Every finding on record at Camarillo Healthcare Center

Based on observation, interview, and record review, the facility failed to maintain a facility wall inside rooms [ROOM NUMBERS], occupied by residents were free from scuff marks, multiple scratches and uneven texture. This failure had the potential to affect the overall sense of an orderly, clean home environment for the occupying residents of both rooms. During a concurrent interview and record review, on 6/5/26, beginning at 8:37 a.m., with the Maintenance Director (MD), the MD verbalized the maintenance department in part relies on staff to report environmental concerns to them. The MD verbalized at each nursing station there was a maintenance binder where staff could write down items that need to be fixed/addressed. Both maintenance logs were reviewed which indicated there were no current items that needed to be fixed/addressed. The MD verbalized nothing needed to be fixed, according to both maintenance logs.During a concurrent observation and interview, on 6/5/26, beginning at 8:42 a.m., with the MD, the facility was toured. In room [ROOM NUMBER] and room [ROOM NUMBER] a section of wall was observed in a state of disrepair with multiple scratches, scuff marks and irregular texture. The MD verbalized both walls were in a state of disrepair and would need to be puttied and painted to be fixed. The MD verbalized staff should have logged the sections of wall in disrepair in the maintenance binder. During a review of the facility's policy and procedure titled Safe and Homelike Environment dated 12/25, indicated in part In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment.

Based on record review and interviews, the facility failed to ensure that the comprehensive care plan was developed and implemented for two of the 10 sampled residents (Resident 41 and Resident 11).1.Resident 41 had no care plan with interventions due to the medical diagnosis related to Cannabis Abuse. 2.Resident 11's care plan interventions related to restorative nursing assistance (RNA) exercises/services were not consistently completed/documented. 1.During a concurrent record review and interview, on 6/5/26, beginning at 1:45 p.m., with the Assistant Director of Nursing (ADON) Resident 41's care plan and medical diagnosis was reviewed. Resident 1's Face Sheet indicated a diagnosis of Cannabis Abuse, Uncomplicated, with an onset date of 5/6/26. The ADON verbalized and confirmed Resident 1 did not have a care plan or interventions for the Cannabis Abuse, Uncomplicated diagnosis. During an interview on 6/5/26, at 1:59 p.m., with the Director of Nursing (DON), the DON verbalized Resident 1 should of had a care plan with interventions due to the medical diagnosis related to Cannabis Abuse. During a review of the facility's policy and procedure for Subject: Care Planning dated 11/24, indicated in part It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-Centered Care Plan for each resident based on resident's needs to attain or maintain his or her highest practicable, physical, mental, and psychosocial well-being. 2. On 6/2/26 at 10:46 a.m. in room [ROOM NUMBER] C, Resident 11 was observed sitting in the wheelchair; caregiver instructions were posted on the wall that indicated, Bed mobility: MI (minimal independence-needs assistive device and extra time), one person assist; Transfers: SBA (standby assist-requires a caregiver to be present for safety), one person assist. During a review of Resident 11's clinical record (CR), Resident 11 was admitted to the facility on [DATE] with diagnoses that included fracture (broken bone) of right lower leg; abnormalities of gait (pattern of walking) and mobility (ability to move independently). A review of Resident 11's quarterly MDS (a comprehensive assessment tool) assessment, dated 5/6/26 indicated Resident 11required: set up for eating, oral hygiene, upper body dressing, and personal hygiene; supervision assistance with toileting hygiene, showering, lower body dressing, transfer and walking; moderate assistance in putting on and taking off footwear. A review of Resident 11's order summary report (active orders) indicated physician order for RNA to: perform BLE (bilateral lower extremities) AAROM (active assisted range of motion-receive partial assistance) EX's x 10 REPS (repetitions) on all planes QD (daily) 5x a week, every day shift and to perform BUE (bilateral upper extremities) AROM (active range of motion-without any outside assistance) EX's x 10 REPS on all planes QD 5x a week, every day shift. A review of Resident 11's care plan, titled, ADL Self Care Performance . dated 9/1/25, indicated interventions including: RNA to perform BLE AAROM EX's x 10 REPS on all planes QD 5x a week and RNA to perform BLE AAROM (typo- it should be BUE AROM) EX's x 10 REPS on all planes QD 5x a week. During a concurrent interview and record review with the assistant director of nursing (ADON) and director of rehab (DOR) on 6/5/26 at 3:47 PM, Resident 11's RNA records revealed incomplete RNA services, with one out of five times missing for week one [2/1/26-2/7/26] and 2 missing for week two [2/8/26-2/14/26] of February 2026. Furthermore, RNA services were not provided two out of five times in week three [5/15/26-5/21/26] and three out of five times in week four [5/22/26-5/28/26] of May 2026. A review of the document Task for BUE and BLE RNA from 5/8/26 to 6/3/26 indicated that the staff documented 5 to 10 minutes spent providing the ROM, however there was no documentation stating how many repetitions each exercise were conducted for BLE and BUE. There were no other documents provided to explain why RNA services were incomplete in February and May 2026. The ADON and DOR confirmed missing/incomplete documentation. A review of the facility policy and procedures (P&P) titled Range of Motion dated 12/2025, the P&P indicated, .Preventive care will be provided so that resident will not experience a reduction in range of motion.RNAs will perform ROM exercises on some residents while ADLs are performed as a nursing measure.

Based on interview and record review, the facility failed to ensure the care plan for cognitive impairment/dementia, for one out of five sampled residents (Resident 1), was updated and revised after a significant change of condition.This failure had the potential to result in Resident 1 not receiving care based on current health status and at risk for unmet care needs. Findings:During a concurrent interview and record review on 6/4/26, at 9:30 a.m., with the minimum data set nurse (a specialized registered nurse who assesses, monitors, and comprehensively documents the health status of residents in skilled nursing facilities- MDS 1), Resident 1's medical record was reviewed. Resident 1's Care Plan for cognitive impairment/dementia indicated on 10/10/25 the BIMS (brief interview for mental status) score was 10 out of 15. MDS 1 verbalized Resident 1 was sent to the hospital and came back to the facility on 1/19/26. MDS 1 verbalized completing a comprehensive assessment on 1/21/26. MDS 1 verbalized Resident 1 had a decline in cognition, communication, and ADL (activities of daily living) decline. MDS 1 verbalized this was a significant change in Resident 1's condition. MDS 1 verbalized Resident 1's cognitive care plan should have been updated 14-21 days after the change of condition assessment. MDS 1 verbalized the care plan should have been updated in January of 2026 and further acknowledged the cognitive care plan had not been updated since 10/10/25. MDS 1 stated, I updated the CAA (care area assessment) worksheet but did not update the care plan and I should have. During a review of Resident 1's CAA Worksheet, dated 2/4/26, indicated in part. Resident 1 has impaired cognition as evidenced by having a BIMS score of 1 out of 15 (ARD-assessment reference date on 1/21/26) which is a decline from her baseline. At risk for fluctuating cognition related to diagnosis of SDAT (Senile Dementia of the Alzheimer Type-a progressive, irreversible, cognitive decline in older adults), recent illness and aging process. During a review of the Centers for Medicare & Medicaid Services Resident Assessment Instrument (CMS's RAI) Manual indicated in part. A significant change is a decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.2. Impacts more than one area of the resident's health status.3. Requires interdisciplinary review/and or revision of the care plan.

Based on record reviews and interviews, the facility failed to ensure the provision of resident care and services were performed within acceptable standards of nursing practice for two of eight sampled residents (Residents 12 and 66) when:1. Physician orders and instructions were not followed for Resident 12.2. Comprehensive and timely pain assessments/reassessments were not performed for Resident 66.3. The timing of insulin (a hormone that lowers the level of glucose [simple sugar]) injections (forcing medication into the body using needle and syringe) for Resident 45 was not followed per physician's prescription instructions.These failures had the potential to compromise Residents 12 and 66's health and safety from unsafe nursing care practices and had the potential to cause dangerous drops in Resident 45's blood sugar level. Findings: 1. During a review of Resident 12's Face Sheet, dated 6/5/26, the FS indicated in part that Resident 12 is a [AGE] year-old female who was admitted to the facility on [DATE] with admitting diagnoses including Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease (a group of diseases that affect how the body uses blood sugar which can lead to kidney damage) and Hypertensive Chronic Kidney Disease with End Stage Renal Disease (a condition where long-term, uncontrolled high blood pressure damages the small blood vessels in the kidney). During a review of Resident 12's Order Summary Report (OSR), dated 6/5/26, the OSR indicated the following physician orders: ACCUCHECK (check blood sugar [BS]) and NOTIFY MD if BS is less than (<) 70 or greater than (>) 250, two times a day for Diabetes Mellitus (ordered 3/19/26); Midodrine Hydrochloride (HCl) (a medication used to treat hypotension or low blood pressure [BP]) oral tablet five (5) milligram (mg) give one (1) tablet by mouth three times a day (TID) for HYPOTENSION, HOLD for systolic blood pressure (SBP - the top number in a BP reading) > 120 (ordered 3/19/26); and Valsartan (a medication used to treat hypertension [HTN] or high BP) oral tablet 80 mg, give 0.5 (half) tablet by mouth one time a day for HTN, HOLD FOR SBP < 108 (ordered 3/19/26). During a review of Resident 12's Medication Administration Records (MARs) for April 2026, the accuracy of staff documentation in the administration for physician's orders: ACCUCHECK, NOTIFY MD if BS < 70 or > 250 . and Midodrine HCl 5 mg three times daily . HOLD for SBP > 120 were reviewed. The MAR, for the ACCUCHECK . order indicated Resident 12's blood sugar readings of 262 and 271 at 1630 (4:30 p.m.) hours on 4/8/26 and 4/22/26, respectively; however, no evidence was found in the clinical record that these results were reported to the physician as directed. Additionally, a review of the MAR for the Midodrine HCl order revealed administration of the medication at scheduled times when resident blood pressure exceeded the threshold for holding the dose. Specifically, Resident 12 received the 0900 (9 a.m.) dose on 4/14/26 (BP: 124/70), 4/15/26 (BP: 132/68), 4/24/26 (BP: 136/60), and 4/26/26 (BP: 124/70). The 1300 (1 p.m.) dose was administered on 4/1/26 (BP: 130/60), 4/10/26 (BP: 124/72), and 4/14/26 (BP: 124/70). The 2100 (9 p.m.) dose was given on 4/2/26 (BP: 122/73), 4/7/26 (BP: 125/62), 4/9/26 (BP: 130/60), and 4/24/26 (BP: 128/66), despite blood pressure readings indicating the medication should have been withheld. During a review of Resident 12's MARs for May 2026, the accuracy of staff documentation in the administration for physician's orders: ACCUCHECK NOTIFY MD if BS < 70 or > 250, Midodrine HCl 5 mg three times a day—HOLD for SBP > 120, and Valsartan 80 mg 0.5 tablet—HOLD FOR SBP < 108 were reviewed. The ACCUCHECK. review found that on 5/16/26 at 1630 (4:30 p.m.), Resident 12's blood sugar reading was 296, yet there was no record indicating physician notification as required by order. For the Midodrine HCl. order, documentation showed administration on instances where systolic blood pressures exceeded the threshold: specifically, for the 1300 doses on 5/22/26 (BP 136/72) and 5/27/26 (BP 134/76), and for the 2100 doses on 5/1/26 (BP 124/70) and 5/18/26 (BP 126/74), which did not adhere to prescribed instructions. Additionally, review of Valsartan. administration revealed the medication was given to Resident 12 on 5/29/26 despite a BP reading of 106/58, contrary to the order to hold for SBP < 108. During a concurrent interview and record review on 6/5/26 at 1:52 p.m. with the facility's Assistant Director of Nursing (ADON), staff documentation in Resident 12's MARs, for April and May 2026 was reviewed. The ADON was informed that inconsistencies were identified on the staff administration documentation relating to the orders, ACCUCHECK ., Midodrine HCl 5 mg ., and Valsartan 80 mg The ADON verified these discrepancies and acknowledged that staff had not followed the accompanying instructions by the physician for these orders on the specified dates and times. During a review of the facility's policy and procedures (P&P) titled Medication Administration (Med Pass), revised 2/2009, the P&P indicated in part, PROCEDURES. A. Basics of Med Pass. Pour-Pass-Chart – correctly prepare the med, give it correctly, then chart your action. Six (6) Rights, a. Right Resident, b. Right Medication, c. Right Dose, d. Right Route/Method, e. Right Time, and f. Right Documentation. The P&P also indicated that, E. Vital Signs – if there is a vital sign as part of the med order, make sure that it is taken by the med nurse just before the medication is administered. A review of [NAME] and Perry's 7th Edition of Mosby's Fundamentals of Nursing, on page 419 under the section titled Legal Implications in Nursing Practice, it is stated that Nurses are obligated to follow physician orders unless they believe the orders are in error or would harm clients. According to Nursing Fundamentals by [NAME], [NAME] and [NAME], second edition, 2010 p. 322, Documentation is the professional responsibility of all health care practitioners. It provides written evidence of the practitioner's accountability to the client, the institution, the profession, and society. 2. Review of The Joint Commission (is an independent non-profit organization that accredits and certifies healthcare facilities ranging from hospitals to nursing homes in the United States website, https://www.jointcommission.org/en-us/standards/national-performance-goals/pain-management accessed on 6/5/26, the Joint Commission indicated in part. If pain is identified, a comprehensive evaluation must be conducted.it must capture location, intensity, quality/character, frequency, aggravating/relieving factors, and impact on daily activities.standards of practice for pain assessment in a skilled nursing facility, require systematic screening, comprehensive baseline evaluation, and timely reassessment.staff must document pain intensity, location, and functional impact, and reassess within 30 to 60 minutes after administering any new analgesic or intervention. During a review of Resident 66's Face Sheet, dated 6/2/26, indicated in part. Resident 66 had diagnoses of pain in right knee, pain in left knee, low back pain, and chronic pain syndrome. During a review of Resident 66's Physician Orders, dated 6/2/26, indicated to monitor pain level using the following scale; 0=No pain, 1-3=Mild, 4-6=Moderate, 7-10=Severe every shift. During a review of Resident 66's Physician Orders, dated 6/2/26, further indicated to give Norco 10-325 mg (a medication to relieve moderate to moderately severe pain) 1 tablet by mouth every 8 hours as needed (PRN) for moderate to severe pain. During a concurrent interview and record review on 6/4/26, at 2:51 p.m. with the assistant director of nursing (ADON), Resident 66's medical record was reviewed. Resident 66's medication administration record (MAR), dated 5/03/26, indicated Resident 66 received Norco 10-325, 1 tablet at 7:27 p.m. and the pain scale assessment was 7/10 (Moderate to Severe), prior to giving this medication. The MAR further indicated at 7:27 p.m., the follow-up code was Effective (E). Further review of Resident 66's Medication Administration Note dated 5/3/26 at 11:47 p.m., indicated the PRN administration was Effective and the follow-up pain scale was 0/10 (4 hours and 20 minutes later). The ADON verbalized if a resident is given pain medication, then the pain reassessment should be done within an hour and acknowledged the pain reassessment was late. Further review of the Medication Administrative Note did not indicate the location and or the type of pain. During a concurrent interview and record review on 6/4/26, at 2:55 p.m. with the ADON, Resident 66's medical record was reviewed. Resident 66's medication administration record (MAR), dated 5/27/26, indicated Resident 66 received Norco 10-325, 1 tablet at 3:57 p.m. and the pain scale assessment was 7/10 (Moderate to Severe), prior to giving this medication. The MAR further indicated at 3:57 p.m., the follow-up code was Effective (E). Further review of Resident 66's Medication Administration Note dated 5/28/26 at 12:09 a.m., indicated the PRN administration was Effective and the follow-up pain scale was 0/10 (8 hours and 12 minutes later). The ADON acknowledged the pain reassessment was late and further verbalized the facility policy does not indicate a time frame when pain should be reassessed. Further review of the Medication Administrative Note did not indicate the location and or the type of pain. During a review of the facility's policy and procedure (P&P) titled, Pain Management dated 4/2012, the P&P indicated in part. Purpose: the facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by: screening to determine if the resident has been or is experiencing pain.comprehensively assessing the pain.Procedures: Assessment: 1. The resident will be assessed for pain: B. Any change from the initial pain assessment form to reflect the resident's current pain status will be reflected in the plan of care thereafter.C. Every shift recorded on the MAR.D. Upon development of new symptoms of acute or chronic pain that has not been previously assessed. 3. During an observation and concurrent interview with Resident 45 on 6/2/26 at 10:21 a.m. in room [ROOM NUMBER]B, Resident 45 expressed concerns about the timing of the insulin he receives from the nursing staff that they give it to him after he had eaten. During a review of Resident 45's clinical record (CR), this indicated, Resident 45 was admitted to the facility with diagnoses including but not limited to diabetes mellitus type 2 (chronic metabolic disease characterized by high blood sugar). A review of Resident 45's quarterly MDS (a comprehensive assessment tool) assessment, dated 2/27/26, indicated Resident 45 was cognitively intact. A review of resident 45's order summary report (active orders) indicated physician order for the following medications: 1) Lispro (fact-acting) insulin to be injected subcutaneously (SQ) before meals per sliding scale. The sliding scale directed the following doses based on finger stick blood sugar measurements: 0-150: 0 units (u); 151-200: 2 u; 201-250:1u; 251-300:2u; 301-350:3 u; 351-400:4u; 401+:5u; below 80 and above 400 notify MD. 2) Lispro (fact-acting) insulin 3 units to be injected SQ with meals. 3) Lispro (fact-acting) insulin to be injected SQ at bedtime per sliding scale. The sliding scale directed the following doses based on finger stick blood sugar measurements: 0-200: 0 u; 151-200: 2 u; 201-250:1u; 251-300:2u; 301-350:3 u; 351-400:4u; 401+:5u; below 80 and above 400 notify MD. 4)Lantus (long-acting) insulin 12 units to be injected SQ every 12 hours. A review of the mealtime hours for station 2, where Resident 45's room was located, revealed the following mealtimes: Breakfast at 7:35AM, lunch at 12:15 PM, and dinner at 5:00 PM. A review of Resident 45's electronic medication administration record (eMAR) dated 6/2026, this indicated: -Lispro insulin before meal injection solution was scheduled at 0630, 1130 and 1630 hours. -Lispro insulin with meals injection solution was scheduled at 0715, 1215 and 1715 hours. -Lispro insulin at bedtime injection solution was scheduled at 2100 hour. -Lantus insulin every 12 hours injection solution was scheduled at 0900 and 2100 hours. A review of Resident 45's eMAR-location of administration report indicated that the Lispro insulin with meals injection solution scheduled at 07:15 a.m. on 6/1/26 was administered at 09:34 a.m. and the Lispro insulin with meals injection solution scheduled at 07:15 a.m. on 6/2/26 was administered at 10:40 a.m., which were administered more than two hours of the scheduled time. During a concurrent interview and record review with the assistant director of nursing (ADON) on 6/5/26 at 4 p.m., the ADON confirmed that the administration of Resident 45's Lispro insulin was more than two hours after the scheduled time, when it should have been administered with meals as ordered. During a review of the facility's policy and procedure (P&P) titled Medication Administration revised 2/2009, the P&P indicated, .Special time meds must be given as close to the scheduled time as possible. You do NOT have a two (2) hour window for these meds. Examples: 1.AC meals, 2. PC meals, 3. With meals.

Based on observation, interview, and record review, the facility failed to ensure an accurate, effective system for monitoring parameters of nutritional status when the quantity of consumption for therapeutic (to cure or restore to health) liquid nutritional supplements were not documented for one of five sampled residents (Resident 10). This facility failure of not documenting the accurate amount of therapeutic supplements taken had the potential to ineffectively evaluate nutritional interventions and delay an alternative nutrition approach, if necessary, to help prevent or minimize a potential negative outcome and possible continued weight loss for Resident 10. Findings:During an interview on 6/2/26, at 10:40 a.m., with Resident 10, Resident 10 verbalized having weight loss for some unknown reason. Resident 10 verbalized eating her meals and is taking supplemental calorie shakes. During a review of Resident 10's Physician Orders, dated 6/2/26, indicated to give Resident 10.Ensure one time per day for supplement 237 cc (or 8 fluid ounces) by mouth.to give House Supplement two times a day for nutritional support 4 fluid ounces by mouth with lunch and dinner.During a review of Resident 10's Physician Orders, dated 6/2/26, indicated to record Resident 10's intake each shift: record daily intake in ml/cc.During a review of Resident 10's Care Plan for Nutrition indicated in part. Resident 10 is at an increased risk for malnutrition or potential nutritional problem related to: at risk for weight loss, dehydration, fluid and electrolyte imbalance due to polypharmacy, dysphagia, and therapeutic diet.On 1/7/26 Nutrition/Hydration Annual: Medium Risk 5.0.On 2/10/26 Resident 1 weight was 139 pounds.On 4/10/26 Resident 1 had weight loss and was 133 pounds.On 5/20/26 weight loss was 127 pounds.in three months had 8.6% weight loss.Interventions indicated in part.Ensure one time a day for supplement of 237 cc (or 8 fluid ounces) by mouth.House Supplement with meals for nutritional supplement Vanilla flavor.if eats less than 75%, offer meal replacement.monitor and report to physician for any signs and symptoms of decreased appetite and unexpected weight loss.monitor/record/ report to physician signs and symptoms of malnutrition and significant weight loss.provide, serve diet as ordered. Monitor intake and record each meal.House supplement BID (twice a day) for nutritional support.During a review of Resident 10's Nutritional Interdisciplinary Team Update dated 5/20/2026, indicated in part. Resident 10 weight 127, 8.6 % weight loss in three months, average meal intake 51-100% . Progress: lost 4 pounds in a week, and had a significant weight loss of 12 pounds in three months and 20 pounds in 6 months.po (by mouth) intake is fair getting multiple supplement.recommended continuing with current plan of care, nursing to encourage po intake of meals and supplements.will continue to monitor po intake and weights.During a review of the facility's policy and procedure (P&P) titled, Weight Change Protocol dated 2023, the P&P indicated in part. Early identification of a weight problem and possible causes can minimize complications.the following criteria define significant or insidious weight changes.7.5% weight loss or gain in 3 months.the facility RD will assess, nutritionally diagnosis, suggest interventions, monitor, and evaluate the success of the interventions.Assessment: Nutrition content of the diet provided and percent of intake for multiple days.calculate energy, protein, and fluid needs using parameters as in the initial assessment.Determine if the: diet order is appropriate to meet the goal.intake of the resident will be sufficient to meet needs or goals.Interventions: Diet supplementation (preferred between meals unless requested with meals).Monitors: a care plan is to be developed stating the problems, the goal, and the approaches, interventions to accomplish the goal.Evaluation: the evaluation process is done again if there is another significant weight change. interventions are changed if not effective.The facility policy does not address documenting the amount (cc/ml) of therapeutic supplement consumed by the resident.During a review of the Journal of the Academy of Nutrition and Dietetics, titled Academy of Nutrition and Dietetics: Revised 2022 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient and Expert) in Adult Weight Management, dated 2022, indicated under the Nutrition Monitoring and Evaluation Standard 4, the Registered Dietitian (RD) evaluates the impact of the sum of all interventions on overall resident outcomes and goals. It further indicated under Standard 6.3 that the RD evaluates the effectiveness when they participate in evaluation and selection of new products (eg. Nutritional supplements, dietary supplements.). During a review of Resident 10's Meal Intake Record dated 6/1/2026-6/4/2026 indicated:On 6/1/26 at 11:06 a.m. 76%-100% was percentage of meal eaten.On 6/1/26 at 11:06 a.m. 76%-100% was percentage of meal eaten.On 6/1/26 at 9:09 p.m. 76%-100% was percentage of meal eaten.On 6/2/26 at 12:11 p.m. 76%-100% was percentage of meal eaten.On 6/2/26 at 1:55 p.m. 76%-100% was percentage of meal eaten.On 6/2/26 at 6:37 p.m. 76%-100% was percentage of meal eaten.On 6/3/26 at 7:30 a.m. 76%-100% was percentage of meal eaten.On 6/3/26 at 12:00 p.m. 76%-100% was percentage of meal eaten.On 6/3/26 at 5:30 p.m. 76%-100% was percentage of meal eaten.On 6/4/26 at 10:13 a.m. 76%-100% was percentage of meal eaten.On 6/4/26 at 2:05 p.m. 76%-100% was percentage of meal eaten. No differentiation of meal intake versus Ensure and House Supplement intakes. During a review of Resident 10's Intake and Output Record dated 6/1/2026-6/4/2026 indicated:On 6/1/26 on Day shift was 560 cc/ml fluid intakeOn 6/1/26 on PM shift was 550 cc/ml fluid intake On 6/1/26 on Night shift was 100cc/ml fluid intake On 6/2/26 on Day shift was 580 cc/ml fluid intakeOn 6/2/26 on PM shift was 600 cc/ml fluid intakeOn 6/2/26 on Night shift was 380 cc/ml fluid intakeOn 6/3/26 on Day shift was 540 cc/ml fluid intakeOn 6/3/26 on PM shift was 600 cc/ml fluid intakeOn 6/3/26 on Night shift was 260 cc/ml fluid intakeOn 6/4/26 on Day shift was 540 cc/ml fluid intake No differentiation of fluid intake versus Ensure and House Supplement intakes. During an interview on 6/4/26, at 3:45 p.m., with the registered dietician (RD), the RD was asked about documenting the intake of therapeutic supplements in Resident 10 's medical record. The RD verbalized therapeutic supplements do not have a separate documentation in the medical record. The RD verbalized the medication administration record (MAR) indicates the supplements are given to the resident. The RD verbalized the amount of therapeutic supplement intake is recorded with the total % of meal intake, however the documentation does not differentiate between the meal and the supplement. When asked how do you know or determine the therapeutic supplementation is effective when not knowing the total amount/quantity (cc/ml's) of supplementation consumed, the RD verbalized the resident lets me know if taking the supplements. The RD verbalized the kitchen staff let me know if supplements are being wasted. The RD further verbalized there is no documentation in the medical record on the quantity consumed of the therapeutic supplement by the resident. The RD further acknowledged there is no process for documenting the amount of PO (by mouth) intake of the therapeutic supplementation.During a review of the Academy of Nutrition and Dietetics Nutrition Care Manual (NCM), dated 2025, the NCM indicated in part. The amount and type of food, fluid, supplement and/or enteral [providing nutrition through a tube] or parenteral [providing nutrition through a vein] intake or infusion amounts should be monitored closely to ensure that the patient is meeting their nutritional requirements. These foods and liquids must be counted as part of daily fluid intake. Examples of fluids include the following: .oral nutritional supplements.For patients receiving oral nutritional supplements, supplement acceptance and tolerance should be documented in the medical record. Frequently and carefully monitor body composition including measured weight, weight change, body mass index and the ability to meet nutrition needs orally. Without appropriate monitoring by the RDN, patients can experience delayed wound healing and/or worsening of nutritional status.

Based on observation, interview, and record review, the facility failed to follow proper infection control practices and maintain a safe, and sanitary environment when:1.One staff member was observed feeding two residents at the same time. 2.One staff member was observed handling resident food with bare hands. 3.Three direct care staff were observed not adhering to proper hand hygiene. These facility failures had the potential for cross contamination of microorganisms and had potential to spread infection to residents and jeopardizing the quality and safety of care. Findings: 1.During an observation on 6/3/26, at 12:00 p.m., in the main dining room, a certified nurse assistant (CNA 1) was observed feeding two residents at the same time. CNA 1 was using bare hands to touch utensils and feed one resident (Resident 83), then using same bare hands to touch the other resident's utensils (Resident 22) and proceeded to feed that resident. CNA 1 continued to feed both residents using bare hands. During a concurrent observation and interview, on 6/3/26, at 12:07 p.m., in the main dining room, with the registered dietician (RD), the RD was informed of CNA 1 using bare hands to feed both residents and touching both utensils without using gloves or hand hygiene in between. The RD observed and acknowledged that this could be cross contamination and verbalized CNA 1 should only be feeding one resident at a time. During an interview on 6/4/26, at 9:24 a.m., with the infection preventionist (IP), the IP was informed of CNA 1 feeding two residents at the same time using bare hands. IP verbalized the staff should be feeding one resident at a time. During a review of the facility's policy and procedure (P&P) titled, Meal Service, Nursing Responsibilities dated 1/2026, the P&P indicated in part.To Insure accurate and safe meal service.Procedures: 8. Assist resident with the dining process as needed. If indicated the resident will need assistance or encouragement with the meal, staff are to provide the necessary assistance and encourage meal and liquid intake. If resident needs to be spoon fed by staff, staff must sit next to resident and personalize the assistance as much as possible. One staff member to feed one resident. 2.During an observation on 6/2/26, at 11:55 a.m., in the main dining room, an assistant (Assist 1) was observed using bare hands to handle a resident's toast. During an interview on 6/4/26, at 9:25 a.m., with the infection preventionist (IP), the IP was informed of Assist 1 using bare hands when handling a resident's toast. The IP verbalized Assist 1 should not be touching food with bare hands and should have worn gloves. During a review of the facility's policy and procedure (P&P) titled, Food Handling undated, the P&P indicated in part. Food will be prepared and served in a safe and sanitary manner.Procedure: Food & Nutrition Services personnel should never use bare hand contact with any foods, ready to eat or otherwise. 3.During an observation on 6/2/26 at 10:56 a.m., Staff 1 was seen waiting inside room [ROOM NUMBER]A as Staff 2 wheeled patient 137 into the room. The room had a washing station, and hand sanitizer is hanging on the left side (outside) of the door. Staff 1 and Staff 2 were heard discussing how to safely transfer Resident 137 from wheelchair to bed while referring to the caregiver alert instructions placed on the wall. Staff 2 wheeled out Resident 137 and requested assistance with the transfer from another staff member (Staff 3). Staff 1 and Staff 2 donned gloves without washing or sanitizing their hands. Staff 3 arrived to help with the transfer of the resident from wheelchair to bed, and Staff 2 offered Staff 3 with a couple of green gloves. Staff 3 donned gloves without washing his hands first. Staff 1, Staff 2, and Staff 3 used the Hoyer lift to transfer resident 137 to the bed. Staff 1 remained with Resident 137 and was seen wearing and removing gloves without washing or sanitizing her hands while carrying out resident's care. During an interview with the assistant director of nursing (ADON) on 6/5/26 beginning at 4:09 p.m., this finding was discussed and confirmed with the ADON. During a review of the facility's policy and procedure (P&P) titled Infection Prevention-Hand Hygiene undated, the P&P indicated, .This facility considers hand hygiene the primary means to prevent the spread of infection.Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap.and water.before and after contact with residents.before donning sterile gloves.after removing gloves.the use of gloves does not replace hand washing/hand hygiene.

Based on observation and interview, the facility failed to maintain a safe and sanitary environment by ensuring the dining area corridor wall was intact, dry, and free of insects. This facility failure placed residents at risk of exposure to mold from humid or wet walls, which also attracted insects. Findings: During a concurrent observation and interview on 3/4/25 at 10:50 a.m. with charge nurse (CN) in the facility ' s dining corridor, a hole was observed on the wall of the corridor leading from the dining room to the medical records office. The bottom wall siding was detached from the wall creating an opening between the siding and the base of the wall. Several ants were observed going in and out of the hole through the opening in the damaged wall. There was visible damage on the wall area close to the corner. The wall damage was partially obscured by a lift device parked nearby. CN who was present at the time of the observation, confirmed the wall was damaged. CN was asked how long the wall had been damaged. CN stated I don ' t know. I had not noticed that before. During another concurrent corridor wall observation and interview with facilities director (FD) on 3/4/25 at 11:56 a.m., part of the wall had been opened exposing the inside of the wall where the material was observed to be wet. The inside material of the wall was touched and confirmed to be wet. The FD was asked the reason the inside of the wall was wet. FD stated, I don't know, we are working on it. The FD was asked to touch the inside of the wall to confirm the inside of the wall was wet. FD replied Yes, it's wet. But I don't know why, we are working on it. During an interview with the director of nursing (DON) on 3/4/25 at 1:05 p.m., DON was notified of the wet wall problem and concerns of mold inside the wall and the concern of ants observed going in and out of the hole through the damaged wall area. The DON acknowledged and confirmed the corridor wall was damaged with a hole or there's an open area on the wall.During further observation the damaged area was observed to be not blocked or covered with some caution tape or labeling indicating work repair is ongoing . The DON stated We are fixing it. We knew about it.

Based on record review and interview, the facility failed to; 1. Ensure the attending physician (MD1) for one of two sampled residents (Resident 1) conducted a review of resident's medications at each visit. 2. Ensure Resident 1's physician (MD 1) wrote, signed, and dated a progress note at each visit and note was in the resident's medical record. The facility's failures resulted in the physician's progress notes being inaccurate. Findings: 1. A review of the facility policy titled History and Physical, Physician Progress Notes, NP/PA Documentation, dated 11/24, indicated The physician should review the resident's total program of care, including medications . at each visit. During a concurrent review of Resident 1's medical record and interview with the medical records supervisor (MRS) on 3/4/25 at 12:05 p.m., the MRS was asked to provide all the providers (physician, NP, PA) visit notes for the year 2024. A review of MD 1 progress notes, dated 1/8/24, 4/3/24, 6/11/24, 8/14/24, 10/16/24, 1/15/25, and 2/14/25. The seven (7) progress notes indicated the resident was on the following medications: amlodipine (blood pressure B/P medication) 5 milligrams (mgs) tablet, amlodipine 5mg- benazepril 20 mg capsule by mouth daily, cephalexin (antibiotic) 250 mg capsule by mouth 4 times daily for 5 days, clonazepam (sedative) 0.5 mg tablet by mouth twice daily as needed, escitalopram (antidepressant) 10 mg tablet, furosemide (diuretic) 20 mg tablet by mouth once daily, gabapentin (anticonvulsant) 100 mg capsule by mouth twice daily, lisinopril (lowers B/P) 20 mg tablet, nitrofurantoin monohydrate/macrocrystals (antibiotic) 100 mg capsule by mouth twice daily, and sulfamethoxazole 800mg -trimethoprim 160mg (antibiotic) tablet by mouth every 12 hours. The nurse progress note, dated 2/26/24 at 7:45 p.m., indicated [psychiatrist's name] obtained new consent for increased dosage of Buspirone (antianxiety). The nurse progress note, dated 2/8/24 at 10:16 p.m., indicated [MD1's name] with order for the following: fleet enema insert one application rectally every 8 hours as needed for constipation if Dulcolax suppository not effective. Milk of magnesia suspension 400mg/5ml give 30 ml by mouth as needed for constipation. The nurse progress note, dated 2/6/24 at 6:38 p.m., indicated Received telephone order to clarify indication to Buspirone HCI tablet 5 mg give one tablet by mouth three times a day for anxiety. The nurse progress note, dated 3/27/24 at 6:39 p.m., indicated Received order from [physician's name] for vitamin D25, folate, vitamin B12 . The intradisciplinary team (IDT) note, dated 3/28/24 at 6:13 p.m., indicated Resident had an appointment with [physician's name] yesterday and receive additional orders for Valium (muscle spasms) 2.5 mg PO BID . [MD1's name] notified and receive telephone order for tomorrow Valium 2.5 mg by mouth two times a day . The nurse progress note, dated 4/23/24 at 8:09 a.m., indicated Received order from [MD1's name] to increase vitamin D 2000 units to BID. The nurse progress note, dated 4/23/24 at 8:41 p.m., indicated [MD1's name] with new order Buspirone HCl oral tablet 10 mg, give one tablet by mouth two times a day for anxiety. The nurse progress note, dated 5/1/24 at 12:45 p.m., indicated Received order from [MD1's name] for cipro (antibiotic) 250mg for five days R/T UTI. During a telephone communication with the director of nursing (DON) on 4/3/25 at 3:56 p.m., the DON was notified that upon review of Resident 1's physician's progress notes, the physician had not reviewed, documented and updated the medications the resident was taking, on his visit progress notes. All of the seven (7) progress notes had the same medications documented which was incorrect because resident's medications had changed throughout last year. DON acknowledged and stated Ok. 2. A review of the facility policy titled History and Physical, Physician Progress Notes, NP/PA Documentation, dated 11/24, indicated physician progress notes must be written, signed, and dated with each visit . at least every 30 days for the first 90 days after admission and at least once every 60 days thereafter. During a concurrent review of Resident 1's medical record and interview with the medical records supervisor (MRS) on 3/4/25 at 12:05 p.m., the MRS was asked to provide all the providers (physician, NP, PA) visit notes for the year 2024. The MRS reported there are no physician progress notes for 2024 in hard copy of the medical record nor in the electronic medical record, for this resident. The MRS contacted the physician (MD1) over the phone to asked physician to send the resident's visit notes for the entire year of 2024 to the facility. During a telephone interview with Resident 1's physician (MD1) on 3/4/25 at 12:15 p.m., MD 1 confirmed he had not sent any of resident's visit progress notes for the entire year of 2024, to the facility. MD 1 reported he uses a system at his office to create and stored the resident's visit progress notes. MD 1 was asked if the facility MRS have access to that system to print out the resident's progress notes. MD 1 replied No, he does not. Communicated to MD 1 the facility needed to have the resident's physician's progress notes after the visit. MD 1 stated Yes, I know. I know. Yes, I agree. My progress notes need to be in the resident's record after each visit. I will send them now, all notes for 2024, for [MRS's name] to print them out for you. During another interview with the MRS on 3/4/25 at 2:35 p.m., MRS handed over some papers indicating these were all the 2024 physician notes. The papers consisted of physician's notes dated 1/8/24, 4/3/24, 6/11/24, 8/14/24, 10/16/24, 1/15/25, and 2/14/25. The MRS was asked again, if these were all the physician's notes, for this resident, for the year 2024. MRS confirmed and stated Yes, these are all of them for 2024. This is all [MD 1's name] sent me. A review of the physician progress note, dated 1/8/24 at 4:00 p.m., indicated the note was created/encounter performed, documented, reviewed and signed by [MD 1's name] on 3/4/25 at 1:14 p.m. The amendment was closed by [MD 1's name] on 3/4/25 at 1:19 p.m. A review of the physician progress note, dated 4/3/24 at 3:00 p.m., indicated the note was created/encounter performed, documented, reviewed and signed by [MD 1's name] on 3/4/25 at 1:32 p.m. A review of the physician progress note, dated 6/11/24 at 2:00 p.m., indicated the note was created/encounter performed, documented, reviewed and signed by [MD 1's name] on 3/4/25 at 1:44 p.m. A review of the physician progress note, dated 8/14/24 at 11:00 a.m., indicated the note was created/encounter performed, documented, reviewed and signed by [MD 1's name] on 3/4/25 at 1:59 p.m. A review of the physician progress note, dated 10/16/24 at 8:00 a.m., indicated the note was created/encounter performed, documented, reviewed and signed by [MD 1's name] on 3/4/25 at 2:07 p.m. A review of the physician progress note, dated 1/15/25 at 8:00 a.m., indicated the note was created/encounter performed, documented, reviewed and signed by [MD 1's name] on 3/4/25 at 2:24 p.m. A review of the physician progress note, dated 2/14/25 at 2:00 p.m., indicated the note was created/encounter performed, documented, reviewed and signed by [MD 1's name] on 3/4/25 at 2:27 p.m. During a telephone communication with the director of nursing (DON) on 4/3/25 at 3:56 p.m., the DON was notified that upon review of Resident 1's physician's progress notes, notes had discrepancies as to when the notes were performed. The DON said OK.

Based on record review and interview, the facility failed to ensure one of two sampled residents (Resident 1) physician conducted visits at least once every 60 days and timely within the 10 days of the required date of the visit. The facility ' s failure resulted in the resident not being evaluated timely thus potentially having a negative outcome. Findings: During a concurrent review of Resident 1 ' s medical record and interview with the medical records supervisor (MRS) on 3/4/25 at 12:05 p.m., the MRS was asked to provide all the providers (physician, NP, PA) visit notes for the year 2024. The MRS reported none of the physician ' s visit notes were in the medical record, for this resident. The MRS contacted the physician (MD1) over the phone to asked physician to send the resident ' s visit notes for the entire year of 2024 to the facility. During another interview with the MRS on 3/4/25 at 2:35 p.m., MRS handed over some papers indicating these were all the 2024 physician notes. The papers consisted of physician ' s notes dated 1/8/24, 4/3/24, 6/11/24, 8/14/24, 10/16/24, 1/15/25, and 2/14/25. The MRS was asked again, if these were all the physician ' s notes, for this resident, for the year 2024. MRS confirmed and stated Yes, these are all of them for 2024. This is all [MD 1 ' s name] sent me. A review of the physician ' s visit notes indicated the physician visited the resident on 1/8/24 and then on 4/3/24, the timeframe between visits was 86 days apart. Further review of the visit notes indicated the physician visited the resident of 10/16/24 and then on 1/15/25, the timeframe between visits was 91 days apart. During a concurrent review of the facility policy titled History and Physical, Physician Progress Notes, NP/PA Documentation, dated 11/24 and interview with the director of nursing (DON) on 3/4/25 at 3:43 p.m., the policy indicated physician progress notes must be written .each visit . at least every 30 days for the first 90 days after admission and at least once every 60 days thereafter. DON acknowledged and confirmed residents shall be seen or visited at least once every 60 days and a progress note must be written with each visit.

Based on interview and record review the facility failed to ensure an identified pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) with care issues was assessed and documented for one of two sampled residents (Resident 2). This failure had the potential to impede the treatment and interventions of the existing pressure ulcers which can result in deterioration affecting the overall medical condition of Resident 2. Findings: Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 243 in the section titled, Data Documentation indicates, Observation and recording of client status is a legal and professional responsibility. The nurse practice acts in all states and the American Nurses Association Nursing's Social Policy Statement (2003) mandate, or require, accurate data collection and recording as independent functions essential to the role of the professional nurse. During a review of Resident 2's medical record, the following were identified. 1. Right buttock pressure ulcer identified on 8/10/24 was not assessed. During an interview and concurrent record review on 3/11/25 at 1:56 p.m. with the assistant director of nursing (ADON) and treatment nurse (TN), Resident 2's LN (Licensed Nurse) Skin Ulcer Non-Pressure Weekly dated 7/21/24 through 8/15/24 were reviewed. No assessment for the right buttock pressure ulcer identified on 8/10/24 was located. Both the ADON and the TN1 confirmed, The initial LN-Skin Ulcer Non-Pressure Weekly of Resident 2's right buttock skin pressure injury/pressure ulcer discovered 8/10/24 was not done and should have been done. 2. Incomplete assessments of pressure ulcers identified from 8/10/24 to 8/15/24. During an interview and concurrent record review on 3/11/25 at 2:14 p.m. with TN, Resident 2's LN-Skin Ulcer Non-Pressure Weekly dated from 7/21/24 through 8/15/24 indicated, aside from the right buttocks pressure ulcer identified on 8/10/24, additional pressure ulcers were identified on the Resident 2's left buttocks and sacrum (tailbone). The LN-Skin Ulcer Non-Pressure Weekly dated 8/15/24 indicated, no staging of the type and depth of wound, measurements, drainage, odor, wound edges, and surrounding tissue were assessed for Resident 2's pressure injuries on the right and left buttocks and sacrum (tailbone). TN indicated, The 8/15/25 LN-Skin Ulcer Non-Pressure Weekly nursing assessment of Resident 2's right and left buttock and sacrum were not staged and the assessments were not done correctly. 3. Resident 2 refused to be turned and repositioned. During a concurrent interview and record review on 3/11/25 at 2:14 p.m. with the director of nursing (DON), Resident 2's Progress Notes dated 7/21/24 through 8/19/24 indicated Resident's refusal to be turned. The DON acknowledged writing the progress notes dated 8/19/24, which directed staff to encourage Resident 2 to turn and reposition in response to their refusal. Further review of the Progress Notes indicated no assessments were located or documented about Resident 2's refusal to turn and reposition. When DON was asked about the missing assessments, no answer was offered. During a review of the facility's policy and procedure titled, Nursing Assessment, Ongoing dated 1/2011, indicated in part, It is the policy of this facility to ensure each resident receives nursing services that include .continuing assessment of patient needs with input as necessary from health professionals involved in the care of the patient .The initial nursing assessment shall commence at the time of admission of the resident .The ongoing nursing assessment of the resident shall be written as often as the resident's condition warrants and shall include, but is not limited to: . increased problems that may cause injuries to self and others. Also, during a review of the facility's policy and procedure titled, Pressure Ulcers-Prevention and Management dated revised 11/2019, and accompanying, FAQ: Pressure Injury Staging* Hints & Tips dated 11/2020, indicated in part, Procedures: 1. Resident Assessment . B. Identify Risk factors such as: Resident refusal of some aspects of care and treatment . Skin assessment .change in condition recognized, evaluated, reported and addressed. C. Every week, each area will be evaluated, measured and documented on the Pressure Ulcer/Non-Pressure Ulcer record. D. It is the responsibility of the Treatment Nurse to do weekly measurements .2. Prevention Stabilize, reduce or remove underlying risk, monitor impact of interventions and modify interventions as appropriate . A. Repositioning .G. Documentation . H. Treatment .

Based on observation, interview, and record review the facility failed to ensure: 1. One of 25 sampled residents (Resident 624) was treated with dignity (the feeling of being valued and respected as a person) and respect, during and after a room change. This failure had the potential to negatively affect Resident 624's sense of self-worth and care needs to go unmet. 2. One resident (Resident 31) was free of foul body odor. This failure had the potential to violate resident 31's rights to receive quality care and freedom from neglect. Findings: 1. During a concurrent observation and interview, on 2/6/25, at 5:12 p.m., inside Resident 624's room, with Resident 624's family member (Fam 1), the Fam 1 was visibly upset, shaking and in tears. Resident 624's call light was observed hanging on the wall above Resident 624's bed and out of reach. Resident 624's belongings were also observed on a bedside table and out of reach by Resident 624. The Fam 1 verbalzied Resident 624 had been moved to a new room and facility staff had left Resident 624 in the new room, with the call light and personal belongings out of Resident 624's reach. The Fam 1 stated You don't treat a human like this, [Resident 624] cannot speak for [Resident 624], and Resident 624, was left like this, unable to call for help, if she needed it. During an interview on 2/6/25, at 5:12 p.m., with the Housekeeping Supervisor (HS) and Director of Staff Development (DSD), inside Resident 624's room, the HS confirmed Resident 624's call light was out of reach and verbalzied the call light should have been within reach of Resident 624. The HS verbalized housekeeping staff had moved Resident 624 into the room and not nursing staff. The DSD verbalzied it was not facility practice for staff to leave personal items out of reach of residents after a room change. During a concurrent record review and interview on 2/7/25, at 2:00 p.m., with the Director of Nursing (DON), the job description for housekeeping staff was reviewed. The job description for housekeeping staff did not indicate moving/transporting residents to different rooms was a duty/task for housekeeping staff to perform. The DON verbalized it was not in the job description for housekeeping staff to move residents, it was a nursing task. During a review of the facility's policy and procedure titled Nursing Clinical subject Call Light/Bell undated, indicated in part Leave the resident comfortable. Place the call device within resident's reach before leaving room. During a review of facility's policy and procedure titled, Resident Rights, dated 09/2007, indicated, POLICY: It is the policy of this facility that Social Services assures that the facility respects each Resident Rights . 3. Resident in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of other residents would be endangered. 50657 2).During a concurrent observation and interview on 02/05/25 at 10:29 a.m., inside the resident's room, Resident 31 was in bed, on flat position, awake, with head of bed (HOB) flat. The resident was noted with a hospital gown on, stained with food on the front area. Food stains were also noted on the sheets covering the resident from waist down. Resident's hair was tangled, and a pungent urine, musty, and sour unpleasant odor could be smelled from outside to inside of Resident 31's room. Resident 31 stated, I refused to be showered , I prefer bed baths, but had none in several days. During a review of the medical record for Resident 31, the Care Plan (CP), dated 08/30/22, indicated, the resident requires maximum assistance for bed mobility, showers totally dependent (TD),and toileting , hygiene were also totally dependent on staff. During a review of the facility record titled Task Bathing dated 1/7/25 to 2/5/25 indicated on 2/5/25 at 10: 30 a.m. Resident 31 received a sponge bath. During an interview on 02/05/25 at 11:12 a.m., with certified nursing assistant (CNA5), who was outside Resident 31's room, CNA 5 acknowledged the presence of a strong, foul odor permeating to the outside of Resident 31's room. CNA 5 indicated not knowing if Resident 31 received a bed bath in the morning. During an observation and interview with Resident 31 inside the resident's room on 2/5/25 from 10:29 a.m., to 12:00 p.m., no bed baths were noted to be administered to the resident, contrary to what was recorded /documented on the facility record titled Task Bathing. During an interview with the facility's shower technician (ST) on 2/5/25 at 11:31 a.m., when was Resident 31 last showered, ST indicated not remembering when was the resident last showered. ST further indicated not giving bed baths, and it's the CNAs tasks to do so.

Based on observation, interview and record review, the facility failed to ensure a physician order of renal diet no added salt (NAS) order did not have a salt packet on the lunch tray for one of one sampled resident (Resident 82) who was on dialysis treatment. This failure had the potential for Resident 82 to have fluid retention for an already compromised condition (dialysis). Findings: During an observation on 2/05/25 at 12:15 p.m. of the lunch tray check and distribution process, in the hallway outside of resident rooms, Resident 82's lunch tray had a packet of salt. Upon checking the tray card for Resident 82, the diet order indicated renal diet. During an interview on 2/06/25 at 9:40 a.m. with the Registered Dietician (RD), the RD acknowledged that Resident 82's diet order is renal, should be no added sodium (NAS) and should not have salt packets added to meals/on trays. During an interview on 2/06/25 at 11:30 a.m. with the Director of Staff Development (DSD) who was in charge of verifying the resident meal trays, the DSD stated the salt packet was not removed because the meal card did not indicate NAS. During a review of Resident 82's Order Summary (OS), dated 1/15/25, the OS indicated, Resident 82 was prescribed a renal NAS diet by the physician. During a review of the facility's policy and procedure (P&P) titled, Liberal Renal Diet, dated April 2024, the P&P indicated in part, The HPSI Liberal Renal Diet restrictions are based on current recommendations. Because the nutritional needs of kidney patients are often specific to the individual, this diet may not fit the needs of every kidney patient. In this this instance, a licensed and registered dietician should be consulted for an individualized assessment and recommendations.

Based on observation, interview and record review, the facility failed to ensure proper infection control was practiced when: 1. Staff did not wear Personal Protective Equipment (PPE - protective clothing, equipment, and supplies worn by healthcare workers to shield themselves from potential spread of disease such as a gown and gloves) when giving direct care to a resident on Enhanced Barrier Precaution (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes) and did not follow policy and procedure for removal of PPE for one of 25 sampled residents (Resident 624). 2. Staff did not label oxygen tubing and Intravenous (IV 5% Dextrose)- a tube inserted into a vein of a resident to administer fluids and medications directly into the bloodstream) tubing with date per facility policy for one of 25 sampled residents (Resident 49). 3. Respiratory care equipment was not stored in a manner to prevent cross contamination (accidently transferring harmful bacteria) for one of 25 sampled residents (Resident 467). These failures had the potential to result in cross contamination and spread infections to residents, compromising their wellbeing. Findings: 1.During an observation on 02/05/25 at 10:15 a.m. in Resident 624's room, with Occupational Therapist (OT) 2. Resident 624 had a sign on the door informing Resident 624 was on EBP and OT2 was observed assisting Resident 624 to sit up in bed and put shoes on resident without a gown (PPE). During an observation on 02/05/25 at 10:21 a.m. in Resident 624's room, with OT2 and Certified Nursing Assistant (CNA) 7. CNA7 came into Resident 624's room put on a gown, OT2 stated, Oh, I have to have a gown?. CNA7 asked another staff member in the hall for a gown and OT2 placed a gown on before continuing to assist resident into wheelchair and assist with oral hygiene. During an observation on 02/05/25 at 10:42 a.m. in Resident 624's room, with OT2 and CNA7. OT2 was observed stepping outside of Residents room and removed the gown, then proceeded to reenter Resident 624's room to place used gown in dirty bin. During and interview on 02/05/25 at 10:51 a.m. with OT2, OT2 stated she should have been wearing a gown at the start of direct care to Resident 624 and acknowledged that she was giving care without a gown prior to CNA7 handing her a gown. OT2 confirmed Resident 624 was on EBP due to indwelling urinary catheter (a tube placed inside the bladder to drain urine) and states that her gown should have been removed in the room prior to exiting Resident 624s room. During a review of facility policy and procedure titled, IPCP Standard and Transmission-Based Precautions, dated 10/2024, indicated, POLICY . to implement infection control measures to prevent and spread of communicable diseases and conditions. Enhanced Barrier Protection (EBP): expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities . PPE: The use of gown and gloves for high-contact resident care activities is indicated . i. Wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents. c. examples of high-contact resident care activities requiring gown and glove use for Enhance barrier Precautions include: Dressing . transferring, providing hygiene . 6. Implementation: . d. discarding PPE after removal, prior to exit of the room . 48668 2. During an observation on 2/4/25 at 10:21 a.m. Resident 49 was observed to be sleeping in bed with head slightly elevated, with nasal cannula tubing without label connected to oygen concentrator running at 2 liters per minute. There was an intravenous fluid IV 5% Dextrose running by gravity at 10-15 drops per minute, lines was observed to have label but without date and nurse's initial. During an interview on 2/4/25 at 10:30 a.m., certified nurse assistant (CNA6) confirmed there was no label on the oxygen tubing , and the label on the IV fluid did not have nurse's initial and there was no date making it impossible to know who and when the fluid was started. During the interview on 2/6/25 at 2:45 p.m. with the assistant director of nursing (ADON), ADON stated the tubings and IV fluids needed to be labeled dated and signed per policy. During a review of facility's policy and procedure (P&P), titled Oygen Therapy, dated 11/2024, P&P indicated it is the facility policy to administer oxygen in a safe manner, with weekly tubing changes and with appropriate labeling. During a review of facility's policy and procedure (P&P), titled Administration Set (undated), it indicated A label system shall be established to indicate time and date of the tubing change and initials of the nurse performing the procedure. 50707 3. During a review of Resident 467's Admission Record (AD), the AD indicated Resident 467 was admitted on [DATE] with diagnoses that include acute respiratory failure with hypoxia (a serious medical condition that occurs when the body doesn't receive enough oxygen) and chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). During an observation on 2/4/25 at 11:05 a.m., in Resident 467's room, a nasal canula was observed on top of an oxygen concentrator (a medical device used to deliver oxygen) exposed and not covered. Additionally, a nebulizer mask was observed on top of a nightstand exposed and not covered. During a concurrent observation and interview on 2/4/25 at 2:44 p.m., with Licensed Nurse (LN) 1, in Resident 467's room, a nasal cannula and a nebulizer mask were observed in the same placement as observed prior. LN 1 acknowledged the nasal canula and nebulizer mask are exposed and not covered. LN 1 stated they should be stored in a bag when not in use. During an interview on 2/6/25 at 10:52 a.m., with the Infection Preventionist (IP), the IP stated nasal cannulas and nebulizer masks should be stored in a plastic bag when not in use. During an interview on 2/7/25 at 11:34 a.m. with the Director of Staff Development (DSD), the DSD stated oxygen tubing and nebulizer masks should be placed in plastic bags when not in use. The facility was unable to provide a policy and procedure to address the proper storage of oxygen nasal cannula tuing and nebulizer mask when not in use.

Based on observation, interview, and record review, the facility failed to follow their cleaning policy and procedure (P&P) when: 1. A floor drain in the dry goods storage area and the floors were not maintained in a sanitary manner. 2. Two of two ice chests used to distribute ice to residents were not cleaned before and after use. These failures had the potential to cause food borne illness to a highly susceptible resident population. Findings: 1. During a concurrent observation and interview on 02/04/25 at 9:23 a.m., with the Registered Dietician (RD) and the Dietary Assistant Manager (DAM), extensive debris and grime was visible in and around the floor drain in the dry storage area. Produce (red tomatoes/a potato), food scraps, and trash debris were observed behind, and under, metal racks of the walk-in refrigerator in the dry storage area and behind the ice machine on the floor. DAM and RD acknowledged the drain was dirty and the floor in the walk-in refrigerator appeared like it had not been swept or mopped. During a review of the facility's policy and procedure (P&P) titled General Cleaning of Food & Nutrition Services Department, dated 2023, the P&P indicates in part 1. Floors must be mopped at least once per day. 2. Sweep floor, pushing all debris forward. 8. Mop under and around equipment, along the walls and in corners .Drains: 1. FNS staff should remove large debris as it accumulates . 2. During an observation of the posted Ice Container Daily Cleaning Log (ICDCL), dated for the month/year of February 2025, the ICDCL indicates no cleaning of ice chests was performed on 02/04/25 and 02/05/25. During a concurrent interview and record review on 02/06/25 at 9:55 a.m., with the Registered Dietician (RD) and the Dietary Assistant Manager (DAM), DAM reviewed the ICDCL, dated for the month/year of February 2025, and acknowledged the ice chest cleaning log was incomplete as it indicated the ice chests were not cleaned on 02/04/25 and 02/05/25. During record review of the facility's policy and procedure (P&P) titled Ice Chest Cleaning Procedure dated 2023, the P&P indicates All ice chests will be cleaned and sanitized before and after each use, and when contaminated or visibly soiled, using the following procedure.

Based on interview and record review, facility failed to ensure: 1. There was a physician's justification for the use of antianxiety medication Xanax (a medication used to help reduce symptoms of aniety disorders) for use beyond 14 days in one of three selected residents for unnecessary medication review (Resident 53). 2. A physician signature was completed on informed consents for psychotherapeutic medications for one of 25 sampled residents (Resident 85). These failures had the potential for Resident 53 to be on unnecesary medication Xanax and the potential for Resident 85 not being informed of their medications and the potential side effects of the psychotropic medications. Findings: 1. During a concurrent interview and record review on 2/5/25 at 11:00 a.m. the medication administration record (MAR) dated January 2025 indicated an order of Xanax 0.25 mg by mouth as needed for anxiety started on 12/17/24 with duration of 90 days. Infection Preventionist (IP) nurse, who is in charge of psychotropic monitoring stated last progress note received from the provider was dated 1/14/25 and there was nothing for February 2025 yet. During the exit conference on 2/7/25 at 5:00 p.m., the facility was given a chance to provide policy on use of as needed psychotropic medication but was unable to provide the right policy. Code of Federal Regulations (CFR) at section S483.45(e)(4) indicated PRN orders for psychotropic drugs are limited to 14 days. Except as provided in S483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. 49405 2. During a review of facility's policy and procedure titled, Use of Psychoactive Medications dated 05/2015, indicated in part, Requirements for use of Psychoactive Medication: When drugs are used to control behavior or to treat a disordered thought process, the following shall apply: . An Inform Consent [a patient agrees to take a medication after understanding its risks, benefits, and alternatives] shall be obtained by the prescriber . During a review of Resident 85's Facility Verification of Resident Informed Consent Psychotherapeutic Medications, indicated consents dated below did not have a signature from a prescribing Physician: - 02/03/25 for Xanax [a medication that produces a calming effect on the brain, which helps to reduce anxiety and promote relaxation] 0.25 mg [dose of medication], PO [abbreviation for oral route given by mouth] PRN [as needed] anxiety [mental health condition characterized by excessive worry, fear, and unease] panic attack AEB [abbreviation as evidence by] palpitation [sensations where a person feels their heartbeat pounding, racing, or fluttering in their chest or throat]. - 11/10/24 for Ambien [a medication that treats insomnia (a sleep disorder)] 10mg, PO at HS [bedtime]. - 07/23/24 for Ambien 10 mg. 10mg PO QHS [at bedtime] insomnia MB [manifested by] inability to sleep. - 07/22/24 for Ambien 5 mg QHS PRN (as needed) for Insomnia mb inability to sleep . During a concurrent interview and record review on 02/06/25 11:07 a.m. with Director of Nursing (DON), Facility Verification of Resident Informed Consent Psychotherapeutic Medications, dated 2/3/25, 11/10/24, 7/22/24 and 7/23/24 were reviewed. The Facility Verification of Resident Informed Consent Psychotherapeutic Medications for dates indicated there was no signature from a prescribing Physician. DON stated, there should be signature from a physician and confirmed that consents on dates listed were missing a physician signature.

Based on interview and record review, the facility failed to ensure an advance directive (AD - a written statement of a person's wishes regarding medical treatment) was noted in residents re-admission agreement for one of 25 sampled residents (Resident 85). This failure had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment and had the potential to cause conflict with Resident 85's wishes regarding health care. Findings: During review of Resident 85's medical record on 02/05/25 at 08:44 a.m., the medical record indicated that resident 85 was readmitted to facility on 07/05/24 and Resident 85's AD was completed and signed on 04/04/24. During a review of Resident 85's Re-admission Agreement dated 07/05/24, the re-admission agreement indicated Resident 85 did not have an AD on readmission 07/05/24. During a concurrent interview and record review on 02/06/25 at 10:30 a.m. with Director of Admission (DOA), Resident 85's Electronic Health Record (EHR) was reviewed. The EHR indicated Physician Orders for Life-Sustaining Treatment (POLST) was dated 11/14/23, Resident's AD was dated 04/08/24, resident readmission agreement dated 07/05/24 and signed by Resident 85 on 07/08/24. DOA confirmed that Resident 85 had an AD prior to re-admission to facility 07/05/24. DOA stated that the facilities re-admission agreement reinstates a legally binding contract that in part the resident acknowledges that all personal and identifying information and supplements attached accurately reflects the residents current personal and identifying information and the Readmission Agreement indicates that the resident does not have an AD on admission 07/05/24. During an interview on 02/06/25 at 11:47 a.m. with DOA, DOA stated, that resident had an AD dated 4/8/24 and was presented to facility on readmission 07/05/24. DOA confirms the re-admission paperwork did not reflect the resident had an advance directive on readmission and should have. During a review of the facility's policy and procedure titled, Physician Orders for Life Sustaining Treatment (POLST) dated 12/2009, indicated in part, The POLST form should be executed as part of the health care planning process and ideally is a complement to a resident's advance directive. A POLST does NOT replace an advance directive .

Based on observation, interview, and record review, the facility failed to: 1. Maintain two rooms in good repair, for one unsampled Resident (Resident 14) and one sampled Resident (Resident 87). 2. Monitor hot water temperature readings and air conditioner temperature recordings. These facility failure had the potential for Resident 14 and Resident 87 to not be provided with a homelike and comfortable environment and had the potential for resident health problems and poor well-being of residents. Findings: 1. During a concurrent observation and interview, on 2/4/25, starting at 11:14 a.m., with the Housekeeping Supervisor (HS), the Maintenance and Housekeeping Log was reviewed. The HS verbalized the logbook indicated there were no outstanding items that were in disrepair. During a tour of Resident 87's room an observation was made of a closet drawer unable to be opened. The HS confirmed the drawer could not be opened and verbalized it was off its track. In Resident 14's room an observation was made of a broken electrical outlet cover above Resident 14's bed. The HS verbalized the electrical outlet cover would need to be replaced. During a review of the facility's policy and procedure titled Safe and Homelike environment dated 12/23, indicated in part Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment. 2. During an interview on 02/04/24 at 3:48 PM with Maintenance Supervisor (MS) and Administrator (ADM), MS verbalized that the facility has no monitoring logbooks for hot water temperature and thermostat levels for air conditioning. During a review of Policies and Procedures (P&P) titled Hot Water Temperature dated 01/23 , the Hot Water Temperature indicated in part, standards for water temperatures in resident areas is 105 F minimum and 120 F maximum. Standards for water temperatures in Laundry and Kitchen is 140 F minimum and 160 F maximum. Take water temperatures in various resident rooms at the beginning, middle and the end of each water heater loop, various resident showers, dining rooms and handwashing sinks .make adjustments of the water heaters as needed During a review of P&P titled Air Temperatures dated 01/23, the Air Temperatures indicated in part, standards in resident areas indicate Heat to minimum of 68 F, Cool to comfortable range between 78-85 F. Measure air temperatures in various resident rooms and common spaces. Take temperatures in different rooms each day .adjust the thermostat as needed.

Based on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident #31), had a comprehensive care plan that included interventions (actions) for the refusal of sitting upright while eating. This failure had the potential for Resident 31 to choke on food or liquids which can result in aspiration and possibly death. Findings: During a review of Resident 31's Admission Record (AR), undated, the AR indicated admitted [DATE] with diagnoses including congestive heart failure (weakened heart with difficulty pumping blood throughout the body), chronic respiratory failure with hypoxia (not enough oxygen in the body causing shortness of breath), gastro-esophageal reflux disease (irritation of the food pipe lining causing symptoms such as burning pain), and cognitive communication deficit (a disorder that affects a person's ability to communicate). During a concurrent observation and interview on 02/04/25 at 3:42 p.m. with Resident 31 inside the resident's room, Resident 31 was awake, lying flat on the bed eating lunch by self. Resident 31 had spilled food and had food stains on resident's clothing and on the bed was noted. Resident 31 stated, I prefer eating lying down because of pain and difficulty breathing when sitting up. During a concurrent interview and record review on 02/04/25 at 3:51 p.m. with nurse supervisor (NS1), Resident 31's Care Plan (CP), dated 02/04/25 included resident refused to elevate HOB while eating on bed and at all time. No interventions to address the refusal to elevate the HOB while eating was located in the interventions of the CP. NS1 stated there were no nursing interventions in the care plan to educate the resident. During an interview on 02/04/25 at 4:10 p.m. with certified nurse assistant (CNA4), CNA4 stated [Resident 31's name] eats laying down all the time and the CNA's are instructed to place the meal trays in front of Resident 31's on bedside table. During an interview on 02/04/25 at 4:31 p.m. with licensed nurse (LN3), LN3 stated that Resident 31 refuses to eat upright because of pain. LN3 also stated, the resident eats laying down with the bed part flat all the time. During a review of Resident 31's medical record, no notes of physician notification of the resident 's refusal to sit upright while eating was located in the medical record. During an interview on 2/04/25 at 4:40 p.m. with the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Registered Dietician (RD), and the Director of Rehabilitation (DOR), DON, ADON, RD, and DOR indicated there are notes in the medical record about the physician being notified of Resident 31 refusal to eat upright and notes of the risks of eating lying flat were explained. During further record review no notes were located of the physician being notified of Resident 31's refusal to eat upright and no documentation that the risks of eating while lying down were explained to the resident and the resident representative from 1/26/24 to 2/4/25. During a concurrent interview and record review on 2/04/25 at 5:18 p.m. with the ADON, Resident 31's electronic medical record (eMR) was reviewed. The ADON was not able to produce documentation in the progress notes, care plan, interdisciplinary team meetings, or in the health and physical that addressed educating Resident 31 on the risks of eating while lying down. During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated 11/2024, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive Person-Centered Care Plan for each resident based on resident's needs to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to ensure there was monitoring for signs and symptoms of bleeding for a resident (Resident 53) who is on anticoagulant Eliquis (Medication that prevent or treat blood clots). This failure had the potential for Resident 53 to be unmonitored while on Eliquis, and have side effects of bleeding. Findings: During a concurrent interview and record review on 2/5/25 at 10:00 a.m. the medication administration record (MAR) dated January 2025, indicated an order of Eliquis 2.5 mg 1 tablet by mouth two times a day. There was no monitoring for signs of bleeding seen in the MAR. Minimum Data Set (MDS) coordinator verified that there was no monitoring for bleeding side effect found in the chart. During a review of facility's policy and procedure (P&P), titled Medication Management, dated May 2022, P&P indicated In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, attending physician, and the pharmacistperform ongoing monitoring for appropriate, effective, and safe medication use.

Based on observation, interview, and record review, the facility failed to dispose of expired medications per policy and procedure. This failure had the potential for expired medications to be administered to residents. Findings: During a concurrent observation and interview, on 2/6/25, starting at 8:53 a.m., with licensed nurse (LN 4), three expired medications were found in medication cart two. One vial of Latanoprost 0.005% solution (a medication used to treat high eye pressure) one vial of Prednisolone Acetate 1% (a medication used to relieve symptoms such as swelling and redness) and one vial of Brinzolamide 1% (a medication used to treat high eye pressure). All three medications had an expiration date of 2/4/25. The LN 4 verbalized all three medications were expired and needed to be placed in the waste container in the medication room. During a review of the facility's policy and procedure titled Nursing Administration subject Storage of Medications undated, indicated in part Expired medications will be removed from use, for appropriate disposal.