Every finding on record at Casa de las Campanas

Based on observation, interview, and record review, the facility failed to store food under sanitary conditions to prevent contamination when:Prepared potatoes were stored uncovered in the walk-in refrigerator.Raw chicken was not stored on the lowest shelf of the walk-in refrigerator and was stored above raw pork.As a result, food was at risk for contamination, putting residents at risk for foodborne illness.Findings: 1. During a kitchen observation and concurrent interview on 7/28/2026 at 8:45 AM with the executive chef (EC), a large container of cut yellow potatoes in water was stored uncovered in the walk-in refrigerator. The EC acknowledged the potatoes were not covered and stated prepared food should be covered to prevent contamination and reduce the risk of residents becoming ill. During an interview on 7/31/2026 at 1:35 PM, the registered dietitian consultant (RDC) stated prepared foods should be covered to prevent contaminants from falling into the food and should not be left exposed. A review of the facility policy titled, Labeling, Dating, and Storage Procedures, revised 8/24/25, indicated, Purpose: To ensure safe food handling, prevent foodborne illness, and maintain regulatory compliance by standardizing labeling, dating, and storage practices. Storage Requirements: Store in clean, sealed, food-safe containers; Cover/wrap all items tightly.2. During a kitchen observation and concurrent interview on 7/28/2026 at 8:45 AM with the executive chef (EC), a bin of raw chicken was observed on the second shelf from the floor in the walk-in refrigerator, above boxes of raw bacon. The bacon was stored in an open box and covered with paper. The EC acknowledged the raw chicken was not stored on the bottom shelf and was stored above the bacon. The EC stated raw chicken should always be stored on the bottom shelf and should not have been placed above the bacon because improper storage could contaminate food and cause residents to become ill.An observation and record review on 7/28/26 at 8:52 A.M., an undated facility policy posted on a refrigerator in the kitchen indicated raw foods should be stored according to type, with pork stored above poultry and poultry stored on the lowest shelf.During an interview on 7/31/2026 at 1:35 PM, the registered dietitian consultant (RDC) stated raw poultry should have been stored on the bottom shelf to prevent cross-contamination, and kitchen staff were responsible for checking food storage daily. During an interview on 8/04/2026, at 4:31 PM, the interim director of nursing (IDON) stated food service staff should follow food storage requirements, and that improper storage of raw chicken could result in infection.

Based on observation, interview, and record review, the facility failed to ensure medications were available and administered according to the physician's order for four of four residents (Resident 66, 71, 69 and 70) observed during medication administration.This deficient practice had the potential to affect the residents' health and wellbeing.Findings:A medication administration observation was conducted on 7/30/26 with Licensed Nurse (LN) 5.1. Resident 66 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (brain disorder that causes uncontrollable movements and difficulty with balance and coordination) according to the facility's admission Record.During medication preparation for administration on 7/30/26 at 8:14 A.M. for Resident 66, LN 5 stated she could not administer the ferrous sulfate (dietary supplement) 300 mg (milligrams- tiny unit of weight) liquid because it was not available and was on order from the pharmacy. A review of physician's orders for Resident 66 was conducted. The physician's orders indicated, Ferrous Sulfate Oral Solution.give 5 ml [milliliter].every morning for supplement.2. Resident 71 was readmitted to the facility on [DATE] with diagnoses including bimalleolar fracture of right lower leg (bony bumps on sides of ankle) according to the facility's admission Record.During medication preparation for administration on 7/30/26 at 8:39 A.M. for Resident 71, LN 5 stated she could not administer the calcium (dietary supplement) 500 mg because the medication was not available and on order from the pharmacy. A review of physician's orders for Resident 71 was conducted. The physician's orders indicated, Calcium Oral Tablet 500 MG.by mouth one time a day for supplement for AGE-RELATED OSTEOPOROSIS [weak and fragile bones] WITHOUT CURRENT PATHOLOGICAL FRACTURE [broken bone caused by underlying disease]3. Resident 69 was admitted to the facility on [DATE] with diagnoses including left rib fracture according to the facility's admission Record.During medication preparation for administration on 7/30/26 at 8:54 A.M. for Resident 69, LN 5 stated she could not administer lidocaine 5% patch (pain patch), areds (dietary supplement for eyes) and probiotic (dietary supplement for digestion) because the medications were not available and on order from the pharmacy. A review of physician's orders for Resident 69 was conducted. The physician's orders indicated,.AREDS 2 Oral Capsule.Give 2 capsules by mouth in the morning.Probiotic.give 1 capsules by mouth for GI [gastrointestinal-stomach and intestines] prophylaxis [prevention].Lidocaine External Patch 5% .to left chest topically [on the skin] in the morning for pain management.4. Resident 70 was admitted to the facility on [DATE] with diagnoses including paroxysmal atrial fibrillation (a type of irregular heartbeat) and presence of prosthetic heart valve (an artificial device used to replace a damaged heart valve) according to the facility's admission Record.During medication preparation for administration on 7/30/26 at 9:07 A.M. for Resident 70, LN 5 stated she could not administer cetirizine (allergy medication) 10 mg and aspirin 81 mg delayed release because the medications were not available and on order from the pharmacy. A review of physician's orders for Resident 70 was conducted. The physician's orders indicated, Aspirin 81 Oral Tablet Delayed Release.1 tablet by mouth one time a day for CVA [stroke] prophylaxis.Cetirizine HCL Oral Tablet 10 MG.Give 1 tablet by mouth one time a day for Allergy symptoms.An interview on 7/30/26 at 3:15 P.M. with LN 5 was conducted. LN 5 stated when medications were not available for administration to residents, a fax was sent to the pharmacy to reorder. LN 5 stated if the medication did not arrive on the same day, a licensed nurse would follow up the next day.An interview on 7/30/26 at 3:45 PM with the Interim Director of Nursing (IDON) was conducted. The IDON stated she expected for licensed nurses to call or fax pharmacy needed medications for residents. Joint observation of the medication room was conducted with the IDON. There were no available aspirin, iron, calcium, probiotic, cetirizine or lidocaine patch in the medication room. The IDON stated she did not find fax confirmation that medications were requested from the pharmacy. The IDON further stated there were no documentation in the residents' progress notes to indicate medications were ordered.During a follow up interview on 8/4/26 at 9:58 A.M. with the IDON, the IDON stated it was important to have medications available because they were ordered by the physician and a change of condition could cause rehospitalization of the resident.A review of the facility's policy and procedure (P&P) titled, Medication Unavailable, revised April 2027 was conducted. The P&P indicated, All medication orders will be administered according to valid Physician's Order.If an ordered Medication is unavailable at its scheduled time for Administration, the nurse must: a. Ensure that the Medication is not available in the EDK [emergency kit] b. Notify the Pharmacy that the medication must be delivered and obtain an estimated time of delivery.

Based on observation, interview and record review, the facility failed to notify a resident (Resident 35) and/or the resident's representative of transfer/discharge and bed hold for one of three residents reviewed for hospitalization. This failure had the potential for the resident and/or the resident's representative to be misinformed of the transfer/discharge as well as bed hold rights. Findings:Resident 35 was admitted to the facility on [DATE] with diagnoses including cellulitis (deep infection of the skin caused by bacteria) of left lower leg and gangrene (death of a body tissue) of left lower leg according to the facility's admission Record. During an observation and interview on 7/28/26 at 8:53 A.M., Resident 35 was lying in bed and stated she was transferred to the hospital but could not remember the date. A review of Resident 35's electronic medical record (EMR) was conducted on 7/29/26 at 8:54 A.M. A transfer form in Resident 35's EMR indicated Resident 35 was transferred to the hospital on 7/3/26 due to unresponsiveness with a blood sugar reading of 20. On 8/4/26 at 8:12 A.M., an interview and joint record review was conducted with Licensed Nurse (LN) 1. LN 1 reviewed Resident 35's EMR and stated a change of condition documentation indicated Resident 35 was sent out to the hospital on 7/3/26 due to unresponsiveness. LN 1 checked the EMR for Resident 35 and stated there was no notice of transfer or bed hold notice. LN 1 checked Resident 35's paper chart and the Notice of Proposed Transfer/discharged form was blank. The BED HOLD INFORMED CONSENT form had a signature dated 6/22/26. The second part of the bed hold form which indicated, CONFIRMATION OF TRANSFER & BED HOLD PROVISION was incomplete. LN 1 stated the forms should be completed according to federal regulations and should notify the resident or representative of their right to appeal. An interview was conducted on 8/4/2026 at 3:52 PM with the Interim Director of Nursing (IDON). The IDON stated she expected staff to offer bed hold notice to inform the family that the resident was able to return to the facility and whether there were any out of pocket expenses. The IDON stated both the notice of transfer and bed hold forms should be completed. A review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notice, revised December 2016 was conducted. The P&P indicated, Under the following circumstances, the notice will be given as soon as it is practicable but before the transfer or discharge.An immediate transfer or discharge is required by the resident's urgent medical needs. A review of the facility's P&P titled, Bed-Holds and Returns, revised March 2022 was conducted. The P&P indicated, All residents/representatives are provided written information regarding facility bed-hold policies, which address holding or reserving a resident's bed during periods of absence [hospitalization or therapeutic leave]. Residents are provided written information about these policies at least twice.well in advance of any transfer.at the time of transfer [or, if the transfer was an emergency, withing 24 hours].

Based on observation, interview, and record review, the facility failed to ensure 2 of 8 residents (Residents 31 and 65) reviewed for activities of daily living (ADL-self- care activities such as grooming, bathing, and toileting) received assistance with shaving and nail care (cleaning, trimming and/or filing of nails). This failure had the potential for residents to sustain injury, infection and decreased self-esteem. Findings:1. Resident 31 was readmitted to the facility on [DATE] with diagnoses including muscle weakness and need for assistance with personal care according to the facility's admission Record. An observation and interview on 7/28/26 at 9:35 A.M was conducted. Resident 31 was sitting up in bed while Certified Nurse Assistant (CNA) 1 assisted Resident 31 with breakfast. Resident 31 was observed to have long fingernails on both hands and with black debris under the nails. Resident 31 stated he would like his fingernails trimmed. CNA 1 stated nail care was provided to residents only if they requested it. CNA 1 further stated staff would also ask residents during bath time if they wanted their fingernails trimmed. CNA 1 stated Resident 31 needed nail trimming. 2. Resident 65 was readmitted to the facility on [DATE] with diagnoses including acute respiratory failure (severe shortness of breath, confusion and bluish skin requiring immediate medical intervention) and cervical spinal stenosis (narrowing of space inside the neck region of the backbone putting pressure on the spinal cord and nerves) according to the facility's admission Record. During an observation and interview on 7/28/26 at 9:54 A.M., Resident 65 was lying on the right side in bed. Resident 65 could not turn his head to the left. Resident 65 was observed unshaven and with brown debris under his fingernails and around the cuticles. An interview on 7/30/26 at 10:18 A.M. was conducted with CNA 2. CNA 2 stated nail care for residents was provided on Sundays and shaving was provided on every shower day. During an interview on 7/30/26 at 10:36 A.M. with CNA 3, CNA 3 stated nail care and shaving were offered on shower days and as needed. An interview on 7/31/26 at 3:15 P.M. was conducted with the Director of Staff Development (DSD- a licensed nurse certified for staff training). The DSD stated residents' nail care and shaving were completed every Sunday. The DSD stated it was important to provide nail care and shaving for the residents' dignity. The DSD further stated bacteria can build under fingernails and residents with dementia (an impairment of brain function, such as memory loss and judgment) may place their fingers in their mouth. During an interview on 8/4/26 at 3:52 P.M. with the Director of Nursing (DON), the DON stated fingernail trimming and shaving were an important aspects of ADLs and infection control. A review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, reviewed January 2026 was conducted. The P&P indicated, Purpose.The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. During a review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, dated January 2026, the P&P indicated, Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to adequately monitor residents' clinical conditions for 2 of 16 sampled residents (Residents 47 and 52) when:Resident 47's urinary characteristics were not routinely monitored and documented for changes while the resident had an indwelling catheter and a history of urine culture positive for Candida (a type of yeast that can cause infection). 2. Vital signs were not obtained and documented for Resident 52 in accordance with the facility's established practice for monitoring new admissions. As a result, residents were at risk for changes in their clinical conditions not being identified, assessed and addressed in a timely manner. Findings: 1. Resident 47 was admitted to the facility on [DATE] with diagnoses that included urinary retention and neuromuscular dysfunction of the bladder per the facility admission record. During an observation on 7/28/26 at 9:43 AM, Resident 47's indwelling urinary catheter tubing contained urine with visible sediment. Review of Resident 47's clinical admission assessment, dated 5/26/26, indicated the resident had an indwelling urinary catheter. The section to assess Resident 47's urine characteristics was not completed.Review of Resident 47's admission nursing note, dated 5/26/26, indicated Resident 47 had an indwelling urinary catheter in place. The note did not describe Resident 47's urine characteristics. Review of Resident 47's alert nursing note, dated 6/8/26, indicated Resident 47's urine was amber in color with sediment. Review of laboratory results dated [DATE] indicated Resident 47's urine culture was positive for two species of Candida. During an observation and concurrent interview on 07/31/2026 at 9:22 AM, certified nursing assistant (CNA) 11 removed Resident 47's urinary drainage bag from the privacy cover. [NAME] and tan sediment was observed built up along the inside of the drainage bag, with a large amount of sediment at the connection between the catheter tubing and drainage bag. CNA 11 stated she was not aware of the sediment and that changes in the resident's urine should be reported to the licensed nurse. Further review of Resident 47's nursing progress notes and skilled nursing evaluations from admission through 7/31/26 did not indicate Resident 47's urine characteristics were routinely documented before or after the documentation on 6/8/26. During an interview and record review on 8/4/26 at 11:10 A.M., the Infection Preventionist (IP) nurse stated CNAs were expected to empty residents' urinary drainage bags every shift and report changes in urine to the nurse. The IP stated licensed nurses (LN) were expected to assess changes in urine, as well as report and document abnormal findings. The IP reviewed Resident 47's clinical record and stated there was no documentation that indicated CNAs or LNs had reported changes in the resident's urine. The IP stated she observed Resident 47's urinary drainage bag and that the sediment should have been reported and monitored. The IP stated a large amount of sediment buildup could obstruct the catheter and cause pain and discomfort, which might lead to urine back up and infection. During an interview on 08/04/2026 at 4:32 PM, the interim director of nursing (IDON) stated the facility did not have a formal system for documenting and monitoring the urine characteristics of residents with indwelling urinary catheters. The IDON stated CNAs were expected to report changes in urine to the charge nurse for assessment. The IDON stated if staff did not describe and document the appearance of the urine, vital information could be missed which could lead to complications including a urinary tract infection. A review of the facility policy titled, Catheter Care, Urinary, revised January 2026, indicated, Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Complications: 1. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately. b. if urine has an unusual appearance (i.e., color, blood, etc.). Documentation: The following information should be recorded in the resident's medical record. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor.2. Resident 52 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (a condition that affects brain function and can cause confusion), diastolic heart failure (condition where the heart has difficulty relaxing and filling with blood), and paroxysmal atrial fibrillation (episodes of an irregular heartbeat) per the facility admission record.Review of health status note, dated 5/22/26 at 8:15 A.M., indicated Resident 52 was found unresponsive in bed with no apical pulse or respirations during morning rounds. Review of the History and Physical, dated 5/20/26, indicated Resident 52 presented with worsening confusion, generalized weakness and progressive cognitive and physical decline. The physician described the resident as frail, confused, and oriented to self only. The assessment and plan directed staff to clinically monitor the resident for acute encephalopathy, atrial fibrillation and chronic diastolic heart failure. A review of Resident 52's physician's orders indicated 40-25mg of Benicar HCT and 25 mg of hydrochlorothiazide were ordered as needed for hypertension when systolic blood pressure was greater than 150 mmHg. Review of alert nursing note, dated 5/20/26 at 11:32 P.M., indicated Resident 52 had sustained an unwitnessed fall during the morning shift. The note documented vital signs were obtained at 9:50 P.M.Further review of Resident 52's clinical record indicated a complete set of vital signs was not documented after 5/20/26 at 9:50 P.M. through the time Resident 52 was found unresponsive during the morning rounds on 5/22/26. A skilled nursing evaluation note created on 6/20/26, approximately one month after Resident 52's death, indicated a pulse of 58 beats per minute and respirations of 16 breaths per minute effective 5/21/26 at 3:45 A.M. Blood pressure and oxygen saturation were not recorded. During an interview on 7/31/26 at 9:22 A.M. with certified nursing assistant (CNA) 11, CNA 11 stated vital signs were taken once a shift or more if needed and documented in the resident's chart on the computer. During an interview and record review on 8/4/26 at 5:30 P.M., the director of staff development (DSD) stated vital signs should be taken and documented on the computer every shift for all new admissions. Resident 52's progress notes and vital sign records were reviewed with the DSD. The DSD acknowledged vital signs were not documented every shift for Resident 52. The DSD stated documenting vital signs one month after they were obtained was not facility practice. During an interview on 8/4/26 at 5:40 P.M., the interim director of nursing (IDON) stated vital signs should be obtained upon admission, every shift, and prior to administering medications with vital sign parameters. The IDON acknowledged Resident 52 was prescribed medications that required monitoring of vital signs. The IDON stated that without obtaining vital signs, staff may not know whether to administer medications or whether the resident was experiencing a change of condition.The facility did not provide a policy that addressed the frequency of obtaining vital signs upon request.

Based on observation, interview, and record review, the facility failed to implement an interdisciplinary team (IDT- a group of people with different training and job skills who work together on a shared goal) recommended fall prevention intervention for 1 of 2 residents (Resident 22) reviewed for accidents when a floor mat was not placed on the left side of the resident's bed. As a result, Resident 22 remained at risk for further injury from a fall.Findings:Resident 22 was admitted to the facility on [DATE] with a diagnosis of history of falling per the facility admission record.A review of the facility progress note, dated 7/28/26, indicated Resident 22 was found on the floor on the left side of the bed following an unwitnessed fall at approximately 11:30 P.M. The note further indicated Resident 22 had sustained bleeding injuries to the forehead, left eye, left elbow and right arm. Review of the interdisciplinary team (IDT) post-fall note, dated 7/28/26, indicated Resident 22 reported he turned onto his left side and fell from the bed. The IDT recommended a floor mat be placed on the left side of the resident's bed.During an observation and interview on 7/28/26 at 3:53 P.M., Resident 22 was lying in bed with a bandage on his forehead and a floor mat on the right side of the bed. No floor mat was on the left side of the bed. Resident 22 stated he rolled out of the left side of the bed and hit his head. During an observation and interview on 8/4/26 at 9:57 A.M., licensed nurse (LN) 11 acknowledged there was no floor mat on the left side of Resident 22's bed. LN 11 stated Resident 22 had fallen from the left side of the bed, so a floor mat should be placed on the left side. LN 11 stated if Resident 22 fell again, he would be risk for further injury due to the hard impact of the fall. During an interview on 8/4/26 at 4:38 PM, the interim director of nursing (IDON) acknowledged the floor mat was on the wrong side of Resident 22's bed. The IDON stated Resident 22 was at risk for further injury if the IDT recommendations were not implemented.A review of the facility policy titled, Fall Risk Assessment, revised 01/026, indicated, Policy Statement: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Policy Interpretation and Implementation. 9. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions.

Based on observation, interview, and record review, the facility failed to ensure licensed nurses (LNs) followed physician orders and the plan of care related to dialysis (the process of removing toxic substances from the blood via machine when a person's kidneys no long function adequately) care when LNs did not know how to check the resident's arteriovenous (AV- connection between an artery and a vein used as an access site for dialysis) fistula for one of one resident (Resident 67) reviewed for dialysis care.This deficient practice had the potential to cause Resident 67 to develop dialysis access complications.Findings:Resident 67 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (the last stage of kidney disease which the kidneys can no longer support the body's needs) and dependence on renal dialysis.An observation and interview on 7/30/26 at 10:53 A.M. was conducted with Resident 67. Resident 67 was in bed and stated her niece was taking her to dialysis today, 7/30/26. Resident 67 showed her left upper arm and stated a needle was placed on her arm for dialysis. Resident 67 stated facility staff did not check her upper arm which was used for dialysis.An interview and joint record review on 7/30/26 at 11:01 A.M. was conducted with Licensed Nurse (LN) 2. LN 2 reviewed the electronic medical record (EMR) for Resident 67. LN 2 stated Resident 67 had physician's orders for dialysis treatments on Tuesdays, Thursdays and Saturdays, and to check Resident 67's AV fistula for a bruit (a sound heard through a stethoscope) and a thrill (vibrations felt by palpation, using fingers to feel) every shift. LN 2 stated she checked for a bruit by placing her fingers over the AV fistula to feel swooshing and to check thrill, LN 2 stated she used a stethoscope to listen to the swooshing sound.During an interview on 7/30/26 at 11:57 A.M. with LN 3, LN 3 stated bruit was checked by palpating the AV fistula and thrill was checked by listening with a stethoscope.An interview on 7/31/26 at 2:28 P.M. was conducted with LN 4. LN 4 stated it was her first time working in the unit and did not know where Resident 67's dialysis access site was. LN 4 checked Resident 67's EMR and stated Resident 67 had an AV fistula on the left upper arm according to physician's orders.An interview on 8/4/26 at 3:52 P.M. with the Interim Director of Nursing (IDON) was conducted. The IDON stated she expected licensed nurses to know how to check a bruit and thrill to ensure that the fistula was functioning.A review of the facility's policy and procedures (P&P) titled, End-Stage Renal Disease, Care of a Resident with, dated January 2026 was conducted. The P&P indicated, Policy Statement.Residents with end-stage renal disease [ESRD] will be cared for according to currently recognized standards of care.Staff caring for residents with ESRD, including receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents.The P&P did not provide guidance on care of a resident's dialysis access site.

Based on observations, interviews, and record reviews, the facility failed to ensure one of one resident (Resident 62) received Trauma Informed Care (TIC- an intervention and organizational approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health) when staff did not know that Resident 62 had a diagnosis of post-traumatic stress disorder (PTSD- a mental and behavioral disorder that can develop because of exposure to a traumatic event). This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to past torture experience).Findings:Resident 62 was admitted to the facility on [DATE] with diagnoses including post- traumatic stress disorder and anxiety disorder (a mental health disorder characterized by worry or fear that interferes with daily functioning) according to the facility's admission Record.An observation and an interview on 7/29/26 at 10:46 A.M. were conducted with Resident 62. Resident 62 was lying in bed and was able to sit up at the edge of bed. Resident 62 stated she had a traumatic experience in the past when her father left the stove on and the house caught fire.Interviews were conducted at the unit where Resident 62's room was located.An interview on 7/30/26 at 10:18 A.M. was conducted with Certified Nurse Assistant (CNA) 2. CNA 2 stated residents with PTSD have had trauma in the past and it was important for staff to know to understand their condition and prevent re-traumatization. CNA 2 stated there were no assigned residents with the diagnosis of PTSD.An interview on 7/30/26 at 10:36 A.M. was conducted with CNA 3. CNA 3 stated PTSD meant that the resident has had a traumatic experience. CNA 3 further stated she should know if a resident had PTSD to prevent triggers and follow the care plan for the resident. CNA 3 stated there were no residents in her section with the diagnosis of PTSD.An interview and joint record review on 7/30/26 at 11:16 A.M. was conducted with Licensed Nurse (LN) 2. LN 2 reviewed the electronic medical record (EMR) for Resident 62. LN 2 stated a care plan was developed on 7/29/26 which indicated impaired coping and a mood disorder related to PTSD. LN 2 stated staff should be aware of any residents with PTSD to know how to approach and care for the resident. During an interview on 7/30/26 at 11:57 A.M. with LN 3, LN 3 stated she was not aware of any residents with the diagnosis of PTSD.During an interview on 7/30/26 at 12:26 P.M. with LN 5, LN 5 stated no residents had a diagnosis of PTSD.During an interview on 7/31/26 at 3:15 P.M. with the Director of Staff Development (DSD- a licensed nurse certified for staff training), the DSD stated she was not aware of any residents with the a diagnosis of PTSD.An interview on 8/4/26 at 3:52 P.M. was conducted with the Interim Director of Nursing (IDON). The IDON stated Resident 62 had a diagnosis of PTSD and staff should be aware of triggers to avoid and provide needed care for the resident.A review of the facility's policy and procedure (P&P) titled, Trauma Informed Care and Culturally Competent Care, dated January 2026 was conducted. The P&P indicated, Purpose.To address the needs of trauma survivors by minimizing triggers and/or re-traumatization.3. For trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. 4. Triggers are highly individualized.Resident Assessment.2. Utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments. 3. Use assessment tools that are facility-approved and specific to the resident population.Resident Care Planning.1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident.

Based on interview and record review, the facility failed to adequately assess and monitor one of three sampled residents (Resident 1) who had a change in condition.This failure had the potential for Resident 1 to experience discomfort and further deterioration in health condition.Findings:According to the admission Record, Resident 1 was admitted to the facility on [DATE] and discharged on 6/3/26 with diagnoses which included vascular dementia (a decline in thinking and memory skills caused by reduced blood flow to the brain) and functional quadriplegia (an inability to move due to severe disability).Per the MDS (Minimum Data Set- a federally mandated assessment tool) dated 6/3/26, Resident 1 could not be interviewed because he was rarely or never understood.During a record review, the Physician's Order dated 5/29/26 indicated Resident 1 was under hospice services (comfort-focused care for individuals who are expected to live six months or less), and was admitted to the facility for a 5-day respite stay (a short term stay designed to give the primary caregiver a temporary break).During an interview with Licensed Nurse (LN) 1 on 6/24/26 on 9:58 A.M., LN 1 stated Resident 1 was scheduled to discharge home on 6/3/26 around 4 P.M. LN 1 stated around 4 P.M. Resident 1 was placed on a gurney (a bed used to transport a person), and had an episode of emesis (vomiting). LN 1 stated she called hospice and obtained an order for a one-time administration of ondansetron (a medication used to treat nausea). LN 1 stated Resident 1 was monitored for, At least 15 minutes before being discharged home. LN 1 stated she did not do any further assessments such as vital signs, and did not listen to Resident 1's bowel or lung sounds after the episode of emesis.On 6/24/26 at 11:18 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated an episode of emesis was considered a change in condition, and a thorough assessment should have been conducted. The DSD stated if a resident had an episode of emesis, she would first see the resident, make sure he was not laying flat to avoid aspiration (inhalation of food particles into the lungs). The DSD further stated she would get the resident's vital signs, and check to see if the resident had a bowel movement. The DSD stated it was important to do a thorough assessment to ensure Resident 1 did not aspirate, or had any other new conditions that could have contributed to the vomiting.During a follow-up interview with Licensed Nurse (LN) 1 on 6/24/26 on 11:35 A.M., LN 1 stated an episode of emesis would be considered a change in condition. LN 1 stated, I probably would have checked for bowel and lung sounds. LN 1 further stated 15 minutes, Probably was not long enough to wait [to see if the medication was effective].During an interview with the Director of Nursing (DON) on 7/1/26 at 1:43 P.M., the DON stated it was her expectation for the licensed nurse to assess if Resident 1 had any more episodes of nausea or vomiting. The DON stated, also check the GT [gastrostomy tube] to make sure everything was connected, take vital signs, check for residual [leftover food in the stomach] make sure he didn't have anything else going on.in retrospect [Resident 1] could have been observed a little bit longer.During a review of the policy titled Change in a Resident's Condition or Status, revised December 2025, the policy indicated, .the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the INTERACT SBAR Communication Form.During a review of the undated document titled Hospice Service Agreement, the document indicated, Nursing Facility Responsibilities.Provide services that are consistent with the plan of care developed in coordination with hospice (the hospice patient residing in a facility should not experience any lack of services or personal care because of his/her status as a hospice patient) AND help the resident/patient attain the highest practicable physical, mental and psychosocial well-being.

Based on interview and record review, the facility failed to update the plan of care for one of three residents (Resident 1) reviewed for falls.This failure had the potential for Resident 1 to experience subsequent falls and/or injuries.On 8/22/25 Resident 1's facility's record was reviewed. The admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included fracture of right femur (a broken thigh bone) and generalized muscle weakness. A review of the Fall Evaluation dated 6/5/25 indicated Resident 1 was at high risk for falling. During a review of Resident 1's Progress Notes, the Fall Note dated 8/1/25 at 10:19 A.M. indicated, .found resident on the floor, left side of the bed, head slightly under the bed. When asked, [Resident 1] stated he wanted to reach his wheelchair to go to the bathroom and hit his head on the side of the bed. Assessment done, skin tear on the back of the head slightly bleeding, and pain with level of 7 on the right hip. The Progress Note indicated Resident 1 was transported to the hospital via 911, per physician's order.On 8/22/25 at 9:50 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated she was the supervising nurse on duty when Resident 1 sustained a fall on 8/1/25. LN 1 stated she assessed Resident 1 while he was still on the floor. LN 1 stated Resident 1's call light was not activated when she entered his room. LN 1 stated resident was sent to the hospital immediately, and returned the same day. LN 1 stated the new interventions initiated by the facility to prevent Resident 1 from sustaining any additional falls include, .we reiterated that he needs to press the call light. If he's in bed it needs to be in the lowest position, and fall mats. LN 1 stated she does not remember if the interventions were implemented when Resident 1 returned to the facility.On 8/22/25 at 10:23 A.M., a joint interview and record review was conducted with the Interim Director of Nursing (IDON). The IDON stated there were no new interventions documented in Resident 1's record when he returned from the hospital. The IDON stated, I would have done something like move him closer to the nurses station. The IDON stated Resident 1's care plan should have been accelerated to reflect the fall. The IDON stated it was important to prevent future falls, to try to avoid injury and cause harm to the resident.On 8/22/25 the facility's policy was reviewed. The facility's policy titled Falls- Clinical Protocol revised March 2018, the policy indicated, The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable.Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions.The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.

Based on Observation, Interview and Record Review, the facility failed to keep one of five sampled residents (Resident 1) safe from medication errors. This failure caused Resident 1 to receive the wrong medication and posed a risk to Resident 1's health and safety.Findings:Per the facility's admission Record, Resident 1 (Res 1) was admitted to the facility on [DATE]. Resident 1's admission diagnosis was Myasthenia Gravis (a chronic disorder that affects where nerves communicate with muscles). Per the Minimum Data Set (MDS - a resident assessment tool) assessment, Section K0520 indicates that Resident 1 had a G-Tube (a tube that goes into the stomach through the abdominal wall for nutrition, medication, and hydration) present on admission and while a resident in the facilityPer a record review of Res 1 electronic medical record (EMR) on 7/24/2025, the change of condition note dated 3/20/2025 at 4:15 P.M. LN2 documented that Resident was sitting by door disconnected from feeding tube. Nurse gave crushed meds with applesauce by mouth causing resident to choke. Three nurses alerted, suction used on mouth and oxygen given. 911 called.Resident 1's record was reviewed on 7/24/2025. During a review of Res 1's Order Summary Review, the record indicated a new order was placed for medication via G-Tube. The record further indicated that the medications were discontinued and reordered on 2/13/2025, 2/15/2025, and 3/6/2025. Thus, the record showed that there had been no recent changes to the medication orders and that the medications had been administered via the appropriate route (g-tube). LN1 did not give Res1's medications by the ordered route. (g-tube).During an observation and interview on 7/24/2025 at 9:15 A.M. Medication Nurse 1 (MED1) was observed passing medications. MED1 checked medications against the physician's orders, dispensed medications to plastic cups, verified patient, medication, dosage, route, and time. MED1 stated the policy for G-Tube medication administration: Check the Medication Administration Record (MAR); verify patient, medication, dose, route, and time; verify that medications can be crushed.During an interview with the Director of Nursing (DON) on 7/24/2025 at 10:05 A.M., the DON stated Resident 1 was a tube fed resident. On 3/19/2025, R1 was seated in a chair in the hall. The tube feeding had been turned off. Licensed Nurse 1 (LN1) saw R1 seated in the hall and offered her medications, R1 asked for them to be crushed. LN1 crushed the medications, mixed them in applesauce and gave them to R1 by mouth. R1 began to choke and coughed out the applesauce and medications. Staff took R1 into her room, suctioned her, and called 911.The DON stated, LN1 did not verify the name of the resident prior to giving medications. The DON continued She (LN1) broke many, many things related to our medication administration policies. Nurses are expected to follow the Five Rights when passing medications. The DON further stated that LN1 did not properly identify the resident, the medications, or the correct route.The DON further stated that all facility staff who pass medications are observed by the pharmacist to ensure safety at least every six months. Registry staff are observed based on how frequently they work.During a record review on 7/24/2025 at 9 A.M. The document titled PharMerica Medication Administration Observation Report indicated the most recent observation of LN1 was on 11/25/2024.On 7/30/2025 at 12:45 P.M., R1's attending physician (MD) was interviewed. R1's MD stated that R1 was tube fed, and she was not to have anything by mouth. The MD further stated that this incident had the potential for a very bad outcome, but I saw her the following day, and she was ok.During a review of the facility policy titled Administering Medications dated April 2019, indicated .9. The individual administering medications verifies the resident's identity before giving the medications. Methods of identifying the resident include a. checking identification band; b. checking photograph attached to the medical record; and c. if necessary, verifying resident identification with other facility personnel. The policy continues .10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review, the facility failed to implement a comprehensive systematic approach to ensure effective monitoring to maintain acceptable parameters of nutritional status for 1 of 5 sampled Residents (Resident 3) when: 1. The facility did not follow their policy for change of condition (physical change-weight loss) when Resident 3 was not placed on weekly weights (measurement of body weight).2. The Registered Dietitian (RD) did not reassess Resident 3's weight loss to determine appropriate interventions.3. Resident 3's weight loss was not communicated to the physician.4. The Interdisciplinary Team (IDT- a team comprised of professionals from various disciplines who work in collaboration to address residents' needs) did not address the severe unplanned weight loss.5. Resident 3's care plan did not reflect the severe unplanned weight loss, and no interventions (an action taken to address Resident 3's weight loss) were implemented.As a result, Resident 3 experienced a severe, unplanned weight loss of 24.4 lbs. (pounds- a measurement of weight), 14.77% from weights obtained from 4/5/25 to 8/6/25. Resident 3 was at risk to experience medical complications including but not limited to dehydration, loss of muscle mass with decreased mobility, and negatively affect Resident 3's health and well-being, which could include death.Findings:A record review of Resident 3's admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes (a condition in which the body has trouble controlling blood sugar and using it for energy), functional quadriplegia (the inability to move all four limbs due to severe disability or weakness), gastro-esophageal reflux disease (a condition in which stomach contents move up into the esophagus), and a history of falling.A record review of Resident 3's Minimum Data Set (MDS- a standardized comprehensive assessment of residents' health conditions, functional abilities, and care needs) report dated 7/9/25 indicated the resident's brief interview of mental status (BIMS- a cognitive screening test) score was 15, which indicated intact cognition.On 8/5/25 at 8:50 A.M., a joint observation and interview was conducted with Resident 3 in his room. Resident 3 was in bed and had his breakfast tray in front of him. Resident 3 had eaten most of his breakfast. Resident 3 stated he liked breakfast, but lunch and dinner were .hit or miss. I'll ask for a sandwich if I don't like the food. Resident 3 stated, I didn't care for the food the last couple of weeks. and that he had recently lost weight. Resident 3 stated he received a [Nutrition Shake] (meal or snack replacement designed for diabetic patients) with every meal. Resident 3 stated he consumed the entire bottle of the nutritional supplement during breakfast. Resident 3 stated he rarely consumed the full amount of the nutritional shake for lunch and dinner, .sometimes I drink a third, sometimes half, sometimes less. It depends on. Resident 3 stated he weighed about 170 pounds prior to admission to the facility, and now weighed about 140 lbs. Resident 3 stated he would not like to lose any more weight because he did not want his clothes to fit too loosely. Resident 3 stated he did not know the reason he had lost weight, and he had not planned to lose weight.On 8/5/25 at 8:59 A.M., an interview was conducted with Resident 77 (Resident 3's wife and current roommate). Resident 77. Resident 77 stated that Resident 3 would often choose food options from an alternative menu. Resident 77 stated, .my husband is losing weight. He tries to give me his chips sometimes and I tell him he needs to eat it, so he doesn't lose anymore weight.A record review of Resident 3's Weight Summary dated 8/6/25 indicated:4/5/25 165.2 lbs. (pounds-measurement of weight).5/4/25 153.6 lbs.5/10/25 150.6 lbs.5/22/25 147.2 lbs.6/2/25 146.6 lbs.6/19/25 147.6 lbs.7/1/25 148.1 lbs.8/1/25 140.0 lbs.8/6/25 140.8 lbs.Resident 3 experienced a 17.1 lb., 10.35% severe weight loss in ninety days or 3 months, from 4/5/25 to 7/1/25.On 8/6/25 a record review of Resident 3's Nutrition Evaluation dated 4/7/25 was conducted. The Nutrition Evaluation was completed by the Registered Dietitian and indicated Resident 3's usual body weight was between 170-175 lbs. The Nutrition Evaluation indicated Resident 3 was not on a planned weight change program. The Nutrition Evaluation further indicated, .Seen during lunch, reports poor intake x 1.5 weeks.Goal to remain weight stable through recovery. Mod [moderate] nutrition risk per poor intake, recent wt. [weight] loss.Nutrition Monitoring: Monitor intake, weight, evaluate labs when available. Will adjust nutrition POC [Plan of Care] as indicated.On 8/6/25 a record review of Resident 3's Nutrition Evaluation dated 7/7/25 was conducted. Per the Nutrition Evaluation document. Describe any recent weight changes.currently weight stable x 2 months weight loss -17.1# (10.4%) over the first month of admission 3 months ago. [Resident 3] is at potential risk for weight loss, dehydration, and malnutrition r/t [related to] variable PO [oral-by mouth] intake and recent wt. [weight] loss trend. There were no new interventions or recommendations indicated in the Nutrition Evaluation. LN3 and RD verified there was no documentation related to interventions for Resident 3's weight loss. On 8/6/25 at 12:52 P.M., an interview was conducted with the Restorative Nursing Assistant 1 (RNA-Certified Nurse Assistant who work alongside rehabilitation staff to provide exercises for residents with limited mobility). RNA 1 stated she was responsible for obtaining residents' weights. RNA 1 stated newly admitted residents were weighed the day after admission, then once a week for the first four weeks. RNA 1 stated a list of any significant weight changes were provided to the Director of Nursing (DON) and/or the charge nurse. RNA 1 stated, .the Registered Dietitian (RD) doesn't need a copy of the weights because she can read it in [the Electronic Health Record]. RNA 1 stated she had not attended any IDT weight meetings. RNA 1 stated she was aware that Resident 3 had been losing weight and had been refusing RNA exercises because Resident 3 was too tired. On 8/7/25 at 9:56 A.M., a joint interview and record review of Resident 3's facility chart was conducted with Licensed Nurse (LN) 3. LN 3 stated, A significant weight loss is considered a change of condition (COC) because [the weight loss] is not normal for the patient, if [the weight loss] was not planned we need to figure out why it's happening and to implement new interventions to take care of the resident. LN 3 stated there was not a COC completed to address Resident 3's weight loss and to notify the physician. LN3 stated, I did not see a COC in Resident 3's EHR. LN 3 stated Resident 3's care plan should have been updated to reflect the weight loss. LN 3 further stated [Nutritional shake] was not listed in Resident 3's Physician's Orders, and there was no documentation of the amount of the nutritional shake consumed. LN 3 stated it was important to document the amount of [Nutritional shake] consumed by Resident 3 to ensure he was receiving enough calories. On 8/7/25 at 2:12 P.M., a joint interview and review of Resident 3's facility medical record was conducted with the Dietary Manager (DM) 1. DM 1 stated she was responsible for obtaining residents' food preferences upon admission, and updated preferences when there were changes in the residents' condition, such as weight loss. DM 1 stated Resident 3 usually asked for a sandwich for lunch, instead of the standard menu items. DM 1 stated Resident 3 typically ate lunch in the dining room, but lately he had been eating in his room. DM 1 stated I noticed [Resident 3] is only eating half of his sandwiches for lunch. DM 1 stated currently he gets [Nutritional shake] three times a day. DM 1 stated she was not sure if Resident 3 was consuming all of the [Nutritional shake] because there was no recording of the amount of the [Nutritional shake] consumed by Resident 3. DM 1 stated she knew Resident 3 should have had a nutritional shake because the RD had recommended a nutritional shake.On 8/7/25 at 2:49 P.M., a telephone interview was conducted with the Registered Dietitian (RD). The RD stated it was important that residents were weighed weekly upon admission, to see any significant trends.if there's pertinent wounds or conditions that require more calories or nutrition. It's critical to see the weight trend for that month.to give us a good foundation to see if they're eating enough. The RD stated, [Resident 3] wasn't trying to lose weight, but it was acceptable to him. The weight loss is not acceptable to me because it does impact his nutritional status and can lead to malnutrition, and to recover and stay well. In addition, the RD stated, [Resident 3] will be prone to muscle weakness and skin breakdown.gaining weight would improve his quality of life. The RD stated an IDT note to address Resident 3's weight loss should have been in Resident 3's medical records.On 8/8/25 at 1:04 P.M., a telephone interview was conducted with the Medical Director (MD). The MD stated his expectation was for any significant or severe weight loss to be addressed during the IDT meeting. The MD stated he expected weight loss interventions to be implemented. The MD stated, We don't want [Resident 3] to decline, have skin breakdown.a lot of things could happen for this resident such as major physical decline due to weight loss and this could have been easily addressed.During a record review on 8/8/25 the facility's policy titled Weight Management revised 10/24, the policy indicated, Significant weight changes (>/=2% in one week or >/=5% in one month) must be noted on the weekly report forms and reported to the attending physician by the licensed nurse.Residents who have been deemed as having significant weight loss or gain will be assessed by the Registered Dietitian for dietary changes and recommendations.The attending physician will be informed of all significant weight loss and gain.During a record review on 8/8/25 of the facility's policy titled Nutritional Assessment revised 10/17, the policy indicated, The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission.and as indicated by a change in condition that places the resident at risk for impaired nutrition.Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications.During a record review on 8/8/25 of the facility's policy titled Weight Assessment and Intervention revised 3/22, the policy indicated, The threshold for significant unplanned and undesired weight loss will be based on the following criteria:.1 month- 5% weight loss is significant; greater than 5% is severe.3 months- 7.5% weight loss is significant; greater than 7.5% is severe.6 months- 10% weight loss is significant; greater than 10% is severe.According to a 2002 American Academy of Family Physicians Journal article, Involuntary weight loss can lead to muscle wasting, decreased immunocompetence, (the ability for the body to develop an immune response) depression and an increased rate of disease complications. Research has shown institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. (www.aafp.org/afp)According to a literature review of the Academy of Nutrition & Dietetics, Nutrition Care Manual, dated 2022, .Unintended weight loss is linked to increased mortality (death) among older adults . residents in long-term-care facilities who continue losing weight have a higher mortality rate compared with those who stop losing weight. Weight loss of 5% or more within 30 days is associated with a tenfold increase in the likelihood of death . (https://www.nutritioncaremanual.org/).

Based on observation, interview and record review, the facility's QAPI committee failed to ensure action plans related to deficient practices identified in the last recertification survey, dated 8/5/25 through 8/8/25, were implemented by 8/25/25 as their POC (Plan of Correction) indicated.As a result, the facility remained noncompliant with a deficiency cited during the prior survey, which had the potential to affect the health and safety of the residents.Findings:Following a recertification survey dated 8/5/25 through 8/8/25, the facility provided a POC which ensured: an audit of resident weights was conducted, a weekly risk review of all resident nutrition needs assessments, consumption, and needs for assistance would be provided. The POC further indicated a daily clinical review would be conducted to assess resident meal intake and to ensure weight loss prevention interventions were in place. The facility's Plan of Correction was not implemented. On 8/26/25 at 9:25 A.M., an interview was conducted with the Administrator (ADM) and Director of Nursing (DON) regarding the facility's Quality Assurance (QA) committee. The ADM stated all department heads, nursing mangers, the Medical Director, lab/radiology, pharmacist, environmental services, and consultants attend the quarterly QA meetings. The ADM stated the QA committee also conducted ad hoc (as needed) meetings in addition to the quarterly meetings. During the quarterly meetings, the committee discussed and analyzed deficiencies identified during the last recertification survey in addition to issues identified by the facility. The following deficiency identified in the last recertification survey dated 8/5/25 through 8/8/25 was discussed with the ADM and DON: F692- Following a recertification survey conducted 8/5/25 through 8/8/25, the facility provided a POC which ensured all resident nutrition needs assessments, consumption assistance needs, and nutrition interventions would be completed during the weekly Risk (Interdisciplinary Team) meeting. The POC further indicated, The facility system for managing nutrition and hydration needs and weight loss prevention has been updated to include daily clinical review to assess resident meal intake and to ensure that weight loss prevention interventions are in place and that staff is compliant with the interventions per the care plan. The DON would be responsible to ensure ongoing compliance, per the POC. During a review of the facility's policy reviewed 4/2025, titled Quality Assessment and Assurance Committee Quality Assurance & Performance Improvement Plan (QAPI), the policy indicated, Although QAPI focus is on overall organizational functions, we partner with each resident, their family, and/or advocate to achieve his/her individualized goals and provide care that respects their autonomy, preferences and choices. When a need is identified, we will implement corrective action plans or performance improvement projects to improve processes, systems, outcomes, and satisfaction.

Based on observation, interview, and record review the facility failed to implement infection control standards of practice when:1. An used syringe was found on top of a resident's dresser (Resident 2), and2. A blood pressure cuff was used for multiple residents without sanitizing in between use for four of four residents observed during medication pass. This failure had the potential to spread infection amongst the residents.Findings: 1. On 8/5/25 at 10:20 A.M., during the initial tour, Resident 2 was observed lying in bed, with an indwelling catheter (flexible tube that drains urine) hooked on the side of the metal frame bed. On top of Resident 2's dresser was an unwrapped, uncovered, clear, plastic syringe. Resident 2 stated she did not know if she had an indwelling catheter or stoma (surgical opening on the body). On 8/5/25 at 10:30 A.M., a joint observation and interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she was not aware of the reason why there was a used syringe on Resident 2's dresser. On 8/5/25 at 10:38 A.M., an interview was conducted with Licensed Nurse (LN) 4. LN 4 stated Resident 2 had an indwelling catheter changed and urine collection last week. LN 4 further stated the used syringes should have been disposed of. On 8/7/25 at 3:30 P.M., an interview was conducted with the Infection Preventionist (IP). The IP stated the plastic syringe was one-time use, and should have been disposed of after use to prevent cross-contamination. Per the facility's policy and procedure, dated 8/2022, titled Indwelling (Foley) Catheter Insertion, Female Resident, .13. Clean the area and reposition the resident: a. Discard all disposable items into designated containers . 2. Resident 1 was admitted to the facility on [DATE] with diagnoses including sepsis (the body's extreme and life-threatening response to an infection) and hypertension (high blood pressure) according to the facility's admission Record. Resident 60 was admitted to the facility on [DATE] with diagnoses including hypertension according to the facility's admission Record. Resident 25 was re-admitted to the facility on [DATE] with diagnoses including hypertensive heart (heart condition caused by long-term high blood pressure) and chronic kidney disease according to the facility's admission Record. Resident 48 was re-admitted to the facility on [DATE] with diagnoses including hypertension according to the facility's admission Record. A medication administration observation was conducted on 8/7/25 at 8:12 A.M. with Licensed Nurse (LN) 2. LN 2 took a portable, wrist blood pressure (BP) apparatus from a pouch on top of the medication cart and proceeded to take Resident 1's blood pressure. LN 2 did not sanitize the BP cuff prior to and after use. LN 2 returned the BP apparatus to the pouch on top of the medication cart. On 8/7/25 at 8:33 A.M. LN 2 took a portable, wrist blood pressure (BP) apparatus from a pouch on top of the medication cart, proceeded to Resident 60's room and took Resident 60's blood pressure. LN 2 did not sanitize the BP cuff prior to and after use. On 8/7/25 at 8:44 A.M. LN 2 took a portable, wrist blood pressure (BP) apparatus from a pouch on top of the medication cart and entered Resident 25's room. Outside of Resident 25's room a sign was posted which indicated Enhanced Barrier Precaution (EBP-an approach when healthcare workers wore gowns and gloves during high contact with residents to reduce transmission of organisms) for bed B (Resident 25's roommate). LN 2 went to Resident 25's roommate and took his blood pressure. LN 2 then went to Resident 25 and took his blood pressure without sanitizing the BP cuff in between use. LN 2 returned the BP apparatus to the pouch on top of the medication cart without sanitizing the BP cuff after use. On 8/7/25 at 9:07 A.M. LN 2 took a portable, wrist blood pressure (BP) apparatus from a pouch on top of the medication cart. LN 2 entered Resident 48's room and took Resident 48's blood pressure without sanitizing the BP cuff prior to and after use. An interview was conducted on 8/7/25 at 9:26 A.M. with LN 2. LN 2 stated she used her own BP apparatus and forgot to sanitize the BP cuff between residents. LN 2 stated it was important to sanitize to prevent the spread of infection. During an interview on 8/8/25 at 10:30 A.M. with the Assistant Director of Nursing (ADON), the ADON stated staff should sanitize BP cuffs prior to using and in between resident use for infection control. A review of the facility's undated policy and procedure (P&P) titled, Infection Control 09-Disposal and Disinfection of Care Equipment was conducted. The P&P indicated, All medical equipment used by care staff is either disposable or requires proper disinfection. Non-critical reusable medical equipment includes items that only touch intact skin, such as blood pressure cuffs, canes/wheelchairs, gait belts, etc.These items are suitable for disinfection using methods recommended by manufacturer's instructions. The policy did not provide guidance regarding frequency of disinfecting medical equipment.

Based on observation, interview, and record review, the facility failed to ensure medications and nutritional supplements were properly stored for 3 out of 4 medication storage rooms reviewed for medication storage and for one of four residents when:1. Resident 78 had medications unsecured at bedside,2. Station one medication room had an expired medication, and a bottle of nutritional supplement,3. Expired medications and a box of nutritional supplements were stored in the main central supply room.These failures had the potential for unsafe and ineffective use of medications and supplements with decreased therapeutic effectiveness when used past the expiration date. In addition, this failure had the potential for Resident 78's medications to be accessible to unauthorized staff and residents.Findings:1. Resident 78 was admitted to the facility on [DATE] with diagnoses including hypotension (low blood pressure) and diabetes (too much sugar circulating in the blood) according to the facility's admission Record.During observation and interview on 8/6/25 at 3:10 P.M., Resident 78 stated she kept the eye drops at her bedside. Resident 78 took a paper cup from the overbed table and showed three eye drops inside the cup: gen teal, optase {for dry eyes) and gentamicin (an antibiotic). Resident 78 stated she applied one of the eyedrop herself but called for a nurse to administer the other eye drop because it was thicker and difficult to self-administer.An interview with Licensed Nurse (LN) 1 was conducted on 8/6/25 at 3:27 P.M. LN 1 stated it was important not to keep medications at bedside because the resident may double dose.During an interview on 8/8/25 at 8:30 A.M. with the Infection Preventionist (IP), the IP stated if a resident requested to self-administer medications a lock box will be provided for the resident and the medication nurse will check if the resident was taking the medication.An interview was conducted on 8/8/25 at 10:30 A.M. with the Assistant Director of Nursing (ADON). The ADON stated Resident 78 should have a lock box for safety.A review of the facility's undated policy and procedure (P&P) titled, Self-Administration of Medications was conducted. The P&P indicated, Residents have the right to self-administer medications if the interdisciplinary team [IDT-team members with various areas of expertise who work together toward the goals of their resident] has determined that it is clinically appropriate and safe for the resident to do so.If it is deemed safe and appropriate for a resident to self- administer medications, this is documented in the medical record.Self-administered medications are stored in a safe and secure place, which is not accessible by other residents.2. On 8/7/25 at 10 A.M. a concurrent observation of station one medication room and interview was conducted with LN 3. LN 3 checked the medications inside a cabinet for expiration dates. LN 3 found a bottle of ibuprofen (pain medication) 200 mg (milligrams) with an expiration date of 7/20/25. On an open shelf in the medication room, a bottle of juven (nutritional supplement) was observed. LN 3 stated the juven bottle had an expiration date of 8/1/25. 3. On 8/7/25 at 10:14 A.M. a concurrent observation of the main central supply room and interview was conducted with LN 3. Upon entrance to the supply room, a shelf on the left was observed with two bottles of povidone iodine (used to disinfect the skin) with expiration dates of 8/2025. On another shelf on the other side of the room, a box which contained 24 bottles of boost (a nutritional supplement) had an expiration date of 5/19/25 written on the box. LN 3 showed a metal file drawer with bisacodyl suppository (medication for constipation) which indicated an expiration date of 8/2025. During an interview with LN 3 on 8/7/25 at 10:32 A.M., LN 3 stated it was important not to have expired medications and nutritional supplements due to possible adverse effects and the desired indication of the medications or nutritional supplements would not be achieved if expired. During an interview on 8/8/25 at 10:30 A.M. with the Assistant Director of Nursing (ADON), the ADON stated stored medications should not be expired for others to have access to. The ADON further stated expired medications, or nutritional supplements will lose potency, and it was important for resident safety. A review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 1/2025 was conducted. The (P&P) indicated, Medications and biologicals [medicines derived from human blood and plasma] are stored properly.to keep their integrity and to support safe, effective drug administration.Outdated, contaminated, discontinued or deteriorated medications.are immediately removed from stock, disposed of according to procedures of medication disposal.

Based on observation, interview, and record review, the facility failed to ensure food served was in a palatable, flavorful manner, and at the preferred temperature for six residents who complained about the food's taste and temperature. The facility had a census of 50.This failure had the potential for residents to decrease meal intake and lead to weight loss.Findings:On 8/5/25, during the facility's initial tour, there were six residents who had complained that the food was not palatable and the warm food was served cold.On 8/7/25 at 11:30 A.M., the trayline was observed serving the following items: Spanish fish soup, spaghetti [NAME], garlic bread, chicken pea stuff peppers, rainbow chard, roasted beets, charred purple potatoes, sticky rice, and spinach.A review of the Hot and Cold Food Temperature Logs, dated 8/7/25, indicated that the soup was 171 degrees Fahrenheit, the main entree was 161 degrees Fahrenheit, and the milk was 36.2 degrees Fahrenheit.On 8/7/25 at 12:25 P.M., a test tray sample was conducted with the Dietary Manager (DM). The DM tested the temperature of the foods; the soup was 157 degrees, indicating a 14-degree drop in temperature. The spaghetti [NAME] was 139.8, which meant the temperature of the food dropped to 21.2 degrees cooler. The temperature of the milk was 40 degrees Fahrenheit. The flavor of the spaghetti [NAME] was flat, noticeably lacking in salt, and the complexity of the rich taste of the seasoning was missing. The DM tried the food and said the taste could be improved.On 8/7/25 at 12:45 P.M., an interview was conducted with Resident 85. Resident 85 stated that the green substance on his tray was unrecognizable, possibly kale or spinach, but he was unsure. Resident 85 further stated he did not eat it.A review of Resident 85's medical records was conducted. Per the Minimum Data Set (MDS- comprehensive evaluation of a resident's health and functional status), under Section C- Cognitive Patterns, Resident 85's Brief Interview for Mental Status (BIMS-tests mental score) score was 13, indicating no cognitive impairment. Per the Order Listing Report, dated 7/31/25, Resident 85 had a diet order of regular diet and regular texture.On 8/7/25 at 12:52 P.M., an interview was conducted with Resident 86. Resident 86 stated that the spaghetti did not have flavor, and she sent it back to the kitchen.A review of Resident 86's medical records was conducted. Per the Minimum Data Set (MDS), under Section C- Cognitive Patterns, Resident 86's Brief Interview for Mental Status (BIMS) score was 15, indicating no cognitive impairment. Per the Order Listing Report, dated 8/1/25, Resident 86 had a diet order of regular diet and regular texture.On 8/7/25 at 1 P.M., an interview was conducted with Resident 89. Resident 89 stated that he tried the spinach and stated It's bad and the texture was not right.A review of Resident 89's medical records was conducted. Per the Minimum Data Set (MDS), under Section C- Cognitive Patterns, Resident 89's Brief Interview for Mental Status (BIMS) score was 12, indicating no cognitive impairment. Per the Order Listing Report, dated 7/30/25, Resident 89 had a diet order of no added salt, regular texture diet.On 8/8/25 at 10:45 A.M., an interview was conducted with DM. The DM stated the importance of serving palatable and resident-preferred temperature foods was to ensure residents enjoy the food and do not lose weight. Facility did not provide a policy regarding food palatability and temperature.

Based on interview and record review, the facility failed to ensure food items in the reach-in refrigerator in the kitchen had an open date, and expired food was not removed for two of two reach-in refrigerators. This failure placed residents at risk of acquiring foodborne illness. Findings:On 8/5/25 at 8 A.M., an initial tour of the kitchen area was conducted with the Dietary Aide (DA). Inside the reach-in refrigerator was a large tub of opened cottage cheese, with no indication of when it had been opened. The DA stated the food item should have had an open date written on the container. Upon further observation of the reach-in refrigerator below the cottage cheese was a pack of sliced cheese that was torn open and had a smeared black marker written on the front of the package. The date was unreadable. The DA stated that the open cheese should be dated and securely wrapped with plastic wrap or a sealable bag. The DA further stated she could not make sense of the date that was written. In addition, there was a large container of sliced peaches inside the clear container with a label Use By: 8/1/25. The DA stated the peaches should have been removed to ensure it was not served to the residents by mistake. On 8/7/25 at 8:48 A.M, an interview was conducted with the Dietary Manager (DM). The DM stated food items in the kitchen should be labeled and dated and expired food items should have been removed. The DM further stated it was important to label, date, and remove expired food items to ensure resident safety. Per the facility's protocol, titled Trayline Labeling & Dating Guidelines, dated 4/23/25, Cottage cheese and sliced cheese were good for 6 days. ALL ITEMS MUST BE DATED & SECURELY COVERED. Facility did not provide a policy regarding food storage.

Based on interviews and record review, the facility failed to provide a written and follow-up initiation of the advance directives for one of 15 sampled residents (Resident 9).This failure had the potential to prevent Resident 9's wishes from being honored.Findings:Resident 9 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (lung disease), per the admission Record. Per the same document, Resident 9 was responsible for herself and had two durable powers of attorney (DPOA - a legal document that appoints someone to manage affairs if a resident becomes unable to make decisions) for healthcare and financial.A review of Resident 9's medical record was conducted. Per the History and Physical, dated 6/30/25, Resident 9 cannot understand or decide because Resident 9 had dementia (memory loss).Per the Physician Orders for Life-Sustaining Treatment (POLST), dated 6/22/24, under Section D, there was no information about the advance directive (a written statement of a resident's wishes).A further review of Resident 9's medical record was conducted. There was no documented evidence of the advance directive in Resident 9's medical records.Upon further review of Resident 9's medical record, there was no evidence that the facility offered or had follow-up about Resident 9's advance directives.On 8/7/25 at 12:11 P.M., a joint interview and record review was conducted with the Social Service Coordinator (SSC). The SSC stated that she was responsible for gathering advance directives during admission or care conferences. If a resident did not have an advance directive, she would offer one and document it in the progress notes.The SSC further stated Resident 9 did not have an advance directive in the medical record, and should have. The SSC said the importance of having an advance directive was to ensure a resident's wishes are honored when they can no longer make decisions. Per the facility's policy and procedure, dated 9/22, titled Advance Directives, .staff will document in the medical record the offer to assist. If the Resident Has an Advance Directive .copies of the documents will be obtained and maintained in the same section of the residents medical record .

Based on observation, interview, and record review, the facility failed to assess a resident's ability to self-administer medications for one of one resident reviewed for self-administration of medications. (Resident 78).This failure had the potential for Resident 78 to over medicate and affect Resident 78's health and safety.Findings:Resident 78 was admitted to the facility on [DATE] with diagnoses including hypotension (low blood pressure) and diabetes (too much sugar circulating in the blood) according to the facility's admission Record.During the initial tour on 8/5/25 at 9:08 A.M., Resident 78 was sitting at the edge of the bed with the right eye closed. Resident 78 stated the nurse applied eye drops on the right eye and she (Resident 78) applied eye drops on the left eye every hour.A review of Resident 78's physician's orders in the electronic medical record (EMR) was conducted. The physician's orders indicated, Autologous [person's own cells or tissues] serum eye drops 1 drop both eye four times a day for chronic dry eye syndrome in refrigerator patient to provide own med.GenTeal Tears [artificial tears] Severe Day/Night Ophthalmic [for the eyes] Gel Instill 1 drop in right eye every day and evening shift for dry eye syndrome every 1 hour supervised self-administration to stop at 2100[9 P.M.] , restart at 0800 [8 A.M.] AND Instill 1 drop in right eye every day and evening shift for Dry eye to stop at 2100, restart at 0800.During observation and interview on 8/6/25 at 3:10 P.M., Resident 78 stated she kept the eye drops at her bedside. Resident 78 took a paper cup from the overbed table and showed three eye drops inside the cup: gen teal, optase {for dry eyes) and gentamicin (an antibiotic). Resident 78 stated she applied one of the eyedrop herself but called for a nurse to administer the other eye drop because it was thicker and difficult to self-administer.An interview with Licensed Nurse (LN) 1 was conducted on 8/6/25 at 3:27 P.M. LN 1 reviewed Resident 78's physician's orders in the EMR. LN 1 stated Resident 78 had physician's orders for GenTeal to be administered every hour to Resident 78's right eye, erythromycin to be administered at bedtime and Optase to be administered to Resident 78's left eye every hour. LN 1 stated Resident 78 was not supposed to keep medications at bedside unless there was a physician's order, labeled with the resident's name, directions and stored properly. LN 1 stated it was important not to keep medications at bedside because the resident may double dose. LN 1 stated she was unsure of how to properly store Resident 78's medications in the room. LN 1 stated there was no assessment for Resident 78 to self-administer medications.During an interview on 8/8/25 at 8:30 A.M. with the Infection Preventionist (IP), the IP stated if a resident requested to self-administer medications an assessment of the resident will be completed. The IP further stated a physician's order will be obtained, a lock box will be provided for the resident and the medication nurse will check if the resident was taking the medication.An interview was conducted on 8/8/25 at 10:30 A.M. with the Assistant Director of Nursing (ADON). The ADON stated Resident 78 should have an assessment for self-administration of medications, a physician's order, care plan and a lock box. The ADON stated it was important to complete an assessment for Resident 78's safety.A review of the facility's undated policy and procedure (P&P) titled, Self-Administration of Medications was conducted. The P&P indicated, Residents have the right to self-administer medications if the interdisciplinary team [IDT-team members with various areas of expertise who work together toward the goals of their resident] has determined that it is clinically appropriate and safe for the resident to do so.If it is deemed safe and appropriate for a resident to self- administer medications, this is documented in the medical record.Self-administered medications are stored in a safe and secure place, which is not accessible by other residents.

Based on interview and record review, the facility failed to ensure a resident's authorized responsible party had signed the informed consent for the use of the psychotropic medication (medications that affect brain activities associated with mental processes and behaviors) prior to administering the medications for one of five sampled residents reviewed for unnecessary medications (Resident 7).This failure increases the risk of inappropriate use of psychotropic medications.Findings:Resident 7 was admitted to the facility on [DATE] with diagnoses that included Dementia (loss of memory) with agitation, per the admission Record. Per the same document, Resident 7 had a Responsible Party (RP - an individual legally authorized to make decisions on behalf of a resident).A review of Resident 7's medical records was conducted. Per the Minimum Data Set (MDS- comprehensive evaluation of a resident's health and functional status), under Section C- Cognitive Patterns, Resident 7's Brief Interview for Mental Status (BIMS) score was 5, indicating severe cognitive (mental processes) impairment.Per the Physician's order, dated 12/4/24, Resident 7 started Quetiapine Fumarate (a psychotic medication) 100 milligrams (mg) every bedtime, and on 12/16/24, Resident 7 started Brexpiprazole (a psychotropic medication) 1 mg daily. A review of Resident 7's electronic medical record revealed no documented evidence of signed informed consent for either medications. A subsequent review of the paper chart indicated that the informed consent for Quetiapine Fumarate did not have the RP's signature, and no informed consent was present for Brexpiprazole.On 8/7/25 at 11:15 A.M., a joint interview and record review was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 7 should have an informed consent signed by the RP before administering the psychotropic medication. The ADON further stated she would ask the medical record to locate the consents.On 8/7/25 at 4:15 P.M., an interview was conducted with the RP. The RP stated she could not recall any discussion with staff or clinicians about the purpose, risks, or benefits of Resident 7's psychotropic medications prior to Resident 7's medication administration. The RP further stated she signed the informed consent today [8/7/25].On 8/8/25 at 9:52 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 3. LN 3 stated that there was no informed consent for the Brexpiprazole, and the Quetiapine Fumarate was signed by the RP on 8/7/25. LN 3 further stated the informed consent should have been signed before giving the psychotropic medications to ensure the resident or RP was aware of the risks and benefits of the treatment, and the consent was the confirmation of the treatment.Per the facility's policy and procedure, dated 2/2025, titled Psychotropic Medication Use, .Informed Consent or Refusal 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining a documented consent .