN, she stated Resident 1 had an open wound on his left knee and an open area under his right knee. She stated that he did not have a sacral (region at the bottom of the spine) wound. The WCP was following his care weekly. The WCN stated that Resident 1's wounds were getting worse because he was not eating or drinking. She stated that residents are turned and repositioned every two hours by the Certified Nursing Assistants (CNA) according to standards of practice. She stated that the facility did not have a turning log to record the turning of patients for pressure relief. During an interview on [DATE] at 1:45 p.m. with CNA 1, she stated she turns the residents every two hours, but does not record it in a turning log or in the chart. She stated, I just remember to do it [turning] while I'm doing my rounds. During a concurrent interview and record review on [DATE] at 3:05 p.m. with the DON, she stated that the WCN started at the end of October [2020] but was pulled to be a regular staff nurse during the COVID-19 outbreak. Nurses were doing the wound care. The DON stated Resident 1 had fragile skin and had new reddened areas frequently. Reviewed with the DON the Emergency Department Physician Note from the acute care hospital, dated [DATE] at 10:05 a.m., for Resident 1, that stated Physical Exam . Skin: Comments: Sacral Decubitus (pressure) Ulcer . The DON acknowledged that the sacral pressure ulcer (PU) was identified upon arrival at the acute care hospital on [DATE]. Reviewed with the DON a Wound care consult note from the acute care hospital, dated [DATE] at 2:19 p.m., for Resident 1, that identified multiple wounds: Full thickness wound (wound extends beyond all layers of skin) behind the right knee. RLE (right lower extremity) full thickness wound covered with dry black eschar (dead tissue). RLE wound above the ankle with dark red discoloration and partial thickness skin loss. Right heel full thickness wound covered with black dry eschar. Right lateral (outside) foot had purple skin discoloration. Right medial (towards the middle) foot, near first metatarsal head (bone in the ball of the foot), had purple skin discoloration. Left medial foot had purple skin discoloration and partial thickness loss. Left lateral foot had black eschar extending to the 4th and 5th metatarsal head. Right ischial (lower hip bone) was a closed stage 3 (full thickness skin loss that extends into the fat layer) PU. Sacral area had a superficial but full thickness wound with purple discoloration in the wound bed (Impression- sacral DTI (deep tissue injury) that now progressed to stage 3 PU) .Wound present on admission to hospital? Yes The DON acknowledged that a Stage 3 PU to the sacrum and multiple other pressure wounds were identified at the acute care hospital. DON stated, I don't know what happened, the CNAs are supposed to check during showers and ADL (Activities of Daily Living) care. A review with the DON of the facility's Non Pressure Skin Problem Report, dated [DATE], reflected Resident 1 had a trauma injury to the left anterior knee. A review with the DON of the facility's Non Pressure Skin Problem Report, dated [DATE], reflected Resident 1 had MASD (Moisture Associated Skin Damage) to the right posterior knee. Further review with the DON of the facility's Pressure Injury Assessments, dated [DATE], reflected Resident 1 had a DTPI (Deep Tissue Pressure Injury) to his right heel, left lateral foot, and left medial foot. The DON confirmed that the facility had not identified the sacral pressure ulcer and the multiple pressure injuries identified on admission to the acute care hospital. The DON confirmed that the sacral wound, the RLE wounds, and the right foot wounds did not receive treatment at the facility as they had not been identified. Reviewed with the DON Resident 1's Resident Admission Assessment, dated [DATE]. Resident 1 was readmitted to the facility on [DATE] after a stay at the acute care hospital. This assessment identified wounds at the left knee, the right posterior knee, bruising on arms and buttocks, and redness on both heels. The DON acknowledged that Resident 1 did not have a sacral ulcer or pressure injuries recorded upon readmission to facility on [DATE]. She stated that the sacral wound and pressure wounds occurred after the [DATE] readmission to facility. Reviewed with the DON Resident 1's Skin Short Term Care Plan, last updated [DATE]: Problem- Trauma left anterior knee Interventions- Treatment as ordered . (discontinued [DATE]), Monitor for sign/symptoms of infection (redness, pain, presence of drainage), Utilize precaution during care, Observe gentle handling of the resident, Report skin conditions to the responsible party and MD (medical doctor), Handle affected area during care, Assess for pain and discomfort (verbal/ nonverbal). Goal- Will promote healing without complications. Reviewed with the DON Resident 1's Resident Care Plan Pressure Ulcer Risk, last updated [DATE]: Problem/ Need- Risk for pressure ulcers . Approach plan- Pressure reducing mattress to bed, Pressure relieving mattress to bed, Reposition every one to two hours, Vitamin and mineral supplements per orders, Dietary supplements per orders, Pain management per orders, monitor effectiveness, Encourage to elevate heels off of bed with pillows. Resident Goal-Will have no pressure ulcers by next review, Will show no sign/s and development of infection. Requests for updated wound, pressure management, or skin treatment care plans that reflected care for left anterior knee wound, right distal posterior wound, right heel, left lateral and left medial foot was not provided. The DON stated she is unable to provide any updated care plans. She acknowledged that the care plans are incomplete. During a joint interview on [DATE] at 4:40 p.m. with CNA 2 and CNA 3, they stated they check for any skin changes during shower time and report to the nurse. During an interview on [DATE] at 5:00 p.m. with LN 2, she stated that Resident 1 had a knee wound, but did not remember any other wounds. She stated she did not do any wound treatments as they were done during the day shift. When asked how new wounds are identified, she stated the CNAs document on the shower sheet and notify the nurse. A review of Resident 1's Order Summary Report for active orders as of [DATE], indicated wound care orders for the left anterior knee, left lateral foot, left medial foot, right posterior knee and right heel. A review of the WCP Surgical Consult notes dated [DATE], [DATE], [DATE] and [DATE] for Resident 1, indicated the only wounds assessed and treated were the left anterior knee, the right distal posterior knee, the right heel, the left lateral foot, and the left medial foot. A review of the Braden Scale for Predicting Pressure Sore Risk (a standardized tool to assess for risk of pressure sores) for Resident 1 dated [DATE], indicated Resident 1 had a score of 13 out of 23 which indicated he was at moderate risk to develop pressure sores. Skin Monitoring: Comprehensive CNA Shower Review sheets for Resident 1, dated [DATE], [DATE] and [DATE], were reviewed. These sheets indicated Resident 1 had refused a shower on those three days. Requested from the DON additional sheets for the months of ,d+[DATE] and ,d+[DATE]. The DON did not provide any additional Skin Monitoring: Comprehensive CNA Shower Review sheets. A review of the MICU (medical intensive care unit) History and Physical, dated [DATE] from the acute care hospital for Resident 1, indicated Resident 1 had multiple pressure ulcers along bony aspects of bilateral feet . Requests for nutritional care plans and ADL care plans for Resident 1 from the facility by phone and email on [DATE], [DATE], [DATE], and [DATE] and during an onsite visit on [DATE] were not provided. The DON stated she is unable to provide any of these care plans. A review of the facility policy Pressure Injury Management revised [DATE] stated, .The licensed nurse will notify the Director of Nursing Services of any new pressure injury .The Dietary Department or RD (Registered Dietitian) will be notified for nutritional assessment .A licensed nurse will develop a care plan for the resident based on recommendations from IDT (Interdisciplinary Team), dietary, rehabilitation and the attending physician CNAs will complete body checks on resident's shower days and report unusual findings to the Licensed Nurse .Any new pressure injury will be documented on the 24 Hour Log and a Change of Condition will be documented by the licensed nurse to determine causal factors contributing to the development of the pressure injury . A request for ADL policy from facility by phone and email on [DATE], [DATE], [DATE] and [DATE] and during an onsite visit on [DATE]. The DON stated that the facility does not have an ADL or a repositioning and turning policy.

Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards to prevent the development and worsening of pressure ulcers in one of 16 sampled residents (Resident 42) when: 1. Orders for a low air loss mattress, and a nutrition shake to enhance wound healing were not followed; and 2. The pressure ulcer on the coccyx (tailbone) was not reported to the wound care physician, reviewed by the Interdisciplinary Team, and the treatment nurse did not document on the progress of the pressure ulcer to treatment. These failures resulted in Resident 42 developing two new, avoidable, pressure ulcers to the right and left heels, and the worsening of one pressure ulcer to the coccyx while at the facility. Findings: 1. The National Pressure Ulcer Advisory Panel (NPUAP, professional organization dedicated to the prevention and management of pressure injuries) (YEAR) definition of pressure injuries indicated A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence . The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. A pressure injury may also be referred to as a pressure ulcer, pressure sore, pressure wound, decubitus ulcer, and bedsore. Resident 42 was admitted to the facility in the summer of 2019 with [DIAGNOSES REDACTED]. Review of Resident 42's clinical record revealed the following: A document titled, Skin & Body Assessment, dated 8/23/19, indicated Resident 42 returned from the hospital with several wounds, which included a wound with a bandage and surgical staples, bruises, and swelling of her lower right leg. The assessment did not contain documented evidence of wounds to the right or left heels. A Pressure Ulcer Risk Care Plan, dated 8/25/19, indicated Resident 42 was at risk of developing pressure ulcers due to her inability to move independently in bed, and her dementia. The care plan interventions included a pressure relieving mattress to the bed, repositioning every one to two hours, and dietary supplements per orders. A Pressure Ulcer Care Plan, dated 8/26/19, indicated, PRESSURE ULCER AS MANIFESTED BY: bed mobility (the ability to move independently in bed). The care plan interventions included staff were to encourage Resident 42 to turn or reposition at least every two hours, ensure the resident obtained appropriate nutrition to enhance the healing process, and keep the physician informed of the progress and response to the treatment plan. The care plan did not specify the number or location of any pressure ulcers. A Minimum Data Set (MDS, an assessment tool), dated 8/30/19, indicated Resident 42 was non-ambulatory, and required extensive assistance with bed mobility and transfers from her bed to her wheelchair. The MDS indicated Resident 42 had one unhealed pressure ulcer at stage 1 (non-blanchable reddened area usually over a bony prominence). A Nurses Note, dated 9/11/19, at 12 p.m., indicated, .Discoloration noted on bilateral (both) heels. Continued to elevate feet when in bed. Will continue to monitor. A Nutrition Note by the Registered Dietician (RD), dated 9/19/19, indicated Resident 42 had increased calorie and protein needs for wound healing. The RD made recommendations, which included changing her current nutrition shake with 6 grams of protein per serving to a nutrition shake with 9 grams of protein per serving, at each meal. A physician's orders [REDACTED]. A document titled, WEEKLY PRESSURE INJURY REPORT, dated 9/24/19, indicated Resident 42 acquired pressure injuries to her left and right heels. The report indicated the right heel was considered a deep tissue injury (DTI, intact or non-intact skin with localized area of persistent non-blanchable, deep red, maroon, or purple discoloration), and the left heel was considered unstageable (UTD, obscured full-thickness skin and tissue loss). A Nurses Note, dated 9/24/19, at 2 p.m., indicated, (New Order) Received by (name of wound care physician) to start tx (treatment) for (right) heel UTD DTI and to start tx for (left) heel UTD . A physician's orders [REDACTED]. A document titled, SPECIALTY PHYSICIAN WOUND EVALUATION & MANAGEMENT SUMMARY, dated 10/1/19, indicated Resident had an UNSTAGEABLE (DUE TO NECROSIS (dead tissue cells)) OF THE RIGHT HEEL, with a duration of greater than seven days, and a STAGE 4 (full thickness tissue loss with exposed tendon, muscle, or bone) PRESSURE WOUND OF THE LEFT HEEL, with a duration of greater than seven days. A SPECIALTY PHYSICIAN WOUND EVALUATION & MANAGEMENT SUMMARY, dated 10/15/19, indicated Resident 42 had a STAGE 3 (full thickness tissue loss, but no tendon, muscle or bone is exposed) PRESSURE WOUND OF THE RIGHT HEEL, with a duration of greater than 21 days, and a STAGE 4 PRESSURE WOUND OF THE LEFT HEEL, with a duration of greater than 21 days. During a concurrent observation and interview with the treatment nurse (TN) on 10/21/19 at 10:15 a.m., the TN provided wound care to Resident 42. The resident did not have dressings on the left and right heels. The TN stated the heels should have been covered with dressings. The TN stated Resident 42 acquired her pressure wounds to her heels while at the facility. During a concurrent observation and interview with the wound care physician (WCP) and the TN on 10/22/19 at 3:30 p.m., the WCP confirmed Resident 42 was not lying on a low air loss mattress. The WCP recommended a low air loss mattress for her bed, a specialized pressure relieving cushion for her wheelchair, and time in her wheelchair limited to 60 consecutive minutes. During an observation on 10/23/19, at 7:55 a.m., Resident 42 was observed eating her breakfast in bed. Her breakfast items included a nutritional shake with 6 grams of protein, and not the ordered nutrition shake with 9 grams of protein. During a concurrent observation and interview with CNA 2 of Resident 42's breakfast on 10/24/19 at 7:49 a.m., Resident 42 was observed drinking a nutrition shake with 6 grams of protein per serving, rather than the ordered nutrition shake with 9 grams of protein. When asked about the resident's nutrition shake, CNA 2 stated she would encourage Resident 42 to drink her nutrition shake and would offer her pudding or Jell-O, because Resident 42 liked those food items. During an interview with the TN on 10/24/19 at 9:20 a.m., the TN stated he was not sure why Resident 42 did not receive a low air loss mattress when it was ordered on [DATE]. The TN stated he thought the mattress was not available at that time, and then the order was forgotten about. During a concurrent observation and interview with CNA 3 of Resident 42's lunch on 10/24/19 at 12:36 p.m., Resident 42's meal included a nutrition shake with 6 grams of protein per serving, rather than the ordered nutrition shake with 9 grams of protein. CNA 3 stated she planned on encouraging Resident 42 to finish her nutrition shake, and would also offer her a second nutrition shake. During an observation of Resident 42's breakfast meal on 10/28/19 at 7:30 a.m., Resident 42's breakfast tray included a nutrition shake with 6 grams of protein, not the nutrition shake ordered with 9 grams of protein. During an interview with the RD on 10/28/19, at 8:45 a.m., the RD stated she recommended the change in nutrition shakes on 9/19/19 when Resident 42 had significant weight loss and wound healing needs. 2. A document titled Skin & Body Assessment, dated 8/23/19, indicated Resident 42 returned from the hospital with several wounds, which included redness over the coccyx area with a puncture to the left buttock. A Treatment Record for 8/19 indicated Resident 42 began treatment for [REDACTED]. Review of the Nurses Notes from 8/25/19 to 10/5/19, which included progress notes written by the TN, revealed no documented evidence of Resident 42 having a left buttock pressure injury. A physician's orders [REDACTED]. A Treatment Record for 9/19 indicated Resident 42 received treatment for [REDACTED]. A physician's orders [REDACTED].(left) BUTT[NAME]K STAGE 2 CLEAN WITH NS, PAT DRY, APPLY MEDI HONEY, COVER WITH DRY DRESSIN[NAME] A Treatment record for 10/19 indicated Resident 42 received treatment for [REDACTED]. A document titled, SPECIALTY PHYSICIAN WOUND EVALUATION & MANAGEMENT SUMMARY, dated 10/1/19, did not have documented evidence of Resident 42's left buttock stage 2 pressure injury. A document titled, SPECIALTY PHYSICIAN WOUND EVALUATION & MANAGEMENT SUMMARY, dated 10/15/19, did not have documented evidence of Resident 42's left buttock stage 2 pressure injury. Resident 42's clinical record did not contain documented evidence that indicated the Interdisciplinary Team (IDT) reviewed Resident 42's left buttock stage 2 pressure injury on 9/24/19, 10/1/19, 10/8/19, and 10/15/19 when they met to review Resident 42's pressure injuries. During multiple observations of Resident 42 on 10/21/19 between 9 a.m. and 4:30 p.m., the resident was observed lying in bed on her back, with the head of her bed elevated, and her heels resting on pillows. During a concurrent observation and interview with the TN on 10/21/19 at 10:15 a.m., the TN changed a dressing on the resident's coccyx region (tailbone), and stated her coccyx pressure ulcer was acquired before her admission to the facility. During an interview with the WCP and the TN on 10/22/19 at 1:30 p.m., the WCP stated he was not aware Resident 42 also had a pressure injury over her coccyx region. The TN stated he did not notify the WCP of the coccyx pressure injury, and he was responsible for notifying him when new wounds developed. During a concurrent observation and interview with the WCP and the TN on 10/22/19 at 3:30 p.m., the WCP assessed Resident 42's pressure wound to the coccyx region and stated the wound was unstageable. The WCP recommended a low air loss mattress for her bed, a specialized pressure relieving cushion for her wheelchair, and time in her wheelchair limited to 60 consecutive minutes. The TN stated he was sure Resident 42's coccyx pressure ulcer worsened because the resident sat in her wheelchair for long periods of time. During an interview with the Director of Nursing (DON) on 10/22/19 at 4:17 p.m., the DON stated she expected the TN to notify the DON and the WCP whenever a resident developed a new wound. During intermittent observations on 10/24/19 between 9 a.m. and 12:55 p.m., Resident 42 was observed seated in her wheelchair. Between 1 p.m. and 4 p.m., Resident 42 was observed lying in bed, on her back, with the head of her bed elevated and her heels resting on pillows. During an interview with the RD on 10/28/19, at 8:45 a.m., the RD stated she attended the IDT wound care committee meetings, and was not informed of a pressure injury to Resident 42's coccyx. During an interview with the Medical Director (MD) on 10/28/19 at 1:10 p.m., the MD stated he expected the facility staff to notify the WCP of all wounds. A facility policy and procedure titled Prevention of Pressure Ulcers, dated 8/13, indicated General Prevention Measures .For a person in (sic) confined to bed .Change position at least every two hours or more frequently if needed .If a special mattress is needed, use one that contains foam, air, or gel as indicated .Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and medical necessity .For a person in a chair .Change position at least every hour .Routinely assess and document the condition of the resident's skin per facility wound and skin care program for signs and symptoms of irritation or breakdown .Immediately report any sign of a developing pressure ulcer (injury) to the supervisor .Administer vitamins, minerals and protein supplements in accordance with physician orders [REDACTED].