Every finding on record at Ceres Postacute Care

Based on observation, interview, and record review, the facility failed to provide Physical Therapy (PT - a healthcare specialty that aims to improve and restore physical function, reduce pain, and prevent future injuries) treatment and services to increase range of motion (the full movement potential of a joint to flex and extend in any direction) and mobility (the ability to move, change, or control their body position independently and comfortably) to prevent further decrease in range of motion and mobility for one of three sampled residents (Resident 1), when Resident 1 was not provided PT treatment and services on 4/13/26, 4/14/26, and 4/15/26.This failure had the potential to result in further decrease in range of motion and mobility by reducing Resident 1's ability to walk or perform activities of daily living (dressing, toileting, bathing, feeding, and transferring) independently. Findings:During a concurrent observation and interview on 4/28/26 at 11:22 a.m. in Resident 1's room, Resident 1 was sitting up in bed. Resident 1 was alert and oriented to self, place, and time. Resident 1 stated he was unable to walk. Resident 1 stated he gained a lot of weight over the years and his legs have become weak. Resident 1 stated he wanted to lose weight and gain strength back to his legs so he could start walking again. Resident 1 stated he was supposed to receive PT treatment and services five times a week but has been going to PT only twice a week. Resident 1 stated he has been making progress with PT but was not getting as much PT as he should. Resident 1 stated he would like to go to PT every day if he could.During a review of Resident 1's admission Record (AR), dated 4/28/26, the AR indicated, Resident 1 had a history of Chronic Respiratory Failure with Hypoxia (a long-term condition where the lungs cannot adequately transfer oxygen into the blood, leading to consistently low blood oxygen levels), Abnormal Gait (walking) and Mobility, Morbid Obesity (a severe and chronic disease characterized by an accumulation of excessive body fat that poses a risk to health), Metabolic Encephalopathy (brain dysfunction caused by chemical imbalances, systemic illnesses, or organ failure), Osteoarthritis (a chronic, degenerative joint disease characterized by the progressive breakdown of cartilage - the slippery tissue cushioning joint ends) of the left and right knee, and Muscle Weakness. During a review of Resident 1's Minimum Data Set (MDS - process for clinical assessment of all residents of long term care nursing facilities), dated 4/14/26, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS - an assessment of a resident's ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 14 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated Resident 1 was dependent (helper does all the effort) with transfer from bed to chair and required assistance with dressing and personal hygiene (habits to maintain cleanliness).During a review of Resident 1's PT Recert, Progress Report & Updated Therapy Plan (PTR), dated 4/22/26 - 5/21/26, the PTR indicated, .STG [short term goal] Goal #3 - Continue: Pt [patient] will be able to ambulate [walk] at par bars [parallel bars - a rehabilitation tool consisting of two long, adjustable, and stable horizontal handrails] at tolerated distance with MAX A [maximum assistance] with reduced risk for falling. LTG [long term goal] Goal #3 - Continue: Pt will be able to ambulate on level surface for 75 ft [feet] using FWW [front wheel walker - device used to assist with walking] with SBA [stand by assistance]. Justification for Continued Skilled Services: .Continued PT services are necessary in order to facilitate independence with all functional mobility. Plan of Treatment. Frequency: 5 time(s)/week. Potential for Achieving Rehab Goals: Patient demonstrates good rehab potential as evidenced by active participation with plan of treatment.During a concurrent interview and record review on 4/28/26 at 12:09 p.m. with the Physical Therapist Assistant (PTA), Resident 1's Service Log Matrix (SLM), dated 4/1/26 - 4/30/26 was reviewed. The SLM indicated Resident 1 did not receive PT treatment and services on 4/13/26, 4/14/26, and 4/15/26. The PTA stated Resident 1 received PT treatment and services on 4/13/26 but the treatment and services were not billed (process for submitting treatments and services for reimbursement) therefore the treatment and services did not appear on the SLM. The PTA stated Resident 1 was scheduled to receive PT treatment and services on 4/14/26 but did not receive PT treatment and services on 4/14/26. The PTA stated Resident 1 was not scheduled to receive PT treatment and services on 4/15/26 and did not receive PT treatment and services on 4/15/26. The SLM stated Resident 1 was required to receive PT treatment and services five days a week according to Resident 1's PTR and did not.During a concurrent interview and record review on 4/28/26 at 12:30 p.m. with the PTA, Resident 1's Daily Activity Schedule (DAS), dated 4/13/26 was reviewed. The PTA stated the DAS indicated Resident 1 was on the schedule to receive PT treatment and services. The PTA stated Resident 1 received PT treatment and services on 4/13/26 but it was not billed.During a concurrent interview and record review on 4/28/26 at 12:35 p.m. with the PTA, Resident 1's Daily Treatment Log (DTL), dated 4/13/26 was reviewed. The PTA stated the DTL indicated Resident 1 was not on the DTL. The PTA stated the DTL indicated the PT treatment and services was supposed to be provided on 4/13/26 but Resident 1 was not on the DTL.During a concurrent interview and record review on 4/28/26 at 12:37 p.m. with the PTA, Resident 1's DAS, dated 4/14/26 was reviewed. The PTA stated the DAS indicated Resident 1 was on the schedule to receive PT treatment and services. The PTA stated Resident 1 was scheduled to receive PT treatment and services on 4/14/26 but Resident 1 did not receive PT treatment and services on 4/14/26.During a concurrent interview and record review on 4/28/26 at 12:39 p.m. with the PTA, Resident 1's DTL, dated 4/14/26 was reviewed. The PTA stated DTL indicated Resident 1 was not on the DTL. The PTA stated the DTL indicated the PT treatment and services was supposed to be provided on 4/14/26 but Resident 1 was not on the DTL.During a concurrent interview and record review on 4/28/26 at 12:42 p.m. with the PTA, Resident 1's DAS, dated 4/15/26 was reviewed. The DAS indicated Resident 1 was not on the schedule to receive PT treatment and services. The PTA stated Resident 1 was not scheduled to receive PT treatment and services on 4/15/26 and Resident 1 did not receive PT treatment and services on 4/15/26.During a concurrent interview and record review on 4/28/26 at 12:45 p.m. with the PTA, Resident 1's DTL, dated 4/15/26 was reviewed. The DTL indicated Resident 1 was not on the DTL. The PTA stated the DTL indicated the PT treatment and services provided on 4/15/26 and Resident 1 was not on the DTL.During an interview on 4/28/26 at 1:45 p.m. with the Physical Therapist (PT), the PT stated PT treatment and services were provided to Resident 1 on 4/13/26 but he was unable to recall why the treatment and services were not billed. The PT stated if the treatment and services were not billed, the treatment and services will not appear on the SLM. The PT stated if PT treatment and services were required and the treatment and services were not provided, a valid reason was required. The PT stated Resident 1 was not on the schedule to receive PT treatment and services on 4/14/26 and 4/15/26 and Resident 1 did not receive PT treatment and services on 4/14/26 and 4/15/26. The PT was unable to recall why Resident 1 was not on the DAS for 4/14/26 and 4/15/26. The PT stated if a resident was not on the DAS, the PT was unable to touch the resident. The PT stated if a regular resident was not on the DAS, rehabilitation staff should follow up with why the resident was not on the DAS. The PT stated PT treatment and services should be documented, billed, and processed in a timely manner to reflect the treatment and services provided. The PT stated missing three days of PT treatment and services was not acceptable. The PT stated missing three days of treatment was not significant but if treatment and services continued to be missed, it had the potential to set back the resident's rehabilitative progress. The PT stated the rehabilitation department had no direct supervision on the floor currently and he was only available per diem (day by day). The PT stated the facility did not have a full time Director of Rehabilitative Services (DOR) and the DOR was responsible to ensure the DAS was completed. The PT stated if a regular resident was not on the DAS, it was his responsibility to find out the reason why the resident was not scheduled and document the reason. The PT stated Resident 1 was a regular PT resident and required PT treatment and services 5 times week. The PT stated he should have questioned why Resident 1 was not on the DAS on 4/14/26 and 4/15/26 and he did not.During an interview on 4/28/26 at 2:05 p.m. with the DOR, the DOR stated Resident 1's 4/13/26 treatment and services progress note should be billed within 24 hours as a standard of practice. The DOR stated it was the DOR, the Rehabilitative Aide, and the PT's responsibility to ensure residents were seen and met their PT treatment and services frequency as planned. The DOR stated the PT had access to the assignment board and the PT indicated on Resident's 1 progress note the day before to continue plan of care five times a week. The DOR stated the assignment board was mapped out weeks in advance. The DOR stated lack of documentation indicated treatment and services were not provided. The DOR stated if a resident missed a treatment and service, the PT could back fill the treatment and service on a Saturday or Sunday. The DOR stated audits (a systematic examination and verification of records, processes, or financial accounts to ensure accuracy, compliance, and efficiency) were completed weekly to ensure residents met their frequency for PT treatment and services. The DOR stated missed treatment and services could slow rehabilitative progress.During an interview on 4/28/26 at 2:20 p.m. with the Director of Nursing (DON), the DON stated PT treatment and services should meet the resident's frequency. The DON stated missed treatment and services could cause a decline in the resident's rehabilitative progress. The DON stated it was standard of practice to document, upload and bill treatment and services in a timely manner to indicate the treatment and services were provided. The DON stated three missed treatments in a row for Resident 1 was unacceptable without a valid reason.During an interview on 4/28/26 at 2:25 p.m. with the Administrator (ADM), the ADM stated PT treatment and services should meet the resident's frequency. The ADM stated missing treatment and services could cause a decline in the resident's rehabilitative progress. The ADM stated documentation for the treatment and services were required in timely manner to reflect the care provided. The ADM stated the DOR provided oversight at two facilities and the facility was in the process of hiring a full-time and permanent DOR.During a review of the facility's policy and procedure (P&P) titled, Specialized Rehabilitative Services, dated 1/2026, the P&P indicated, POLICY: Our facility will provide rehabilitative services to residents as indicated by the MDS. PROCESS: 1. In addition to rehabilitative nursing care, the facility provides specialized rehabilitative services by qualified professional personnel. 2. Specialized rehabilitative services include the following: a. Physical therapy. Once a resident has met his/her care plan goals, a licensed professional can either discontinue treatment or initiate a maintenance program which either nursing or restorative aides will implement to assure that the resident maintains his/her functional and physical status.

Based on interview and record review, the facility failed to notify the required State Agency (SA) within ten (10) days when there was a Change in Administrator (CHOA) on 11/13/2023. This failure had the potential for the facility information to not be up to date and had the potential for the old Administrator (ADM) to receive communication from the SA that was intended for the current ADM. Findings: During a concurrent interview and record review on 12/2/2025 at 12:33 p.m. with the Director of Nursing (DON), the facility's organizational chart, undated was reviewed. The organizational chart indicated that ADM 1 was the administrator. The DON stated ADM 1 had been the ADM since she assumed position as the DON in May 2025. The DON stated she was aware he was the ADM two years ago when she was a Licensed Nurse (LN) at a sister facility.During an interview on 12/2/2025 at 12:51 p.m. with the Medical Records Director (MRD), the MRD stated she had worked at the facility for 3 years. The MRD stated ADM 1 had been at the facility as the ADM for over 2 years. The MRD stated staff were notified of the change of administrator (CHOA) during a meeting and ADM 1 was introduced to staff. The MRD stated she was not sure what reporting requirements were for a CHOA.During an interview on 12/2/2025 at 1 p.m. with the Social Services Director (SSD), the SSD stated she had worked at the facility for 5 years. The SSD stated there had been three ADM changes since she worked at the facility. The SSD stated ADM 1 was the third ADM change. The SSD stated the ADM 1 started working at the facility in 2023 but was unsure of the exact month. The SSD stated she was not aware if a CHOA report was made to the SA.During an interview on 12/2/2025 at 1:10 p.m. with ADM 1, ADM 1 stated he assumed the role of ADM for the facility on 11/13/2023. ADM 1 stated ADM 2 was the previous administrator and had left the facility before he assumed the role of ADM. ADM 1 stated he was aware that the State of California required facilities to report administrative changes to the SA. ADM 1 stated the [NAME] President of Operations (VPO) was responsible for reporting the change. ADM 1 stated, since becoming the ADM, he had communicated and represented the facility with the SA on many occasions, during surveys and inspections. ADM 1 stated he was responsible for regulatory reporting.During a review of the facility document titled, Offer Letter, the document indicated that ADM 1 was hired on 11/13/2023.During a review of the facility document titled, Letter of Resignation (LR), dated 9/6/2023, the document indicated ADM 2 had sent a formal resignation to the VPO effective 9/15/2023.During a review of the facility document titled, Applicant Individual Information (HS215A) form (HS), dated 12/30/2023, the document indicated, .A. Applicant Facility Information. 1. Facility Name: {named organization} dba (doing business as) {named 3 different facilities} . The document indicated ADM 1 completed and signed the HS on the 12/30/2023. The document had no certified receipt or stamped date indicating the document was received by the SA.During a phone interview on 12/10/2025 at 8:50 a.m. with ADM 1, ADM 1 stated the HS was submitted to the SA via postal service mail carrier. ADM 1 stated he did not have proof the form was mailed to the SA. ADM 1 stated he never verified with the SA if he was listed as the ADM on record. ADM 1 stated he did not know how to verify if he was the ADM on record. ADM 1 stated the facility had been waiting for electronic mail (e-mail) from the SA to confirm the ADM on record had been updated. ADM 1 stated he was unsure when he first learned he was not the ADM on record and would have to refer back to when he got an e-mail from the SA. ADM 1 was unable to provide evidence of the correspondence between the facility and the SA on the CHOA for the facility. ADM 1 stated the facility had no policy and procedure for CHOA. ADM 1 stated the facility had no policy and procedure for reporting to the Regulatory Authority.During a phone interview on 12/10/2025 at 9:05 a.m. with the VPO, the VPO stated she was responsible for notifying the SA of the CHOA. The VPO stated the ADM was responsible for ensuring the facility was in compliance with the SA at all times. The VPO stated an appointment letter along with the HS was sent to the SA. The VPO was unable to provide proof of the mailed documents. The VPO stated when documents were mailed to the SA, the facility would receive a notification back in the form of a letter stating whether the application had been accepted or not. The VPO was unable to provide the letter stating whether the application had been accepted or not.During a record review of the Electronic Licensing Management System (ELMS) for the SA Licensing and Certification (L&C), under the Facility - Related Entity Tab dated 12/11/25, the ELMS indicated the ADM on record was, ADM 2 . role status: Active.start date-7/12/2022 and no end date.During a record review of the ELMS program under the Facility- Applications Tab, dated 12/11/25, the ELMS indicated the prior application for CHOA for the facility was on 4/22/2022 with Application ID: 2966790 and the status: application approved. The ELMS indicated the most recent application for CHOA for the facility was on 12/3/2025, Application ID: 4411485, and status: pending assignment. The ELMS indicated there was no application for CHOA for the facility between 4/22/2022 and 12/3/2025. The ELMS indicated there were no additional pending CHOA applications for the facility.During a review of California Code of Regulations Title. 22, S 72211 - Report of Changes (CCR), dated as 11/28/25 Register 2025, No. 48, reviewed on 12/12/2025, found at https://govt.westlaw.com/calregs/Document/IB8E826655B6111EC9451000D3A7C4BC3?viewType=FullText&originationContext=documenttoc&transitionType=StatuteNavigator&contextData=%28sc.Default%29, the CCR indicated, .(b) When a change of administrator occurs, the Department shall be notified within 10 days in writing by the licensee. Such writing shall include the name and license number of the new administrator.

Based on observation, interview, and record review, the facility failed to post the results of the most recent survey in a place readily accessible for 41 of 41 residents, families, and their legal representatives. This failure had the potential to violate the rights of residents and their representatives to be informed of previous survey deficiencies. Findings: During an observation on 5/12/25 at 10:35 a.m., the facility's survey binder was located in a holder on the wall, next to the main entrance in the facility. The binder did not contain recertification results for the facility's last survey on 5/23/24. During a concurrent interview and record review on 5/16/25 at 9:01 a.m. with the Senior [NAME] President of Clinical Operations (SCO) and the Administrator (ADM), the facility's Survey Results binder, undated was reviewed. The SCO stated the previous years survey results were not included in the Survey Results binder. The ADM stated the previous year's survey results were not included in the binder. The ADM stated a staff member took out the survey results and never returned it. The ADM stated the binder should always have the survey results readily available. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated 8/09, the P&P indicated, . 1. Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the resident's right to: . w. examine survey results .

Based on observation, interview, and record review, the facility failed to follow an infection prevention and control program designed to provide a safe and sanitary environment for three of the eight (Residents 1, 2 and 14) sampled residents when: 1. The facility's written policies and procedures (P&P) for infection prevention and control program (IPCP) did not include the list of communicable diseases (infectious illnesses that spreads from one person to another or from surface to a person), when and to whom possible incidents of communicable disease or infections should be reported, and COVID-19 (Coronavirus disease 2019 -an illness caused by a virus) infection prevention and control was not updated. These failures had potential risk in the development and transmission of communicable diseases and infections for all residents. 2. Certified Nursing Assistant (CNA)1 did not wear appropriate personal protective equipment (PPE- specialized clothing, equipment, and supplies worn by healthcare workers protect residents and themselves from potential infectious hazards) when she provided care to Resident 2 who was on enhanced barrier precaution (EBP- measures used in healthcare settings to prevent the spread of infections) for a wound to the left leg. This failure had the potential for CNA 1 to cause cross contamination (spread infections to other people and places) from Resident 2's left leg wound and to other residents CNA 1 came into contact within the facility, for other residents to become infected, potentially causing health complications. 3. Licensed Vocational Nurse (LVN) 1 used one pair of gloves to administer oral medication, injectable insulin glargine (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication), and eye drops to Resident 1. LVN 1 did not wash hands or apply different gloves to administer the injectable or the eye drops. This failure had the potential risk for Resident 1 to develop an eye and skin infection. 4. Resident 14's urinal (a container used to collect a urine) was hanging in the trash can with urinal's handle touching the trash. This failure had potential for causing cross contamination (spread infections to other people and places) and spread of infection to Resident 14 and other residents. Findings: 1. During a concurrent observation and interview on 5/15/25 at 9:15 a.m. with LVN 1 at Nursing Station 2, LVN 1 was looking for the written P&P for IPCP binder (a set of facility's policies and procedures aimed at preventing the spread of infection) and found the binder inside the closed top cabinet. LVN 1 stated he had not checked the written P&P for IPCP binder for months. LVN 1 with the help of the Infection Preventionist (IP) were unable to locate the posting of the local health department at the nursing station. LVN 1 stated he was not aware of the local health department contact information for reporting communicable diseases. LVN 1 handed the written P&P for infection prevention and control program binder to the IP. During an interview on 5/15/25 at 10:44 a.m. with Director of Nursing (DON), the DON stated the P&P for IPCP should be reviewed. The DON stated, I am assuming every year, not sure. The DON stated she needed to check who's responsibility it was to review the P&P for IPCP. During a concurrent interview and record review on 5/15/25 at 2:59 p.m. with the IP, the IPCP binder and the written P&P's for infection control was reviewed. IPCP Binder indicated, the list of communicable diseases, when and to whom possible incidents of communicable disease or infections should be reported were not included in current written P&P for IPCP binder. The IP stated she needed to put the communicable diseases list and contact information of the local health department in the infection control (a set of procedures and policies aimed at preventing the spread of infection) binder. The IP stated the P&P for COVID 19 - Vaccine was last updated 10/6/2022. The IP stated, .it should be updated. The IP stated written P&P for IPCP was reviewed by Interdisciplinary Team (IDT ) on 1/25. The IP stated she reviewed the IPCP every month. The IP stated she could not locate the date when the IDT last reviewed their current written P&P for IPCP. The IP stated it is important to review the P&P for IPCP to prevent the transmission of communicable disease, infections, and outbreaks. During an interview on 5/15/25 at 3:52 p.m. with CNA 2, CNA 2 stated she had not received an in-service (a training) about communicable diseases. CNA 2 stated she received an in-service with the IP about no gloves on hallways and no dirty linen on the floor. During an interview on 5/15/25 at 3:55 p.m. with LVN 2, LVN 2 stated she was not sure if she received training about communicable diseases. LVN 2 was not aware of where to find the P&P for Communicable Diseases. LVN 2 stated, I am not familiar, let me find out. During an interview on 5/15/25 at 4:01 p.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 did not know where to find the list of communicable diseases. RNA 1 stated she had not received training about communicable diseases. During an interview on 5/15/25 at 4:06 p.m. with CNA 3, CNA 3 stated did not know about communicable diseases and not aware where to locate the infection control P&P. CNA 3 stated she did not remember receiving a training about communicable diseases. During an interview on 5/15/25 at 4:10 p.m. with LVN 3, LVN 3 was unable to state any of the communicable diseases. LVN 3 stated she did not know where to find the P&P for communicable diseases, and stated, I'll find out. During an interview on 5/16/25 at 11:31 a.m. with CNA 4, CNA 4 stated he did not know there was a list of communicable diseases and did not know where to access it. CNA 4 stated he was not familiar with the P&P for IPCP binder. During a review of facility's P&P titled, Policies and Practices-Infection Control, dated 1/18, the P&P indicated, The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment to help prevent and manage transmission of diseases and infections. All personnel will be trained in our infection policies and practices upon hire and periodically thereafter, including how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. 2. During a review of Resident 2's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/15/25, the AR indicated, Resident 2 was admitted to the facility on [DATE] with a diagnosis of chronic ulcer of left leg (a small open sore or wound generally found in the stomach or on the skin). During an observation on 5/12/25 at 11:13 a.m. outside of Resident 2's room, Resident 2's room had an EBP sign outside of his room. CNA 1 entered Resident 2's room to provide care and did not wear PPE. During an interview on 5/12/25 at 3:14 p.m. with CNA 1, CNA 1 stated she should have worn PPE when entering Resident 2's room. CNA 1 stated Resident 1 had a wound to his left leg and wearing appropriate PPE helped to prevent any cross contamination. During an interview on 5/15/25 at 10:13 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated all staff needed to wear PPE before providing care to residents on EBP. LVN 1 stated wearing proper PPE when providing care helped prevent contamination to the residents and other staff. During an interview on 5/15/25 at 3:49 p.m. with the Infection Preventionist (IP), the IP stated all staff needed to wear PPE when entering EBP rooms to provide care. The IP stated Resident 2 had a chronic ulcer in his leg and staff needed to wear gowns and gloves if they had to touch him or the wound. The IP stated proper PPE helped prevent cross contamination from occurring; cross contamination could prevent Resident 2's wound from healing. During an interview on 5/15/25 at 3:55 p.m. with the Director of Nursing (DON), the DON stated CNA 1 needed to wear PPE when providing care to Resident 2 so no cross contamination occurred. The DON stated Resident 2's wound had the potential to become infected if proper PPE was not worn. During a review of the professional reference (PR), found on https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html an article titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 7/12/22, the PR indicated, . [Multi Drug Resistant organisms] (MDROs - germs which have become resistant to medications) may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds . are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply . 3. During an observation on 5/14/25 at 8:59 a.m. with LVN 1, outside Resident 1's room, LVN 1 was preparing Resident 1's medications for 7:00 a.m. and 8:00 a.m. on the top of the medication cart. LVN 1 put on a pair of gloves before entering Resident 1's room. LVN 1 was wearing a glove while holding a medication tray with oral medications, insulin glargine pen, and eye drops and knocked on Resident 1's door. LVN 1 stated, Hello [stated Resident 1's first name], I will give your medications, insulin glargine and eyedrops. LVN 1 did not check Resident 1's wrist band and did not check allergies before administering the medication to Resident 1. During an observation on 5/14/25 at 9:02 a.m. with LVN 1, in Resident 1's room, LVN 1 administered three of three medications by mouth to Resident 1 using a glove to both hands. During an observation on 5/14/25 at 9:03 a.m. with LVN 1, in Resident 1's room, LVN 1 stated, I am giving your long-acting insulin [glargine] on your left arm. LVN 1 used the same gloves when injecting the insulin glargine into Resident 1's left arm. LVN 1 did not change his gloves. During an observation on 5/14/25 at 9:04 a.m. with LVN 1, in Resident 1's room, LVN 1 used the same pair of gloves when instilling one drop of lubricant eye drops to both eyes of Resident 1. LVN 1 used one pair of gloves for different routes of medication administration including oral, insulin glargine injection, and eye drops. During an interview on 5/14/25 at 9:38 a.m. with LVN 1, LVN 1 stated, I did not change my gloves before applying the eyedrops. LVN 1 stated he used one pair of gloves when administering oral, insulin injection and eyedrops medications to Resident 1. LVN 1 stated he should have changed his gloves when administering the eyedrops to both eyes of Resident 1 to prevent cross contamination and potential eye infection. During an interview on 5/15/25 at 8:32 a.m. with the IP, the IP stated nurses should follow standard precautions for medication administration. The IP stated nurses should change the gloves after oral medication administration, insulin glargine administration, and eye drops administration. The IP stated using the same pair of gloves when administering different routes of medications had the potential risk for cross contamination and infection. During an interview on 5/15/25 at 10:44 a.m. with the DON, the DON stated gloves must be changed after each route of medication administrations (oral, insulin glargine injections, and eye drops) to prevent cross contamination and potential infection to the eye and skin. During a review of facility's P&P titled, Standard Precautions, dated 1/18, the P&P indicated, Standard precautions are used in the care of all residents in all situations regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions include the following practices:2. Gloves e. Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another . 4. During a concurrent observation and interview on 5/12/25 at 10:28 a.m. with Resident 14, in Resident 14's room, Resident 14 was laying in bed, awake, alert and oriented times 4 (person, place, time, and event). Resident 14 was pleasant, clean, and well groomed. Resident 14 stated he's been at the facility since 2016. Resident 14 stated he was admitted to the facility from the hospital. Resident 14 stated he has a diagnosis of Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and nurses have been checking his blood sugar four times a day. Resident 14 stated he uses urinal and a brief for episode of urine leakage. Resident 14 pointed to his urinal hanging in the trash can with the urinal holder touching the trash in the trash can at bedside. Resident 14 stated he prefers hanging his urinal in the trash can because of easy access and easily available when he needs it. Resident 14 stated staff remove the trash and empty his urinal at the end of each shift. During a review of Resident 14's AR, dated 5/14/25, the AR indicated, Resident 14 was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus, Atherosclerotic Heart Disease (a buildup of fats and other substances in and on the artery walls), and Atrial Fibrillation (irregular heartbeat). During a review of Resident 14's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/1/25, the MDS section C indicated, Resident 14 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15, which indicated Resident 31 was cognitively intact (a person's mental functions, such as thinking, remembering, and understanding, are in good shape and not impaired). During a concurrent observation and interview on 5/13/25 at 11:15 a.m. with LVN 3, LVN 3 stated the urinal was hanging in the trash can with trash present in the trash can, and his urinal was half full of amber colored urine. LVN 3 stated Resident 14 wanted his urinal hanging in the trash can. LVN 3 stated having the urinal in the trash can cause cross contamination and potential infection to Resident 14. LVN 3 stated nurses needed to monitor Resident 14 for infection and address in Resident 14's weekly progress notes the risk for infection. During an interview on 5/15/25 at 8:32 a.m. with the IP, the IP stated Resident 14 wanted to hang the urinal in the trash can and refused the urinal holder. The IP stated using the trash can as urinal holder can cause cross contamination and potential infection and stated, .more infection issues . The IP stated she verbally talked to the resident about the risk of infection and created a care plan. The IP stated there was no IDT meeting regarding Resident 14's use of trash can as urinal holder and how to minimize and prevent infection. During a concurrent observation and interview on 5/16/25 at 8:24 a.m. with Resident 14, in Resident 14's room, Resident 14's urinal was hanging in the trash can (with trash) at bedside. Resident 14' urinal was a quarter full of yellow colored urine. Resident 14 stated he requested to keep the urinal hanging in the trash can for easy access and easy reach. Resident 14 stated he tried the urinal holder, and he had difficulty accessing his urinal. Resident 14 stated he had been hanging his urinal in the trash can since 2016. Resident 14 stated staff changed his brief at least once a shift. Resident stated staff did not empty his urinal after he used it. During an interview on 5/16/25 at 10:35 a.m. with the DON, the DON stated using a trash can as urinal holder could put Resident 14 at risk for cross contamination and infection. The DON stated emptying the urinal and trash can once a shift would not be sufficient to minimize the risk of infection. During a review of Resident 14's EMR document titled Care Plan Report dated 5/13/25, the Care Plan Report, indicated, .Risk for infection and environmental contamination related to improper storage of urinal bottle . During a review of facility's P&P titled, Standard Precautions, dated 1/18, the P&P indicated, Standard precautions are used in the care of all residents in all situations regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions include the following practices:5. Resident-Care Equipment a. Resident-care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments.

Based on observation, interview, and record review, the facility failed to ensure cold food storage was stored under sanitary conditions in accordance with professional standards for food service safety when refrigerator A was observed at 42 degrees Fahrenheit (F) (unit of measure for temperature) which was above the recommended safe temperature range of 32 to 40 degree F for cold food storage. This failure had the potential to contribute to the growth of foodborne pathogens (a tiny organism, like a germ, that could cause disease. Pathogens included things like bacteria, viruses and fungi) and posed a risk of foodborne illness (any illness resulting from eating contaminated/spoiled foods) symptoms which could range from nausea, vomiting, diarrhea, abdominal pain, fever, headache, and confusion to residents who received meals and nourishment from refrigerator A. During an observation on 5/12/25 at 10:18 a.m. in the kitchen, during the initial tour the temperature of refrigerator A measured at 42 degrees F. During an observation on 5/13/25 at 8:28 a.m. in the kitchen, refrigerator A's temperature was again measured at 42 degrees F. During an interview on 5/13/25 at 2:02 p.m. with Kitchen Staff (KS) 1, KS 1 stated the refrigerator should be maintained between 34- and 36-degrees F. KS 1 stated the temperature of refrigerator A fluctuated depending on how frequently the unit door was opened. During an interview on 5/14/25 at 8:29 a.m. with KS 1, KS 1 stated the refrigerator temperature was checked up to three times per day- at 5:00 a.m., in the afternoon, and during the night shift. KS 1 stated if the temperature was found to be out of range, staff were to report it to maintenance. KS 1 stated if the refrigerator remained out of temperature range for an extended period, the food could spoil. During an interview on 5/16/25 at 8:36 a.m. with Certified Dietary Manager (CDM), the CDM stated the refrigerator temperature should be maintained between 34 and 39 degrees F, allowing for a two-degree range of flexibility. The CDM stated if the temperature rose above this acceptable range, staff were expected to contact her and maintenance immediately and remove the food from the affected refrigerator. The CDM stated the failure to address temperature deviations could result in spoiled food and posed a risk for foodborne illness to residents. During a review of the facility's policy and procedure (P&P) titled, Cold Storage Temperature Monitoring and Record Keeping, dated 2023, the P&P indicated, Refrigerator temperature standards are less or equal to forty-one degrees .the goal is to keep the temperature at thirty-four - thirty-nine degrees . During a review of the facility's P&P titled, Procedure For Refrigerated Storage, dated 2023, the P&P indicated, To keep food at a specific temperature, the air temperature in the refrigerator usually must be about two degrees lower .for example, to hold chicken at forty one degrees, the air temperature must be thirty nine degrees.

Based on observation, interview and record review the facility failed to ensure the accuracy of assessments for one of one sampled residents (Resident 10) when they did not accurately assess the condition of an area of excoriation (injury to the skin caused by scratching or wearing away the surface) on Resident 10's left buttock. This failure to assess Resident 10's left buttock resulted in an inability to monitor the progression of the condition- and determine if it was improved or had worsened. Findings: During a review of Resident 10's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 1/09/25, the AR indicated Resident 10 has a history of hemiplegia (total paralysis of the arm, leg and trunk on the same side of the body), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control) and failure to thrive (a decline caused by chronic diseases and functional impairments). During a review of Resident 10's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 10 had no cognitive impairment. During an interview on 5/12/25 at 3:12p.m. with Resident 10, Resident 10 stated he had a wound on his bottom. During a review of Resident 10's Care Plan Report (CP) dated 4/2/25, the CP indicated the focus was Resident 10 had excoriation located on left buttock. The CP indicated interventions for the left buttock area to be monitored for signs of infection. During a review of Resident 10's Treatment Administration Record (TAR) dated 5/1/25-5/31/25, the TAR indicated staff were to monitor the excoriation for signs and symptoms of infection. During a review of Resident 10's Progress Note (PN) dated 4/16/25, the PN indicated excoriation was still present upon assessment. MD notified of the condition, will continue to monitor for fourteen days. During a review of Resident 10's PN dated 4/2/25, the PN indicated the nurse reassessed Resident 10 and noted excoriation was still present. The MD was notified, and the monitoring order was renewed. During a review of Resident 10's Nursing admission Assessment (NAA) dated 1/9/25, the NAA indicated Resident 10 had excoriation to the buttock. The NAA did not indicate measurements or additional information regarding the skin condition at that time. During an interview on 5/15/25 at 2:41p.m. with Licensed Vocational Nurse 3 (LVN), LVN 3 stated Resident 10 had excoriation on his buttock for some time and that it was not a new issue. LVN 3 stated the assessments and documentation was to be completed in the nursing progress notes. LVN 3 stated it would have been helpful to include information on how the area of excoriation was progressing. LVN 3 stated although wound length was not typically assessed or documented by the facility staff, it would be beneficial to have a record of the progress. During an interview on 5/16/25 at 9:40p.m. with the Director of Nurses (DON), the DON stated the expectation for skin documentation included appearance, stage, measurements, progression, odor and drainage. The DON stated having documentation of the skin's appearance would be helpful in determining whether the condition had improved or worsened. During a review of Job Description: Licensed Vocational Nurse, dated 10/19/15, the LVN documents accurately and thoroughly .collects, reports and documents objective and subjective data.

Based on observation, interview and record review, the facility failed to develop and implement person-centered care plans for two of five sampled residents (Resident 5 and Resident 9) when: 1. Resident 5 who was dependent on a wireless call light system, did not have one accessible. This failure had the potential to result in unmet personal care needs, inconsistent care and compromised dignity and safety for Resident 5; 2. Resident 9 who had been refusing snacks and meal alternatives and was on meal monitoring due to weight loss did not reciece supplimental snacks or meal alternatives. This failure had the potential to result in continued or worsening weight loss, compromised quality of life and failure to meet therapeutic goals. Findings: 1. During a review of Resident 5's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/7/25 , the AR indicated Resident 5 had the following diagnoses: Dementia (a progressive state of decline in mental abilities), muscle weakness, and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from lows of depression to elevated periods of emotional highs). During a review of Resident 5's Minimum Data Set (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 3/25/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function) score of five (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 5 had severe cognitive impairment. During a concurrent observation and interview on 5/12/25 at 12:28 p.m. in Resident 5's room, no call light was observed in Resident 5's room. Resident 5 stated she was unsure of the location of her call light. During a review of Care Plan (CP) dated 6/22/21, the CP for Resident 5's aggressive behavior, which included wrapping up her call light and throwing it under her bed, was in place; however, the listed interventions did not include the use of the wireless handheld call light device. During an interview on 5/14/25 at 2:03 p.m. with Certified Nursing Assistant (CNA) 7, CNA 7 Stated when a resident needed assistance, they were to use their call lights to request help. CNA 7 stated staff were responsible for being attentive and responsive to call light alerts. CNA 7 stated the risk to the residents, if a call light was not available or accessible, included falls, hunger, and unmet care needs. CNA 7 stated call lights were expected to be within the residents' reach and every resident should have had one available. During an interview on 5/14/25 at 2:53 p.m. with Licensed Vocation Nurse (LVN) 3, LVN 3 stated staff were alerted to residents' needs when the call lights were activated. LVN 3 stated it was essential for staff to respond in a timely manner to call lights as delays could result in serious consequences such as falls, or other adverse outcomes. During a concurrent observation and interview on 5/15/25 at 10:33 a.m. with CNA 1, CNA 1 stated that a care plan was the plan of care for a resident and that care plans were individualized based on each residents' needs. CNA 1 stated Resident 5 did not have a cord call light because she preferred using the handheld wireless device. CNA 1 stated anything could happen if a resident did not have access to a call light. CNA 1 stated a call light was essential in helping staff meet residents' needs. CNA 1 stated since Resident 5 had a specific preference of call light, it should have been reflected in the care plan. During a concurrent interview and record review on 5/15/25 at 10:54 a.m. with LVN 2, LVN 2 stated Resident 5 had a history of hiding the corded call light. LVN 2 stated Resident 5 used the handheld wireless call light, which was typically hung on her wheelchair. LVN 2 stated this method of call for assistance should have been included in her care plan to inform all staff of how Resident 5 requested assistance. LVN 2 stated Resident 5 had been using the wireless call light system for over a month. LVN 2 stated care plans needed to be resident-specific to ensure staff were aware of each resident's individual needs and the appropriate interventions. During an interview on 5/16/25 at 9:40 a.m. with the Director of Nursing (DON), the DON stated her expectation was for Resident 5 to have a care plan addressing the use of her handheld call light. During a review of the facilities policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 1/2018, the P&P indicated, the comprehensive, person-centered care plan will maintain the residents highest practicable physical, mental and psychosocial well-being .incorporate identified problem areas .incorporate risk factors associated with identified problems .reflect the residents expressed wishes regarding care and treatment goals .when possible, interventions address the underlying sources of the problem areas, not just addressing only symptoms or triggers. 2. During a review of Resident 9's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/7/25 , the AR indicated Resident 9 had the following diagnoses: muscle wasting (weakening, shrinking and loss of muscle), and protein-calorie malnutrition (when someone doesn't eat enough food with energy and protein, making them weak, tired and more likely to get sick). During a review of Resident 9's Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 2/6/25, the MDS section C indicated, Resident 9 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 99 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview), which indicated Resident 9 was unable to complete the interview. During a review of Resident 9's Medication Review Report (MRR), dated 5/15/25, the MRR indicated Resident 9 had an active order to monitor episodes of eating less than 75% of meals. During a review of Resident 9's Medication Administration Review (MAR), dated 5/1/25-5/15/25, the MAR indicated, in the month of May, Resident 9 consumed more than 75% of her meals on only two occasions: Dinner on 5/13/25, and lunch on 5/15/25. During a review of Resident 9's Progress Notes (PN), dated 4/29/25, the PN indicated Resident 9 ate 60% of her dinner. Staff offered an alternative three times, but Resident 9 refused each offer. During a review of Resident 9's Progress Notes (PN), dated 5/1/25, the PN indicated Resident 9 ate 55% of her dinner. Staff offered an alternative three times, but Resident 9 refused each offer. During a review of Resident 9's Progress Notes (PN), dated 5/4/25, the PN indicated Resident 9 ate 50% of her dinner. Staff offered an alternative three times, but Resident 9 refused each offer. During a review of Resident 9's Progress Notes (PN), dated 5/7/25, the PN indicated Resident 9 ate 55% of her dinner. Staff offered an alternative three times, but Resident 9 refused each offer. During a review of Resident 9's Progress Notes (PN), dated 5/12/25, the PN indicated Resident 9 ate 65% of her dinner. Staff offered an alternative three times, but Resident 9 refused each offer. During an interview on 5/15/25 at 10:33 a.m. with CNA 1, CNA 1 stated the care plan served as the guiding plan of care for the residents. CNA 1 stated the care plan identified the residents' problems, which varied depending on the resident's medical history. During an interview on 5/15/25 at 10:48 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated meal monitoring should have been care planned. LVN 2 stated Resident 9 was on meal monitoring and if she ate less than 75%, staff were expected to offer a snack or an alternative meal. LVN 2 stated that Resident 9 sometimes refused these offers. LVN 2 stated Resident 9 did not have a care plan in place addressing interventions for when Resident 9 refused supplements or alternatives. LVN 2 states there should have been a care plan for Resident 9. During an interview on 5/15/25 at 11:41a.m. with the Director of Nurses (DON), the DON stated there was no care plan with specific interventions in place for when Resident 9 refused alternatives or supplement meals. The DON stated interventions were scattered among other care plans. The DON stated interventions, should have been clearly defined and specific to each specific problem. During an interview on 5/16/25 at 9:40 a.m. with the DON, the DON stated it was her expectation of staff for a care plan to be in place for when Resident 9 refused alternatives and supplements. During a review of the facilities policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 1/2018, the P&P indicated, the comprehensive, person-centered care plan will maintain the residents highest practicable physical, mental and psychosocial well-being .incorporate identified problem areas .incorporate risk factors associated with identified problems .reflect treatment goals, timetables and objectives in measurable outcomes .aid in preventing or reducing decline in the resident's functional status and or functional levels .when possible, interventions address the underlying sources of the problem areas, not just addressing only symptoms or triggers.

Based on observation, interview, and record review, the facility failed to revise a fall care plan for one of four sampled residents (Resident 24) when, Resident 24 had a fall on 1/3/25, a post fall assessment recommended interventions to monitor proper wearing of shoes when up walking with a front wheeled walker (FWW) and Resident 24's care plan interventions indicated for him to wear nonskid socks when up walking with a FWW. This failure had the potential to result in Resident 24 not receiving the care and services from nursing staff and the potential for subsequent falls and injury. Findings: During observation on 5/12/25 at 10:28 a.m. with Resident 24, by the door of Resident 24's room, Resident 24 was self-ambulating with the use of a walker, with upper body bending forward and both arms extended pushing the walker in front of him. Resident 24 was wearing shoes to both feet with regular socks. Resident 24 was heading towards the dining room. During a concurrent observation and interview on 5/12/25 at 4:20 p.m. with Resident 24, at the dining room, Resident 24 was sitting in a regular chair with a walker in front of him. Resident 24 was pleasant, clean and well groomed. Resident 24 stated his correct name and stated the correct location indicating he was alert and oriented times two. Resident 24 stated he needed more therapy to strengthen his legs, and stated, I appreciate any help I could get. Resident 24 stated he was wearing a brief and someone helped him for a brief change. Resident 24 stated he can put on his shoes. During a review of Resident 24's admission Record (AR), dated 1/14/25, the AR indicated, Resident 24 was admitted to the facility on [DATE] with primary diagnosis of Cerebral Infarction (occurs when the blood supply to part of the brain is blocked or reduced) and other diagnoses of Macular Degeneration (an eye disease that affects central vision), generalized muscle weakness abnormalities of gait (the manner of walking) and mobility. During a review of Resident 24's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/4/25, the MDS section C indicated, Resident 24 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 11, which indicated Resident 24's cognition was moderately impaired. During an interview on 5/14/25 at 2:00 p.m. with Restorative Nurse Assistant (RNA) 1, RNA 1 stated Resident 24 is receiving restorative services (are services to maintain and maximize a person's level of function). RNA 1 stated Resident 24 is on Restorative Nursing Program for ambulation. RNA 1 stated Resident 24 can walk with a walker without staff assistance. During a concurrent interview and record review on 5/15/25 at 10:20 a.m. with the Director of Nursing (DON), Resident 24's Electronic Medical Records (EMR- a digital version of a patient's paper chart) titled, Care Plan Report, (undated) and Rehab Post Fall Assessment -V2 dated 1/6/25 were reviewed. The Care Plan Report, indicated, . The resident is at risk for falls related to forgetful gait balance problem. The Rehab Post Fall Assessment -V2 indicated, . 13. Recommendation will monitor proper wearing of shoes and utilization of Front-wheeled walker (FWW) for ambulation . The DON stated Resident 24 had a fall on 1/3/25 and stated Resident 24's at risk for fall care plan did not indicate new intervention (any action or measures taken to prevent a fall). The DON stated Resident 24's fall care plan should have been updated based on Rehab recommendations and interventions to reflect current intervention prevent further falls. The DON stated it was nurses' responsibility to update and revise the care plan , the care plan goal and interventions must be revised after the fall, and stated, . to prevent from happening again. During an observation on 5/16/25 at 8:29 a.m. with Resident 24, in Resident 24's room, Resident 24 was lying in the middle of bed asleep, with feet on the ground, wearing a shoe to his left foot and regular sock to the right foot. During a concurrent interview and record review on 5/16/25 at 8:50 a.m. with Licensed Vocational Nurse (LVN) 4, Resident 24's fall care plan, dated 9/26/20 was reviewed. The fall care plan indicated, . The resident is at risk for falls related to forgetful gait balance problem. Interventions anticipate and meet resident's needs, ensure wearing non-skid socks when ambulating, follow facility protocol, . LVN 4 stated Resident 24 was wearing shoes when ambulating with a walker and not with non-skid socks. LVN 4 stated Resident 24 is at risk for falls and had a fall on 1/3/25. LVN 4 stated Resident 24 leans forward with walker out in front of him when ambulating, and stated, . his walker should stay closed to him to prevent falls. LVN 4 stated monitoring and reminding Resident 24 to keep his walker close to him should be included in the fall interventions. LVN 4 stated Resident 24's fall care plan should be person-centered and needs to be revised and updated to reflect the current function of Resident 24. LVN stated Resident 24's care plan should be reviewed if care plan goal was met. LVN 4 stated a care plan is very important for the staff to know how to take care of the residents to prevent and minimize the falls. During a review of facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated 1/18, the P&P indicated, . Resident-centered approaches to managing falls and fall risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant .

Based on observation, interview, and record review, the facility failed to meet professional standards of quality by not following facility's policy and procedure (P&P) for Administering Medications for two of nine sampled residents (Residents 1 and 3) when, 1. Licensed Vocational Nurse (LVN) 1 and LVN 3 used one resident identifier (name, date of birth , photograph, wrist band [containing resident information of name and date of birth for proper resident identification], and staff verification) before medication administration for Resident 1 and Resident 3. This failure had the potential for medication errors and negative drug interactions (occur when the effects of one drug are altered by another drug that can lead to decreased effectiveness of medication) for Residents 1 and Resident 3. 2. LVN 1 signed (documented medication was administered) Resident 1's Electronic Medication Administration Records (EMAR -an electronic daily documentation record used by a licensed nurse to document medications and treatments given to a resident) when the inhaler medication salbutamol (medication used to treat asthma (a condition in which person's airways become inflame, narrow , and swell, and produce extra mucus, which makes it difficult to breathe) and exercise-induced bronchospasm (a life-threatening emergency that occurs when the muscles surrounding the lungs' small airways tighten, narrowing the airways) was not administered. This failure had the potential for Resident 2 not to receive the inhaler medication as prescribed by the doctor and placed Resident 2 at risk for negative outcome including shortness of breath. Findings: 1. During an observation on 5/13/25 11:43 a.m. with LVN 3, in Resident 3's room, LVN 3 stated I am your nurse, [stated resident's name]. Resident 3 did not respond when LVN 3 stated his name. LVN 3 stated she would check his gastrostomy tube (GT- a feeding tube inserted directly into the stomach through a small incision in the abdomen) placement and will administer one medication and stated, Synthroid (brand name for Levothyroxine [use to treat underactive thyroid]). Resident 3 did not look at LVN 3 while she explained the procedure to Resident 3. Resident 3 wore a wrist band (containing resident information of name and date of birth for proper resident identification) to his right wrist. LVN 3 did not check Resident 3's wrist band. LVN 3 checked GT placement with the use of stethoscope and checked gastric residual (the amount of liquid remaining in the stomach after the feeding). LVN 3 dissolved one tablet of Levothyroxine in 15 millimeters (ml- unit of measurement) of water and administered through GT via gravity. LVN 3 used one resident identifier [Resident 3's name] prior to administering the medication for Resident 3. During a review of Resident 3's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/15/25, the AR indicated, Resident 3 was admitted to the facility on [DATE] with a primary diagnosis of Dementia (a progressive state of decline in mental abilities), Gastrostomy Status (refers to the presence of absence of gastrostomy, which is a surgical opening into the stomach), and Hypothyroidism ( a condition in which the thyroid gland doesn't produce enough thyroid hormone). During a review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/15/25, the MDS section C indicated, Resident 3 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was blank, which indicated, Section C -Cognitive Patterns C0100 was coded 0 No (resident is rarely/never understood). During an observation on 5/14/25 at 8:59 a.m. with LVN 1, outside Resident 1's room, LVN 1 was preparing Resident 1's medications for 7:00 a.m. and 8:00 a.m. on the top of the medication cart. During an observation on 5/14/25 at 9:02 a.m. with LVN 1, in Resident 1's room, LVN 1 put on a pair of gloves before entering Resident 1's room. LVN 1 was wearing a glove while holding a medication tray with oral medications, insulin pen, and eye drops and knocked on Resident 1's door. LVN 1 stated, Hello [stated Resident 1's first name], I will give your medications, Insulin Glargine (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) and eyedrops. Resident 1 did not respond when LVN 1 stated Resident 1's first name. LVN 1 administered three of three medications by mouth to Resident 1 using one resident identifier [Resident 1's first name). During an observation on 5/14/25 at 9:03 a.m. with LVN 1, in Resident 1's room, LVN 1 stated, I am giving your long-acting insulin on your left arm. LVN 1 stated Resident 1's first name and injected the insulin into Resident 1's left arm. LVN 1 used one resident identifier [Resident 1's first name] prior to administering Resident 1's insulin injection. During an observation on 5/14/25 at 9:04 a.m. with LVN 1, in Resident 1's room, LVN 1 stated Resident 1's first name and instilled one drop of lubricant eye drops in the middle of both eyes. LVN 1 used one resident identifier [Resident 1's first name] prior to administering Resident 1's eye drops. During an interview on 5/14/25 9:38 a.m. with LVN 1, at the nursing station, LVN 1 stated he did not check Resident 1'swrist band and photo of Resident 1 before administering her medications. LVN 1 stated he addressed Resident 2 by her first name. LVN 1 stated it was important to check three resident identifiers including the photo and wrist band to ensure the nurses are administering medication to the right patient to prevent medication error. During an interview on 5/14/25 at 3:15 p.m. with LVN 3, at the nursing station, LVN 3 stated nurses needed to check the resident's photo, wrist band and allergies to make sure nurses are administering medication to the right resident to prevent medication error. LVN 3 stated checking two or more resident identifiers is important for non-verbal (non-speaking) and cognitively impaired residents and stated, . we need to do all the check. During an interview on 5/15/25 at 9:58 a.m. with the Director of Nursing (DON), the DON stated her expectation was for the nurses to follow the P&P for medication administration. The DON stated nurses should use two or more resident identifiers, including resident's photo and wrist band before administering the medications. The DON stated the verification with another staff is important for non-verbal and cognitively impaired residents. During a review of the facility's P&P titled, Administering Medications, dated 1/18, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed. 6. The individual administering medication must verify the resident's identity before giving the resident his/her medication. Methods of identifying the residents include: a. Check identification band; b. Checking photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel. 2. During an observation on 5/14/25 at 8:25 a.m. with Licensed Vocational Nurse (LVN) 1, outside Resident 2's room, LVN 1 was preparing Resident 2's 8:00 a.m. medications on the top of the medication cart. LVN 1 prepared nine oral medications and placed them in 2 separate medication cups. During an observation on 5/14/25 at 8:39 a.m. with LVN 1, outside Resident 2's room, LVN 1 knocked on Resident 2's door and stated Resident 2's last name. LVN 1 informed Resident 2 the name of medications in the medication cups and administered nine oral medications to Resident 2. LVN 1 went back to the medication cart parked outside Resident 2's room and signed all 8:00 a.m. medications as administered, including Resident 2's salbutamol inhaler . LVN 1 did not administer Resident 2's inhaler. During a concurrent interview and record review on 5/14/25 at 9:38 a.m. with LVN 1, at the nursing station, LVN 1 reviewed Resident 2's EMAR, dated 5/14/25, the EMAR indicated, Albuterol Sulfate HFA Inhalation Aerosol Solution (mist that has medicine in it) 108 (90 Base) MCG/ACT (refers to the unit of measurement for drug dosage which indicates the amount of medication in a single dose from an inhaler) 2 puff inhale orally three times a day for shortness of breath at 0800 1200 1600 [4 p.m.]. LVN 1 stated he did not administer Resident 2's inhaler at 8:00 a.m. and stated, I forgot. LVN 1 stated he signed the EMAR for salbutamol inhaler during the morning medication pass and did not administer it. LVN 1 stated, I should not sign the EMAR. During an interview on 5/16/25 10:48 a.m. with the DON, the DON stated her expectation was for nurses to follow the P&P for medication administration and documentation. The DON stated nurses should not sign the EMAR if the medication was not given. The DON stated this practice can result in medication error. During a review of the facility's P&P titled, Administering Medications, dated 1/18, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed. 19. The individual administering the medication must initial the resident's MAR after giving each medication.

Based on observation, interview and record review, the facility failed to ensure the resident environment remains free of accident hazards (a danger or risks) as possible for one of four sampled residents (Resident 31) when, Resident 31's room was cluttered (filled with disorganized items, making it difficult to move around and find things) with multiple boxes at the back of Resident 31's room blocking the door from opening fully and the carpet on the floor had curled edges. These failures placed Resident 31 at risk for an avoidable accident including falling and fall related injuries. Findings: During a concurrent observation and interview on 5/12/25 at 11:30 a.m. with Resident 31, in Resident 31's room, Resident 31 was lying in bed facing the door, watching a movie on his personal computer. Resident 31 stated he had been at the facility for eight months and came from an acute care hospital. Resident 31 was alert and oriented times 4 (indicating correct awareness of person, places, time and event). Resident 31 requested to keep his door closed. Resident 31's room smelled of strong urine. Resident 31 had an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) bag that was covered with a privacy bag attached to the bed frame. Resident 31 stated he had a catheter to drain his urine and was being followed by a urologist (a medical doctor who specializes in the diagnosis and treatment of diseases and conditions of the urinary tract), and stated, .had a blockage. Resident 31 had a walker by the foot of the bed and stated he could walk with or without his walker. Resident 31's room was disorganized with scattered personal belongings, bedside table filled with food, and carpet on the floor with curled edges. Resident 31's door to his room was unable to fully open due to the presence of multiple boxes at the back of the door. During a review of Resident 31's admission Record (AR), dated 5/14/25, the AR indicated, Resident 31 was admitted to the facility on [DATE] with a primary diagnosis of Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and generalized muscle weakness. During a review of Resident 31's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/6/25, the MDS section C indicated, Resident 31 had a Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15, which indicated Resident 31's cognition was cognitively intact (a person's mental functions, such as thinking, remembering, and understanding, are in good shape and not impaired). During a concurrent interview and record review on 5/16/25 at 8:30 a.m. with the Social Services Director (SSD), Resident 31's Electronic Medical Records (EMR- a digital version of a patient's paper chart) titled, Care Plan Report, (undated) and Interdisciplinary Team (IDT) Care Conference, dated 4/11/25 and 1/9/25 were reviewed. The Care Plan Report and IDT Care Conference, indicated no documentation for the cluttered room. The SSD stated the IDT did not identify and discuss Resident 31's safety and health risks related to a cluttered room. The SSD stated she was aware of Resident 31's cluttered room and she had no discussion with Resident 31 about it. The SSD stated Resident 31's cluttered room was posing lots of risks for Resident 31 and stated .can be a fire risk and a fall risk. The SSD stated Resident 31 had a carpet on the floor inside his room that could be a trip hazard. During an observation on 5/16/25 at 8:47 a.m. with Resident 31, at the front entrance area, Resident 31 was ambulating without a walker, holding the indwelling catheter bag. During a concurrent interview and record review on 5/16/25 at 8:50 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 31 had a lot of personal belongings inside his room and a carpet on the floor and stated, . a trip hazard. LVN 4 reviewed Resident 31's EMR titled, Care plan Report, dated 9/29/24, the care plan report indicated, The resident is at risk for falls related to gait/balance problems, incontinence . LVN 4 stated Resident 31 used a walker when ambulating and had episodes of ambulating without assistive device. LVN 4 stated IDT was aware of the cluttered room and strong smell of urine. During an observation on 5/16/25 at 9:10 a.m. with Housekeeping Staff (HS) 1, HS 1 was observed mopping Resident 31's floor and pointed at the multiple boxes at the back of Resident 31's room. HS 1 stated Resident 31's room was always cluttered and stated, . too much things, too much food . Resident 31's door to the room was partially open. During an interview on 5/16/25 9:17 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated she was the assigned CNA for Resident 31. CNA 5 stated Resident 31 had a cluttered room, and he refused to allow staff to touch his personal belongings. CNA 5 stated there was a safety risk and stated .heavy fall risk. CNA 5 stated she reported to the nurses about Resident 31's cluttered room. During an interview on 5/16/25 at 10:35 a.m. with the Director of Nursing (DON), the DON stated Resident 31's cluttered room posted safety and health risks to Resident 31. The DON stated Resident 31's carpet on the floor was a potential trip hazard and could result in a fall. During a concurrent observation and interview on 5/16/25 at 11:34 a.m. with Resident 31, outside Resident 31's room, Resident 31 was sitting in his walker seat facing the television in his room. Resident 31's door was partially open. Resident 31 stated he asked the staff to put that tape around the floor carpet and stated . so the girls cannot trip. Resident 31 stated, . this facility is not doing anything for me. During a review of facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, dated 1/18, the P&P indicated, Based on previous evaluations and concurrent data, the staff will identify the interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Fall Risk Factors 1. Environmental factors that contribute to the risk of falls include: . d. obstacles in footpath; 3. Medical Factors that contribute to the risk for falls include: .e. balance and gait disorders; Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .

Based on interview and record review, the facility failed to ensure a staff member was aware of their job duties when Restorative Nurse Aide (RNA) 1 did not have a signed job description prior to her working as an RNA. This failure had the potential to cause RNA 1 to be unaware of her job duties. Findings: During an interview on 5/14/25 at 1:35 p.m. with RNA 1, RNA 1 stated she had transitioned from being a Certified Nursing Assistant (CNA) to an RNA three months ago. RNA 1 stated she did not recall signing a job description for her new role. During a concurrent interview and record review with the Director of Staff Development RNA 1's Employee Files, undated, were reviewed. The DSD stated she could not find a signed job description for RNA 1. The DSD stated whenever a staff member gets a new role, like going from a CNA to and RNA, they should have signed a job description going over their new duties otherwise they may not be fully aware of their responsibilities. During an interview on 5/15/25 at 4:11 p.m. with the Director of Nursing (DON), the DON stated RNA 1 should have signed her job description before starting her new role. The DON stated signing the new job description ensured RNA 1 was familiar with her new job duties and responsibilities. During a review of the facility's RNA Job Description, dated 10/23/25, the Job Description indicated, . Job skills . 1. Knowledge of procedures and techniques involved in administering simple treatments and providing related bedside care services . 2. Knowledge of basic medical asepsis, sterile technique and standard precautions . 3. Willingness to work rotating shifts and different units. 4. Ability to contribute to a patient- centered environment . I understand this job description and its requirements; I understand that this is not an exclusive list of the job functions and that I am expected to complete all duties as assigned; I understand the job functions may be altered by management without notice; I understand this job description in no way constitutes an employment agreement and I am an at-will employee. I certify that I am able to perform the essential functions of this position with or without reasonable accommodation .

Based on observation, interview, and record review the facility failed to ensure a resident's drug regimen was free from unnecessary drugs for one of six sampled residents (Resident 19) when Resident 19 was administered oxycodone hydrochloride (medication used to treat intense pain) without adequate monitoring. This failure had the potential to cause Resident 19 to experience side effects such as constipation, decreased respirations, dizziness, and increased fall risk. Findings: During a review of Resident 19's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 5/15/25, the AR indicated, Resident 19 was admitted to the facility on [DATE] with a diagnosis of chronic pain syndrome (condition that causes pain which does not easily go away). During an interview on 5/12/24 at 10:30 a.m. with Resident 19, Resident 19 stated he had had a diagnosis of chronic pain which he needed to take oxycodone hydrochloride continuously for it. During a concurrent observation and interview on 5/15/25 at 10:15 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 19's Medication Administration Record (MAR), dated 5/25, and Progress Notes dated 5/15/25 were reviewed. The MAR indicated Resident 19 received oxycodone hydrochloride continuously every eight hours for chronic pain. The Progress Notes indicated no documentation was present to monitor Resident 19's side effects after taking oxycodone hydrochloride. LVN 1 stated there was nothing documented indicating Resident 19 was being monitored for potential side effects of the medication on his MAR or Progress Notes. LVN 1 stated properly documenting the monitoring for Resident 19's oxycodone hydrochloride should have been done because it helped ensure side effects such as constipation, decreased respirations, dizziness, increased fall risk were well tracked. During an interview on 5/15/25 at 3:55 p.m. with the Director of Nursing (DON), the DON stated staff were not documenting any monitoring of potential side effects of Resident 19's use of oxycodone hydrochloride. The DON stated nurses should have documented whether or not Resident 19 was experiencing side effects, otherwise staff would not know what effect the medication had on Resident 19. During a review of the facility's policy and procedure (P&P) titled, Pain assessment and management, dated 1/18, the P&P indicated, . 2. Monitor the following factors to determine if the resident's pain is being adequately controlled . c. the presence of adverse consequences or treatment . During a review of the professional reference (PR), found on https://www.ncbi.nlm.nih.gov/books/NBK482226/ titled, Oxycodone dated 2/20/24, the PR indicated, . Patients taking oxycodone require monitoring for the presence of constipation, pain relief, adverse effects, and appropriate usage .

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 5.88 % percent. There were 34 opportunities for errors and two medication errors occurred for two of nine sampled residents (Resident 1 and Resident 2) when: 1. Resident 2 did not receive the inhaler medication Salbutamol (medication used to treat asthma (a condition in which person's airways become inflame, narrow , and swell, and produce extra mucus, which makes it difficult to breathe) and exercise-induced bronchospasm (a life-threatening emergency that occurs when the muscles surrounding the lungs' small airways tighten, narrowing the airways) at the prescribed time of administration of 8:00 a.m. on 5/14/25. 2. Resident 1 did not receive the eye drops medication (Lubricant eye drops Ophthalmic [relating to or representing the eye] Solution 0.5% at the prescribed time of administration of 7:00 a.m. on 5/14/25. These failures resulted in a medication error for Resident 1 and Resident 2 and the potential for Resident 1 to experience worsening of dry eyes and Resident 2 to experience shortness of breath. Findings: 1. During an observation on 5/14/25 at 8:25 a.m. with Licensed Vocational Nurse (LVN) 1, outside Resident 2's room, LVN 1 was preparing Resident 2's 8:00 a.m. medications on the top of the medication cart. LVN 1 prepared nine of nine oral medications and placed them in 2 separate medication cups. During an observation on 5/14/25 at 8:39 a.m. with LVN 1, outside Resident 2's room, LVN 1 knocked on Resident 2's door and stated Resident 2's last name. LVN 1 informed Resident 2 the name of medications in the medication cups and administered nine of nine oral medications. LVN 1 went back to the medication cart parked outside Resident 2's room and signed Resident 2's Electronic Medication Administration Record (EMAR -an electronic daily documentation record used by a licensed nurse to document medications and treatments given to a resident), indicating she had administered all 8:00 a.m. medications to Resident 2. Resident 2 had a doctor's order for an inhaler medication Salbutamol (medication used to treat asthma (a condition in which person's airways become inflame, narrow , and swell, and produce extra mucus, which makes it difficult to breathe) and exercise-induced bronchospasm (a life-threatening emergency that occurs when the muscles surrounding the lungs' small airways tighten, narrowing the airways) to be administered at 8:00 a.m. and it was not administered. During a record review of Resident 2's admission Record (AR), dated 5/15/25, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing) and Pneumonia (an infection that inflames the air sacs in one or both lungs). During a concurrent interview and record review on 5/14/25 at 9:38 a.m. with LVN 1, Resident 2's EMAR dated 5/14/25 was reviewed. The EMAR indicated, Albuterol Sulfate (brand name of Salbutamol) HFA Inhalation Aerosol Solution (mist that has medicine in it) 108 (90 Base) MCG/ACT (refers to the unit of measurement for drug dosage which indicates the amount of medication in a single dose from an inhaler) 2 puff inhale orally three times a day for shortness of breath at 0800 1200 1600 [4 p.m.]. LVN 1 stated he did not administer Resident 2's inhaler at 8:00 a.m. LVN 1 stated I forgot. LVN 1 stated he signed the EMAR indicating he administered Salbutamol inhaler during the morning medication pass and did not administer it. LVN 1 stated, I should sign the EMAR. LVN 1 stated he administered Resident 2's Salbutamol inhaler at 9:30 a.m. LVN 1 stated he did not follow the prescribed time of the administration for Resident 2's inhaler which was due at 8:00 a.m. LVN 1 stated the inhaler medication was one and a half hours late. LVN 1 stated Resident 2 had the potential risk of difficulty in breathing. During an interview on 5/16/25 at 9:26 a.m. with LVN 1 , LVN 1 stated when a medication is administered at the wrong time it was considered a medication error. LVN 1 stated he notified the doctor and family about the medication error, and staff would monitor for any change in condition for Resident 2. During an interview on 5/15/25 at 9:58 a.m. with the Director of Nursing (DON), the DON stated her expectation was for nurses to follow the Policy and Procedures (P&P) for medication administration to prevent medication error. The DON stated late administration of medication was a medication error. The DON stated nurses should follow the prescribed time of the medication administration. The DON stated nurses should call the doctor for instructions on when to give the next dose if the prescribed time is three times a day. The DON stated the time of administration will be too close for the next dose and stated, .do not know the outcome. of being too close in timing of medication administration. The DON stated the late administration of the inhaler had the potential for Resident 2 experiencing a difficulty in breathing. During a review of the facility's P&P titled, Administering Medications, dated 1/18, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed. 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribe time, .7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. During a review of the professional reference (PR), found on https://www.ncbi.nlm.nih.gov/books/NBK519065/ an article titled, Medication Dispensing Errors and Prevention, dated 2/12/24, the PR indicated, . Types of Medication Errors: Prescribing, Omission, Wrong time, Unauthorized medication, Improper dose, Wrong dose prescription or wrong dose preparation, Administration errors such as incorrect route of administration, administering the drug to the wrong patient, extra dose, or wrong rate, Monitoring errors such as failing to take into account the patient's liver and renal function, failing to document allergy or potential for drug interaction, Compliance errors such as not following protocol or rules established for dispensing and prescribing medications . 2. During an observation on 5/14/25 at 8:59 a.m. with LVN 1, outside Resident 1's room, LVN 1 was preparing Resident 1's medications for 7:00 a.m. and 8:00 a.m. on the top of the medication cart. LVN 1 put on a pair of gloves before entering Resident 1's room. LVN 1 was wearing a glove while holding a medication tray with oral medications, insulin [Glargine] pen, and eye drops and knocked on Resident 1's door. LVN 1 stated, Hello stated Resident 1's first name], I will give your medications, insulin [Glargine] and eyedrops. LVN 1 did not check Resident 1's wrist band and did not check allergies before administering the medication to Resident 1. During an observation on 5/14/25 at 9:04 a.m. with LVN 1, in Resident 1's room, LVN 1 was wearing a glove, pulled Resident 1's upper lid and instilled one drop of lubricant eye drops in the middle of both eyes. During a concurrent interview and record review on 5/14/25 9:38 a.m. with LVN 1, Resident 1's EMAR, dated 5/14/25 was reviewed. The EMAR indicated, Lubricant eye drops Ophthalmic Solution 0.5% instill 1 drop to both eyes three time a day 0700 1130 1700 [5 p.m.]. LVN 1 stated based on the doctor's order, the lubricant eye drops were prescribed for dry eyes three times a day. LVN 1 stated Resident 1's eye drops medication was due at 7:00 a.m. and was administered at 9:00 a.m. LVN 1 stated Resident 1's eye drops medication was administered two hours late. LVN 1 stated he should follow the prescribed time of administration to prevent dryness of the eyes. LVN 1 stated . maybe I asked the doctor to change the time of administration. During a record review of Resident 1's admission Record (AR), dated 5/15/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of Dry Eye Syndrome (a condition when your tears can't produce and adequate lubrication for your eyes). During an interview on 5/15/25 at 9:58 a.m. with the Director of Nursing (DON), the DON stated her expectation for nurses was to follow the Policy and Procedures (P&P) for medication administration to prevent medication error. The DON stated late administration of medication was a medication error. The DON stated nurses should follow the prescribe time of the medication administration. The DON stated nurses should call the doctor for instructions on when to give the next dose if the prescribed time was three times a day. The DON stated the time of administration will be too close for the next dose and stated, .do not know the outcome. of being too close in timing of medication administration. The DON stated late administration of the lubricated eye drops can cause worsening of the Resident 1's eyes. During an interview on 5/16/25 at 9:26 a.m. with LVN 1, LVN stated the wrong time of medication administration was considered a medication error. LVN 1 stated he notified the doctor and family about the medication error, and staff will monitor for any change in condition for Resident 1. During a review of the facility's P&P titled, Administering Medications, dated 1/18, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed . 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribe time, .7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. During a review of the professional reference (PR), found on https://www.ncbi.nlm.nih.gov/books/NBK519065/ an article titled, Medication Dispensing Errors and Prevention, dated 2/12/24, the PR indicated, .Types of Medication Errors: Prescribing, Omission, Wrong time, Unauthorized medication, Improper dose, Wrong dose prescription or wrong dose preparation, Administration errors such as incorrect route of administration, administering the drug to the wrong patient, extra dose, or wrong rate, Monitoring errors such as failing to take into account the patient's liver and renal function, failing to document allergy or potential for drug interaction, Compliance errors such as not following protocol or rules established for dispensing and prescribing medications .

Based on observation and interview during the survey period of 5/12/25 to 5/16/25, the facility failed to provide the minimum of at least 80 square feet per resident in multiple residents rooms (Rooms 1, 2, 3, 4, 5, 6, 11, 12, 13, 14, 15, 16, 17 and 18), when the amount of usable living space was not adequate for residents. This failure had the potential for residents in Rooms 1, 2, 3, 4, 5, 6, 11, 12,13, 14, 15, 16, 17 and 18 to not have reasonable privacy or adequate space. Findings: During an environmental tour with the Maintenance Supervisor (MS) and Maintenance Assistant (MA), on 05/15/25 11:09 a.m., the inspection indicated the following rooms did not meet the minimum square footage as required by regulation. However, variations were in accordance with the particular needs of the residents. The residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. These rooms were as follows: Room number(#) Square feet #Residents 1 140 2 2 140 2 3 140 2 4 140 2 5 210 3 6 210 3 11 140 2 12 140 2 13 210 3 14 210 3 15 140 2 16 140 2 17 148 2 18 168 2 Recommend waiver to be continue in effect. _____________________________________ Health Facilities Evaluator Supervisor Signature Date:

Based on interview and record review, the facility failed to ensure licensed nurses assessed and provided interventions in accordance with professional standards of practice as outlined in the comprehensive care plan for one of four residents (Resident 1), when Resident 1 did not receive a complete and accurate initial wound assessment on readmission (4/25/2024) and did not have weekly wound monitoring, assessments and wound measurements for Resident 1's left inner ankle (wound #8) and right outer ankle (wound #9) from 4/25/2024 to 5/9/2024 and licensed nurses did not assess, measure and notify a physician of changes to wound #8 and wound #9 from 5/9/2024 to 6/27/2024. These failures resulted in an avoidable necrotic (death of cells or tissue through disease or injury) wounds to Resident 1's lower extremities which included Resident 1's left inner ankle (wound #8) and right outer ankle (wound #9) wounds; and resulted in an admission to a general acute care hospital (GACH) on 7/14/2024 for sepsis (a serious condition in which the body responds to an infection) related to left foot necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin) that required surgical amputation (the removal by surgery of a limb because of injury) on 7/15/2024 to Resident 1's left lower extremity . Findings: During a review of Resident 1's Admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was readmitted from the hospital to the facility on [DATE]. Resident 1 has a history that includes but not limited to end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), diabetes type II (high levels of sugar in the blood) chronic pain syndrome (persistent pain), atrial fibrillation (an irregular and often very rapid heart rhythm), unspecified dementia (symptoms that negatively affect memory, thinking, and social abilities severely enough to interfere with daily functioning), and chronic obstructive pulmonary disease (disease causing restricted airflow and breathing problems). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 9 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating moderate cognitive impairment. During a record review of Resident 1's Progress Nurses Note, dated 4/25/2024, the Progress Nurses Note indicated, Licensed Vocational Nurse (LVN) 1 . notified Resident 1's primary physician via phone regarding Resident 1's readmission (4/25/2024) and made aware regarding skin issues . Primary physician provided phone orders to .monitor skin discolorations .[times] 14 days and reassess . There was no documentation in the Progress Nurses Note to indicated nursing staff identified wound #8 and wound #9 individually to the primary physician. During a record review of Resident 1's Wound Evaluation & Management Summary, dated 5/9/2024, the Wound Evaluation & Management Summary indicated, Wound Physician 1 identified wound #8 .Unstageable (Due to Necrosis) of the left [inner] ankle .wound size .1.0x2.0 centimeter [cm- units of measurement] surface area 2.00 cm .Duration [greater than] 35 days . 100% thick adherent black necrotic tissue .Wound #9 . Unstageable (Due to Necrosis) of the right [outer] ankle .wound size .1.5x1.0 centimeter surface area 1.5 cm . Duration [greater than] 35 days .100% thick adherent black necrotic tissue . During a concurrent interview and record review on 3/21/2025 at 12 :10 p.m., with the Administrator (ADM), Resident 1's electronic medical records , Nursing Admission Assessment and Wound Evaluation & Management Summary, dated 4/25/2024 to 7/14/2024 were reviewed. The ADM stated Resident 1's wound # 8 and wound #9 could not have developed necrosis (death of cells or tissue through disease or injury) from the time they were identified as discoloration on the Nursing Admission assessment dated [DATE], to the Wound Physician 1 assessment Wound Evaluation & Management Summary dated 5/9/2024. The ADM stated on 4/25/2024 discoloration was documented by LVN 1 regarding Resident 1's left inner ankle (wound #8) and right outer ankle (wound #9); the ADM stated that LVN 1 did not document wounds. The ADM stated on 5/9/2024 Wound Physician 1 documented Resident 1 had a left inner ankle wound (#8) and right outer ankle wound (#9). The ADM was not able to explain how Resident 1 was assessed to have necrotic wounds per the Wound Physician note of 5/9/25 and that LVN 1 should have identified more than discoloration on the initial readmission assessment on 4/25/2024. During a concurrent interview and record review on 3/21/2025 at 1:35 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Nursing Admission Assessment (NAA, dated 4/8/2024 and 4/25/2024 was reviewed. The NAA, dated 4/8/2024, indicated Resident 1's right outer ankle (wound #9) had a scab (a dry, rough protective crust that forms over a cut or wound during healing) measuring 10.5 centimeters (cm-unit of measurement) x 11.5 cm and residents left inner ankle (wound #8) was documented to have a popped blister measuring 15cm x 9 cm. The NAA indicated, on 4/25/2024, Resident 1 was admitted with left inner ankle discoloration (wound #8) and right foot discoloration (wound #9) no measurements were taken on 4/25/2024. LVN 1 stated his initial assessment of Resident 1 on 4/25/2024 indicated left inner ankle and right outer ankle discoloration and that these areas were not documented as wounds. LVN 1 stated he did not consider the discolored areas, wounds at the time of readmission on 4/25/2024. LVN 1 stated he did not review descriptions of wound #8 and wound #9 documented in previous facility records for Resident 1. LVN 1 stated facility licensed nurses do not stage wounds, only describe them in progress nursing notes. LVN 1 stated the facility NAA defines wound staging for skin assessments. LVN 1 stated as an example on Resident 1's prior admission on 4/8/2024 the popped blister would be considered a stage II pressure injury. LVN 1 stated only the facility wound physician stages wounds. LVN 1 stated nurses have not had wound training. LVN 1 stated he did not ask the Director of Nurses (DON) for guidance when assessing Resident 1's skin on 4/25/2024. LVN 1 stated nurses are responsible for accurate resident assessments. LVN 1 stated in his clinical judgement, he appropriately documented Resident 1's left inner ankle as discoloration and the right outer ankle as discoloration, and he did not consider those areas wounds. LVN 1 stated the facility has never taken any pictures of wounds, and the nurses are responsible for daily skin assessments and notification to the primary physician if there are any skin changes. LVN 1 stated he was aware of Wound Physician 1's assessment of Resident 1's necrotic wounds #8 and #9 on 5/9/2024 and stated he believed his description of discoloration was accurate. During a record review of Resident 1's Hospital Discharge records, dated 4/25/2024, the Hospital Discharge records indicated active routine continuous wound care orders signed 4/18/2024, .Paint all foot ulcer s (an open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane) with betadine and allow to air dry [twice a day] . During a concurrent interview and record review on 3/21/2025 at 2:10 p.m., with LVN 1, Resident 1's Hospital Discharge records, dated 4/25/2024 was reviewed. LVN 1 stated he was not aware of any wound care treatments being conducted in the hospital prior to Resident 1's readmission to the facility on [DATE]. LVN 1 stated Resident 1was not continued on hospital wound care on 4/25/2024. LVN 1 stated he was the admission nurse for Resident 1 on 4/25/2024, and it is the admission nurse's responsibility to review and transcribe all incoming discharge orders from the hospital. LVN 1 stated he did not review, transcribe or follow up with active hospital discharge wound orders for Resident 1 upon admission on 4/25/2024. LVN 1 stated during his head-to-toe skin assessment he did not identify the left inner or right outer ankle as wounds, so no wound treatments were obtained. LVN 1 stated in his clinical judgment he believed his assessment was accurate on 4/25/2024 and stated necrosis would not develop from 4/25/2024 to 5/9/2024. LVN 1 stated failure to follow orders and assess and monitor residents accurately could cause harm or injury to residents. LVN 1 stated clinically, nurses have the knowledge to assess and stage wounds, but facility DON instructed licensed nursing staff not to stage wounds. LVN 1 stated licensed nursing staff along with certified nursing staff (CNA) should be monitoring each residents' skin daily while providing care. LVN 1 stated there was no documentation by nursing staff of changes to Resident 1's ankles from admission on 4/25/2024 until Wound Physician 1 identified wound #8 and #9 on 5/9/2024. LVN 1 was aware of Physician Wound 1's assessment of necrotic wounds on 5/9/2024 and could not explain how that could have occurred. LVN 1 stated the necrotic wounds assessed by Wound Physician 1 were in the same location as the discoloration that he documented on 4/25/2024 During a concurrent interview and record review on 3/21/2025 at 2:48 p.m., with the Director of Staff Development (DSD), Resident 1's Wound Evaluation and Management Summary , dated 5/9/2024 was reviewed. The Wound Evaluation and Management Summary indicated, Wound Physician 1 identified, measured and treated ankle wounds (#8 & #9) and indicated wounds were unstageable due to necrosis. The DSD stated per documentation, the ankle wounds to the outer right ankle (wound # 9) and inner left ankle (wound #8) went untreated and unmeasured from 4/25/2024 to 5/9/2024 and were not measured or assessed from 5/9/2024 to 6/27/2024. The DSD stated the Interdisciplinary Team (IDT- group of health care professionals with various areas of expertise who work together to meet the resident's goals) meetings are conducted for pressure wounds and there was no IDT meetings held for wound #8 and #9. The DSD stated there was no IDT meetings conducted because nursing staff did not identify wounds #8 and #9. During an interview on 3/21/2025 at 4:17 pm, with the Director of Nurses (DON), the DON stated facility staff have had wound education and clinical nurses should be capable of assessing wounds appropriately during skin assessment. The DON stated the facility is not allowed to photograph wounds, the wound physician is the only individual measuring wounds, providing treatment plans and recommendations for residents. The DON stated Resident 1's wounds # 8 and #9 were not documented as wounds and were instead documented as discoloration during nursing admission assessment on 4/25/2024. The DON stated the licensed nurse (LVN 1) assessed the resident inaccurately during the readmission skin assessment on 4/25/2024 and should have known the difference between discoloration and necrosis. The DON stated the facility nursing staff were not competent during the assessment and care of the wounds for Resident 1 between 4/25/2024 and 6/27/2024. The DON indicated facility nursing staff failed to assess and treat Resident 1's ankles (wounds #8 and 9) from 4/25/2024 until identified by the Wound Physician 1 on 5/9/2024. The DON stated the IDT team would not have reviewed the discoloration because the facility did not consider discoloration as a wound. The DON stated once identified on 5/9/2024 by Wound Physician 1, no additional wound assessment by the wound physician were conducted until 6/27/2024 when Wound Physician 2 assessed, measured and provided an updated treatment plan for Resident 1's necrotic ankle wounds (#8 and #9). The DON stated licensed nurses did not assess, measure and notify a physician of changes to wound #8 and wound #9 from 5/9/2024 to 6/27/2024. The DON stated it was her expectation that all licensed nursing staff should have been measuring wounds weekly. The DON stated the facility did not have a wound physician from 5/9/2024 to 6/27/2024. The DON stated the facility does not have designated wound nurses and charge nurses are responsible for wound treatments of their residents. The DON stated nursing staff failed to follow protocols for wound policy and procedures indicating accurate assessment, measurement and description of all wounds. The DON stated facility nursing staff failed their job description and their responsibility to ensure the plan of care was followed and the needs of the resident were met. The DON stated nursing staff failed to assess wounds on admission and then failed to monitor wounds #8 and #9 once identified by a Wound Physician 1 on 5/9/2024. The DON stated there were no updates provided to the primary physician. The DON stated the potential risk for Resident 1 due to the lapse in care and the lack of monitoring of the wounds could have potentially led to an amputation of lower extremities. During a concurrent interview and record review on 4/4/2025 at 9:15 a.m., with the DON, Resident 1's Nursing Admission Assessment, dated 4/8/2024 to 7/14/2024 were reviewed. The DON stated on the NAA dated 4/8/2024 had documentation indicating Resident 1's right ankle had a dry scab measuring 10.5 cm x 11.5cm and left inner ankle had a popped blister measuring 15cm x 9 cm. DON then stated Resident 1 had a hospitalization from ,d+[DATE]-[DATE] and upon readmission the NAA dated 4/25/2024, the NAA indicated Residents 1 left inner ankle and right outer ankle were documented as discoloration by the admitting nurse LVN 1. The DON stated LVN 1 should have reviewed previous wound notes during Resident 1's readmission on 4/25/2024 in order to identify prior recorded wounds indicated in NAA dated 4/8/2024. During a concurrent interview and record review on 4/4/2025 at 9:45 a.m., with the DON, Resident 1's electronic medical records , Wound Evaluation & Management Summary and Pressure Ulcers/Skin Breakdown- Clinical Protocol, dated 4/8/2024 to 7/14/2024 were reviewed. The DON stated Wound Physician 1 identified and measured wounds on 5/9/2024. The DON stated the next physician assessment of wound #8 and #9 were not conducted until 6/27/2024. The DON stated licensed nursing staff failed to measure wounds #8 and #9 weekly from 5/9/2024 to 6/27/2024 as indicated in Pressure Ulcers/Skin Breakdown- Clinical Protocol policy and procedure. The DON stated documentation did not indicate measurements of wounds #8 and #9 in the weekly skin summary assessments or progress notes. The DON stated her expectations were that staff follow wound treatments ordered by the physician and track progress which includes wound measurements needed to communicate to the resident's primary physician. The DON stated all licensed nursing staff have the clinical knowledge to follow wound treatments and to take measurements of wounds. DON stated licensed nursing staff have been instructed to describe wounds but not stage any wounds. During a record review of the Resident 1's general acute care hospital (GACH) Consult Note , dated 7/14/2024, the Consult Note indicated, .the foot and ankle team has been consulted for the treatment of necrotizing infection of the medial (means toward the middle or center) rear foot and ankle on the left lower extremity .When informed that the patient may need debridement (the removal of damaged tissue) did reach out the family to discuss my concerns with the lower extremity .Patient has multiple wounds of the bilateral lower extremities with more concerning being the medial ankle of the left foot . Boggy (feeling of sponginess in the tissue) appearance noted to the medial ankle wound on the left leg with necrotic center in a circular ulceration deep and probing to the bone. Slight malodor (a very unpleasant smell) noted from the area with the surrounding erythema (reddening of the skin) to the left ankle including the heel . During a record review of Resident 1's GACH Post-Op (after surgery) Note dated, 7/15/2024, the Post-Op Note indicated, .Pre-operative (before surgery) diagnosis: Septic shock (complication of sepsis)[and] Left foot gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) .Procedure . Left guillotine (all of the tissues from the skin to the bone are cut at the level of the ankle) [below the knee] .Description .[surgical instrument] was used to amputate the distal (furthest part of the body) left lower extremity below the knee . During a review of the facility policy and procedure (P&P) titled, Competency of Nursing Staff dated [DATE], the P&P indicated, .licensed nurses and nursing assistants employed by the facility will . demonstrate specific competencies and skill sets deemed necessary to care for the needs of the residents, as identified through resident assessments and described in the plans of care .competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as . basic nursing skills .skin and wound care .infection control . identification of changes in condition . Competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge . During a review of the facility policy and procedure (P&P) titled, Resident Examination and assessment dated [DATE], the policy and procedure indicated, .Review the residents admission assessment and/or preliminary care plan to assess for any special situations regarding the resident' care .Physical exam .skin . intactness .moisture .color .texture .presence of bruises, pressure ulcers, redness, edema, rashes .Documentation .all assessment data .notify the physician of any abnormalities . wounds or rashes on the residents skin . During a review of the facility policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol dated [DATE], the policy and procedure indicated, .The nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length and depth, presence of exudates and necrotic tissue .the staff .will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions .During resident visits, the physician will evaluate and document the progress of wound healing- especially for those with complicated, extensive, or poor-healing wounds . During a review of the facilities job description manual titled, Licensed Vocational Nurse dated 10/19/2015, the job description indicated, . Job skills . comprehensive knowledge of nursing principles required, including the ability to recognize and identify symptoms and manager emergency situations .collect, reports and documents objective and subjective data .contributes to establishing individualized patient goals . implements the plan of care . evaluates effectiveness of intervention's to achieve patient goals and minimize re-hospitalization . administers medication and performs treatments per physician orders . documents accurately and thoroughly . consults and seeks guidance from RN as necessary During a review of the facilities Wound Physicians [name of company] Wound Service Agreement dated and signed 2/7/2023, the agreement indicated, . [name of company] shall .document the patient status and wound care needs and include specific dressing orders .provide education to the wound care nurse and/or facility personnel on wound treatments .

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when Resident 1 did not receive a complete and accurate initial wound assessment on readmission (4/25/2024) and did not have weekly wound monitoring, assessments and wound measurements for Resident 1's left inner ankle (wound #8) and right outer ankle (wound #9) from 4/25/2024 to 5/9/2024 and licensed nurses did not assess, measure and notify a physician of changes to wound #8 and wound #9 from 5/9/2024 to 6/27/2024. And Resident 1 did not have a comprehensive person-centered care plan (an individual summary of a person's health conditions, specific care needs, and current treatments) for wounds #8 and #9. These failures resulted in no individual care plan for the avoidable necrotic (death of cells or tissue through disease or injury) wounds to Resident 1's lower extremities which included Resident 1's left inner ankle (wound #8) and right outer ankle (wound #9) wounds; and resulted in an admission to a general acute care hospital (GACH) on 7/14/2024 for sepsis (a serious condition in which the body responds to an infection) related to left foot necrotizing fasciitis (a serious bacterial infection that destroys tissue under the skin) that required surgical amputation (the removal by surgery of a limb because of injury) on 7/15/2024 to Resident 1's left lower extremity . Findings: During a review of Resident 1's Admission Record (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission record indicated, Resident 1 was readmitted from the hospital to the facility on [DATE]. Resident 1 has a history that includes but not limited to end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids), anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), diabetes type II (high levels of sugar in the blood) chronic pain syndrome (persistent pain), atrial fibrillation (an irregular and often very rapid heart rhythm), unspecified dementia (symptoms that negatively affect memory, thinking, and social abilities severely enough to interfere with daily functioning), and chronic obstructive pulmonary disease (disease causing restricted airflow and breathing problems). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 9 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating moderate cognitive impairment. During a record review of Resident 1's Progress Nurses Note, dated 4/25/2024, the Progress Nurses Note indicated, Licensed Vocational Nurse (LVN) 1 . notified Resident 1's primary physician via phone regarding Resident 1's readmission (4/25/2024) and made aware regarding skin issues . Primary physician provided phone orders to .monitor skin discolorations .[times] 14 days and reassess . There was no documentation in the Progress Nurses Note to indicated nursing staff identified wound #8 and wound #9 individually to the primary physician. During a record review of Resident 1's Wound Evaluation & Management Summary, dated 5/9/2024, the Wound Evaluation & Management Summary indicated, Wound Physician 1 identified wound #8 .Unstageable (Due to Necrosis) of the left [inner] ankle .wound size .1.0x2.0 centimeter [cm- units of measurement] surface area 2.00 cm .Duration [greater than] 35 days . 100% thick adherent black necrotic tissue .Wound #9 . Unstageable (Due to Necrosis) of the right [outer] ankle .wound size .1.5x1.0 centimeter surface area 1.5 cm . Duration [greater than] 35 days .100% thick adherent black necrotic tissue . During a concurrent interview and record review on 3/21/2025 at 12 :10 p.m., with the Administrator (ADM), Resident 1's electronic medical records, Nursing Admission Assessment and Wound Evaluation & Management Summary, dated 4/25/2024 to 7/14/2024 were reviewed. The ADM stated Resident 1's wound # 8 and wound #9 could not have developed necrosis (death of cells or tissue through disease or injury) from the time they were identified as discoloration on the Nursing Admission assessment dated [DATE], to the Wound Physician 1 assessment Wound Evaluation & Management Summary dated 5/9/2024. The ADM stated on 4/25/2024 discoloration was documented by LVN 1 regarding Resident 1's left inner ankle (wound #8) and right outer ankle (wound #9); the ADM stated that LVN 1 did not document wounds. The ADM stated on 5/9/2024 Wound Physician 1 documented Resident 1 had a left inner ankle wound (#8) and right outer ankle wound (#9). The ADM was not able to explain how Resident 1 was assessed to have necrotic wounds per the Wound Physician note of 5/9/25 and that LVN 1 should have identified more than discoloration on the initial readmission assessment on 4/25/2024. During a concurrent interview and record review on 3/21/2025 at 1:35 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1's Nursing Admission Assessment (NAA, dated 4/8/2024 and 4/25/2024 was reviewed. The NAA, dated 4/8/2024, indicated Resident 1's right outer ankle (wound #9) had a scab (a dry, rough protective crust that forms over a cut or wound during healing) measuring 10.5 centimeters (cm-unit of measurement) x 11.5 cm and residents left inner ankle (wound #8) was documented to have a popped blister measuring 15cm x 9 cm. The NAA indicated, on 4/25/2024, Resident 1 was admitted with left inner ankle discoloration (wound #8) and right foot discoloration (wound #9) no measurements were taken on 4/25/2024. LVN 1 stated his initial assessment of Resident 1 on 4/25/2024 indicated left inner ankle and right outer ankle discoloration and that these areas were not documented as wounds. LVN 1 stated he did not consider the discolored areas, wounds at the time of readmission on 4/25/2024. LVN 1 stated he did not review descriptions of wound #8 and wound #9 documented in previous facility records for Resident 1. LVN 1 stated facility licensed nurses do not stage wounds, only describe them in progress nursing notes. LVN 1 stated the facility NAA defines wound staging for skin assessments. LVN 1 stated as an example on Resident 1's prior admission on 4/8/2024 the popped blister would be considered a stage II pressure injury. LVN 1 stated only the facility wound physician stages wounds. LVN 1 stated nurses have not had wound training. LVN 1 stated he did not ask the Director of Nurses (DON) for guidance when assessing Resident 1's skin on 4/25/2024. LVN 1 stated nurses are responsible for accurate resident assessments. LVN 1 stated in his clinical judgement, he appropriately documented Resident 1's left inner ankle as discoloration and the right outer ankle as discoloration, and he did not consider those areas wounds. LVN 1 stated the facility has never taken any pictures of wounds, and the nurses are responsible for daily skin assessments and notification to the primary physician if there are any skin changes. LVN 1 stated he was aware of Wound Physician 1's assessment of Resident 1's necrotic wounds #8 and #9 on 5/9/2024 and stated he believed his description of discoloration was accurate. During a record review of Resident 1's Hospital Discharge records, dated 4/25/2024, the Hospital Discharge records indicated active routine continuous wound care orders signed 4/18/2024, .Paint all foot ulcers (an open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane) with betadine and allow to air dry [twice a day] . During a concurrent interview and record review on 3/21/2025 at 2:10 p.m., with LVN 1, Resident 1's Hospital Discharge records, dated 4/25/2024 was reviewed. LVN 1 stated he was not aware of any wound care treatments being conducted in the hospital prior to Resident 1's readmission to the facility on [DATE]. LVN 1 stated Resident 1was not continued on hospital wound care on 4/25/2024. LVN 1 stated he was the admission nurse for Resident 1 on 4/25/2024, and it is the admission nurse's responsibility to review and transcribe all incoming discharge orders from the hospital. LVN 1 stated he did not review, transcribe or follow up with active hospital discharge wound orders for Resident 1 upon admission on 4/25/2024. LVN 1 stated during his head-to-toe skin assessment he did not identify the left inner or right outer ankle as wounds, so no wound treatments were obtained. LVN 1 stated in his clinical judgment he believed his assessment was accurate on 4/25/2024 and stated necrosis would not develop from 4/25/2024 to 5/9/2024. LVN 1 stated failure to follow orders and assess and monitor residents accurately could cause harm or injury to residents. LVN 1 stated clinically, nurses have the knowledge to assess and stage wounds, but facility DON instructed licensed nursing staff not to stage wounds. LVN 1 stated licensed nursing staff along with certified nursing staff (CNA) should be monitoring each residents' skin daily while providing care. LVN 1 stated there was no documentation by nursing staff of changes to Resident 1's ankles from admission on 4/25/2024 until Wound Physician 1 identified wound #8 and #9 on 5/9/2024. LVN 1 was aware of Physician Wound 1's assessment of necrotic wounds on 5/9/2024 and could not explain how that could have occurred. LVN 1 stated the necrotic wounds assessed by Wound Physician 1 were in the same location as the discoloration that he documented on 4/25/2024. During a concurrent interview and record review on 3/21/2025 at 2:20 p.m., with LVN 1, Resident 1's Care Plan Report, dated 4/25/2024 was reviewed. LVN 1 stated right foot and left ankle were identified as discoloration and not wounds, and interventions were for staff to monitor for signs and symptoms of infection and notify primary physician of any changes. LVN 1 stated the wounds should have been identified as wounds not discoloration on readmission. LVN 1 stated he did not assess correctly during his readmission assessment. LVN 1 stated because he did not assess Resident 1 correctly, Resident 1's care plans did not meet the needs of Resident 1. During a concurrent interview and record review on 3/21/2025 at 2:48 p.m., with the Director of Staff Development (DSD), Resident 1's Wound Evaluation and Management Summary , dated 5/9/2024 was reviewed. The Wound Evaluation and Management Summary indicated, Wound Physician 1 identified, measured and treated ankle wounds (#8 & #9) and indicated wounds were unstageable due to necrosis. The DSD stated per documentation, the ankle wounds to the outer right ankle (wound # 9) and inner left ankle (wound #8) went untreated and unmeasured from 4/25/2024 to 5/9/2024 and were not measured or assessed from 5/9/2024 to 6/27/2024. The DSD stated the Interdisciplinary Team (IDT- group of health care professionals with various areas of expertise who work together to meet the resident's goals) meetings are conducted for pressure wounds and there was no IDT meetings held for wound #8 and #9. The DSD stated there was no IDT meetings conducted because nursing staff did not identify wounds #8 and #9. During an interview on 3/21/2025 at 4:17 pm, with the Director of Nurses (DON), the DON stated facility staff have had wound education and clinical nurses should be capable of assessing wounds appropriately during skin assessment. The DON stated the facility is not allowed to photograph wounds, the wound physician is the only individual measuring wounds, providing treatment plans and recommendations for residents. The DON stated Resident 1's wounds # 8 and #9 were not documented as wounds and were instead documented as discoloration during nursing admission assessment on 4/25/2024. The DON stated the licensed nurse (LVN 1) assessed the resident inaccurately during the readmission skin assessment on 4/25/2024 and should have known the difference between discoloration and necrosis. The DON stated the facility nursing staff were not competent during the assessment and care of the wounds for Resident 1 between 4/25/2024 and 6/27/2024. The DON indicated facility nursing staff failed to assess and treat Resident 1's ankles (wounds #8 and 9) from 4/25/2024 until identified by the Wound Physician 1 on 5/9/2024. The DON stated the IDT team would not have reviewed the discoloration because the facility did not consider discoloration as a wound. The DON stated once identified on 5/9/2024 by Wound Physician 1, no additional wound assessment by the wound physician were conducted until 6/27/2024 when Wound Physician 2 assessed, measured and provided an updated treatment plan for Resident 1's necrotic ankle wounds (#8 and #9). The DON stated licensed nurses did not assess, measure and notify a physician of changes to wound #8 and wound #9 from 5/9/2024 to 6/27/2024. The DON stated it was her expectation that all licensed nursing staff should have been measuring wounds weekly. The DON stated the facility did not have a wound physician from 5/9/2024 to 6/27/2024. The DON stated the facility does not have designated wound nurses and charge nurses are responsible for wound treatments of their residents. The DON stated nursing staff failed to follow protocols for wound policy and procedures indicating accurate assessment, measurement and description of all wounds. The DON stated facility nursing staff failed their job description and their responsibility to ensure the plan of care was followed and the needs of the resident were met. The DON stated nursing staff failed to assess wounds on admission and then failed to monitor wounds #8 and #9 once identified by a Wound Physician 1 on 5/9/2024. The DON stated there were no updates provided to the primary physician. The DON stated the potential risk for Resident 1 due to the lapse in care and the lack of monitoring of the wounds could have potentially led to an amputation of lower extremities. During a concurrent interview and record review on 4/4/2025 at 9:15 a.m., with the DON, Resident 1's Nursing Admission Assessment, dated 4/8/2024 to 7/14/2024 were reviewed. The DON stated on the NAA dated 4/8/2024 had documentation indicating Resident 1's right ankle had a dry scab measuring 10.5 cm x 11.5cm and left inner ankle had a popped blister measuring 15cm x 9 cm. DON then stated Resident 1 had a hospitalization from ,d+[DATE]-[DATE] and upon readmission the NAA dated 4/25/2024, the NAA indicated Residents 1 left inner ankle and right outer ankle were documented as discoloration by the admitting nurse LVN 1. The DON stated LVN 1 should have reviewed previous wound notes during Resident 1's readmission on 4/25/2024 in order to identify prior recorded wounds indicated in NAA dated 4/8/2024. During a concurrent interview and record review on 4/4/2025 at 9:45 a.m., with the DON, Resident 1's electronic medical records, Wound Evaluation & Management Summary, Pressure Ulcers/Skin Breakdown- Clinical Protocol, and Care plan Report dated 4/8/2024 to 7/14/2024 were reviewed. The DON stated Wound Physician 1 identified and measured wounds on 5/9/2024. The DON stated the next physician assessment of wound #8 and #9 were not conducted until 6/27/2024. The DON stated licensed nursing staff failed to measure wounds #8 and #9 weekly from 5/9/2024 to 6/27/2024 as indicated in Pressure Ulcers/Skin Breakdown- Clinical Protocol policy and procedure. The DON stated documentation did not indicate measurements of wounds #8 and #9 in the weekly skin summary assessments or progress notes. The DON stated her expectations were that staff follow wound treatments ordered by the physician and track progress which includes wound measurements needed to communicate to the resident's primary physician. The DON stated all licensed nursing staff have the clinical knowledge to follow wound treatments and to take measurements of wounds. DON stated licensed nursing staff have been instructed to describe wounds but not stage any wounds. During a concurrent interview and record review on 4/4/2025 at 10 a.m., with the DON, Resident 1's Care Plan Report, dated 4/25/2024 was reviewed. The DON stated the care plans for right foot and left ankle were identified as discoloration and not wounds, and interventions included staff to monitor for signs and symptoms of infection and notify primary physician of any changes. The DON stated Resident 1's care plans did not have an accurate description of all of Resident 1 wounds. The DON verified wounds #8 and #9 were not on the care plan. The DON stated Resident 1's care plan did not meet his wound needs. During a record review of the Resident 1's general acute care hospital (GACH) Consult Note , dated 7/14/2024, the Consult Note indicated, .the foot and ankle team has been consulted for the treatment of necrotizing infection of the medial (toward the middle or center) rear foot and ankle on the left lower extremity .When informed that the patient may need debridement (the removal of damaged tissue) did reach out the family to discuss my concerns with the lower extremity .Patient has multiple wounds of the bilateral lower extremities with more concerning being the medial ankle of the left foot . Boggy (feeling of sponginess in the tissue) appearance noted to the medial ankle wound on the left leg with necrotic center in a circular ulceration deep and probing to the bone. Slight malodor (a very unpleasant smell) noted from the area with the surrounding erythema (reddening of the skin) to the left ankle including the heel . During a record review of Resident 1's GACH Post-Op (after surgery) Note dated, 7/15/2024, the Post-Op Note indicated, .Pre-operative (before surgery) diagnosis: Septic shock (complication of sepsis)[and] Left foot gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) .Procedure . Left guillotine (all of the tissues from the skin to the bone are cut at the level of the ankle) [below the knee] .Description .[surgical instrument] was used to amputate the distal (furthest part of the body) left lower extremity below the knee . During a review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered dated [DATE], the P&P indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The interdisciplinary team (IDT [team of healthcare professionals]) , in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The comprehensive, person-centered care plan will .include measurable objectives and timeframes .incorporate identified problem areas .aid in preventive or reducing decline in the residents functional status .enhance the optimal functioning of the resident .areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan .Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process .Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes .When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers .The nurse and/or the interdisciplinary team must review and update the care plan . During a review of the facility policy and procedure (P&P) titled, Competency of Nursing Staff dated [DATE], the P&P indicated, .licensed nurses and nursing assistants employed by the facility will . demonstrate specific competencies and skill sets deemed necessary to care for the needs of the residents, as identified through resident assessments and described in the plans of care .competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as . basic nursing skills .skin and wound care .infection control . identification of changes in condition . Competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge . During a review of the facility policy and procedure (P&P) titled, Resident Examination and assessment dated [DATE], the policy and procedure indicated, .Review the residents admission assessment and/or preliminary care plan to assess for any special situations regarding the resident' care .Physical exam .skin . intactness .moisture .color .texture .presence of bruises, pressure ulcers, redness, edema, rashes .Documentation .all assessment data .notify the physician of any abnormalities . wounds or rashes on the residents skin . During a review of the facility policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol dated [DATE], the policy and procedure indicated, .The nurse shall describe and document/report the following: Full assessment of pressure sore including location, stage, length and depth, presence of exudates and necrotic tissue .the staff .will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions .During resident visits, the physician will evaluate and document the progress of wound healing- especially for those with complicated, extensive, or poor-healing wounds . During a review of the facilities job description manual titled, Licensed Vocational Nurse dated 10/19/2015, the job description indicated, . Job skills . comprehensive knowledge of nursing principles required, including the ability to recognize and identify symptoms and manager emergency situations .collect, reports and documents objective and subjective data .contributes to establishing individualized patient goals . implements the plan of care . evaluates effectiveness of intervention's to achieve patient goals and minimize re-hospitalization . administers medication and performs treatments per physician orders . documents accurately and thoroughly . consults and seeks guidance from RN as necessary During a review of the facilities Wound Physicians [name of company] Wound Service Agreement dated and signed 2/7/2023, the agreement indicated, . [name of company] shall .document the patient status and wound care needs and include specific dressing orders .provide education to the wound care nurse and/or facility personnel on wound treatments . During a review of professional reference from the National Library of Medicine titled, Patient Safety and Quality: Chapter 12 Pressure Ulcers: A patient Safety Issue, dated April 2008, the professional reference indicated .The nurse should assess and stage the pressure ulcer at each dressing change. Experts believe that weekly assessments and staging of pressure ulcers (an open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane) will lead to earlier detection of wound infections as well as being a good parameter for gauging of wound healing Most experts agree that when a pressure ulcer develops its location, size (length, width, and depth), and color of the wound; amount and type of exudate (serous(producing serum), sangous (bloodred), pustular (pus-filled); odor; nature and frequency of pain if present (episodic [short amount of time] or continuous); color and type of tissue/character of the wound bed, including evidence of healing (e.g., granulation tissue ) (new connective tissue that develop at the wound site in the process of healing) or necrosis(death of cells or tissue through disease or injury) (slough (yellow devitalized tissue)or eschar (a dry, dark scab or falling away of dead skin); and description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration(A softening and breaking down of skin resulting from prolonged exposure to moisture) should be assessed and documented. Upon identifying the ulcer characteristics, the initial stage of the should be completed .

Based on observation, interview and record review, the facility failed to post the results of the most recent abbreviated survey document titled, Statement of Deficiencies in a place readily accessible to residents and their representatives. This failure had the potential to violate the rights of the residents and their representatives to be informed of abbreviated survey deficiencies and the facility's plan of correction. Findings: During an observation on 5/21/24 at 9:20 a.m., a binder labeled Survey Inspection was located in a holder on the wall in the main entrance. The binder contained the 2019 health recertification survey deficiencies and plan of corrections and previous years abbreviated surveys. There were no abbreviated survey documents available from 2020 to 2024. During a concurrent interview and record review on 5/21/24 at 11:05 a.m., with the Administrator (ADM), a document titled, Survey Inspections, undated was reviewed. The ADM stated, the binder contained the 2019 health recertification survey deficiencies and plan of corrections and previous years abbreviated surveys. The ADM stated, there were no abbreviated survey documents from 2020 to 2024. The ADM stated, the facility had one complaint and three facility reported incidents (FRI) for the past 12 months that resulted in deficiencies and should be placed in the survey binder and they were not. The ADM stated, the survey binder allows residents and visitors to know survey deficiencies and the facility's plan of correction. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated 1/18, the P&P indicated, . Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . w. examine survey results .

Based on observation, interview, and record review the facility failed to have an air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the food preparation sink. This failure had the potential to result in 36 of 36 residents being exposed to contaminated water (when substances pollute the water and make it unusable for cooking and drinking) which could ultimately result in food born illness from eating contaminated food. Findings: During a concurrent observation and interview with Certified Dietary Manager (CDM), on 5/20/24 at 8:52 p.m., at the food prep sink in the facilities kitchen, the CDM validated that there was not an air gap under the food prep sink. The CDM stated she does not know why there is not an air gap under the food prep sink. The CDM stated there should be an air gap under the sink so that the water does not back up into the sink. The CDM stated that maintenance would be the person responsible for making sure there is an air gap. During an interview on 5/20/24 at 9:43 p.m., with Maintenance Staff (MAINS), MAINS stated that he was not aware that the food prep sink did not have an air gap under the sink. MAINS stated the facility should have an air gap under the sink to prevent the back flow of contaminateddirty water (when substances pollute the water and make it unusable for cooking and drinking) into the sink. During a concurrent observation and interview on 5/22/24 at 4 p.m., in the hot water heater closet, MAINS provided the location of the air gap for the food prep sink. MAINS explained that the plumbing under the sink runs through the wall into the hot water closet and drains into a drain in the corner of the hot water closet. The drain had three black pipes draining into the drain. Each pipe was a different length, there was a pipe for the handwashing sink in the hot water closet, the handwashing sink in the kitchen and the food prep sink in the kitchen. Each sink was turned on to identify the pipes. The drain for the food prep sink was less than two inches from the bottom of the drain. MAINS stated the food prep sink should be greater than two inches from the bottom of the drain and the food prep sink pipe was not greater than two inches from the bottom of the drain. The MAINS stated and the water could back flow into the food prep sink and contaminate the food and make the residents sick. During an interview with the Registered Dietitian (RD), the RD stated, . I did not notice the air gap . I saw the hot water closet where the air gap is located once when I first started . the food prep sink is required to have an air gap to prevent the back flow of dirty water and contamination of the food . During a review of the facility's policy and procedure titled, Accident-Safety Precautions [undated] indicated . Backflow Prevention/Air Gaps . An air gap is the most reliable backflow prevention device . All food preparation sinks, ice machines . or other equipment that discharge liquid waste or condensate shall be drained through an air gap into an open floor sink . An air gap between the water supply inlet (drainpipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 5-202.13 Backflow Prevention, Air Gap. During periods of extraordinary demand, drinking water systems may develop negative pressure (when water flows in the opposite direction) in portions of the system. If a connection exists between the system and a source of contaminated (dirty) water during times of negative pressure, contaminated water may be drawn into and foul (to make dirty) the entire system. Standing water in sinks . and other equipment may become contaminated with cleaning chemicals or food residue .

Based on observation, interview and record review, the facility failed to cover one of one outside trash bin with a lid. This failure had the potential to harbor and feed pests. This failure had the potential for an infestation of pests which could lead to unsanitary conditions and the spread of disease. Findings: During an observation on 5/22/24 at 2:01 p.m. in the parking lot of the facility, the trash bin was uncovered, the lid was open and hanging on the back of the bin. During a concurrent observation and interview on 5/22/24 at 3:47 p.m. with Maintenance Staff (MAINS), MAINS validated the lid of trash bin was open MAINS stated, . the lid on the trash should always be closed to prevent rodents and insects . During a review of the facility's policy and procedure titled, Waste Disposal dated 1/2018, indicated, .1. All .waste destined for disposal shall be placed in closeable leak proof containers .b. Disposal of all . waste shall be in accordance with applicable federal, state, and local regulations .

Based on observation, interview, and record review the facility failed to ensure a safe clean comfortable homelike environment was provided for four of 21 residents when: 1.One third of the floor in Resident 10, 18, 19, and 26's rooms had yellow and brown stains. This failure resulted in Residents 10, 18, 19 and 26 not being provided a clean comfortable homelike environment. 2. In Resident 6 and Resident 23 room red tape was used to attach the call light cord to the call light socket. This failure resulted in a potenial fire hazard and Resident 6 and 20 not being provided a safe, comfortable homelike environment. Findings: 1. During a review of Resident 10's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 4/1/24, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of nine (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 10 had moderate cognitive impairment. During a review of Resident 18's MDS, dated [DATE], the MDS indicated a BIMS score of 99. The MDS indicated, Resident 18 was unable to complete the interview. During a review of Resident 19's MDS, dated [DATE], the MDS indicated a BIMS score of six out of 15 which indicated Resident 19 had severe cognitive impairment. During a review of Resident 26's MDS, dated [DATE], the MDS indicated a BIMS score of nine out of 15 which indicated Resident 18 had moderate cognitive impairment. During a concurrent observation and interview on 5/20/24 10:10 a.m. with Certified Nursing Assistant (CNA) 4 in Resident 19's room, one third of Resident 19's floor had yellow and brown stains. CNA 4 stated the floors looked stained and they should have been in a cleaner condition. CNA 4 stated stained floors could cause people to question the cleanliness of the facility. During a concurrent observation and interview on 5/20/24 at 10:18 a.m. with CNA 4 in Resident 10, 18, and 26's room, the floor had yellow and brown stains. CNA 4 stated the flooring in this room was also stained. CNA 4 stated the floor should be clean. CNA 4 stated the condition of the floor makes the room appear dirty. During a concurrent observation and interview on 5/20/24 at 10:18 a.m. with Licensed Vocational Nurse (LVN) 3 in Resident 10, 18, and 26's room, one third of the floor had yellow and brown stains. LVN 3 stated housekeeping regularly mops, sweeps, and disinfects the floor but the stains do not come out. LVN 3 stated the stains on the floor do not make the room look homelike. LVN 3 stated stains on Residents 10,18, and 26's rooms was not a homelike environment, During an interview on 5/23/24 at 9:29 a.m. with the Housekeeping Supervisor (HS), the HS stated housekeeping staff regularly cleaned the floors in Resident 10, 18, 19, and 26's rooms and the stains could not be removed. The HS stated the floors needed to be stripped (process in which the top layer of floor's wax is removed in order to better clean the floors) and rewaxed in order to get rid of the stains, the floors should not have looked as stained as they did. The HS stated having a clean room was important because the rooms are the residents' homes. The HS stated the condition of Residents 10, 18, 19, and 26's rooms did not promote a homelike environment. During an interview on 5/23/24 at 9:34 a.m. with the Maintenance Staff (MAINS), the MAINS stated Residents 10, 18, 19, and 26's floors should have been stripped and waxed to remove the stains when the stains were noticed. The MAINS stated the stained floors did not provide a homelike environment. During an interview on 5/23/24 at 10:00 a.m. with the Director of Nursing (DON), the DON stated the flooring in Resident's 10, 18, 19, and 26's rooms should be clean and not have any stains. The DON stated a cognitively intact Resident may have expressed their concern regarding the floors' cleanliness because of the stains. The DON stated stained floors may make the residents uncomfortable when in their rooms. The DON stated stained floors did not promote a homelike environment. During a review of the facility's policy and procedure (P&P) titled Homelike Environment, dated 1/2018, indicated . 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. These characteristics include: a. clean, sanitary and orderly environment . During a review of the facility's Housekeeping Supervisor job description, dated 10/19/2015, the job description indicated, . Responsibilities/Accountabilities: 1. Manages the housekeeping department to ensure the provision of a clean and safe environment for customers, visitors and staff; . 5. Inspects the center on a regular basis to determine the effectiveness of the housekeeping function; 6. Ensures that the building is maintained in an odor free and clean condition; 7. Takes immediate action on any observed deficiencies . During a review of the facility's Maintenance Director job description, dated 10/19/2015, the job description indicated, . the maintenance director is responsible for the overall maintenance operation of the center, and he/she is responsible for performing repairs and maintenance on equipment . Responsibilities/Accountabilities 1. Performs overall supervision of the maintenance department including 'hands on' performance of maintenance and repair work . 3. maintains the building and grounds in compliance with federal, state, and local laws . 15. performs other responsibilities, as may be required, and as directed by the administrator . 20. performs other duties as requested . 41608 2. During a review of Resident 6's MDS, dated [DATE], the MDS indicated a BIMS score of 12 which indicated Resident 6 had moderate cognitive impairment. During a review of Resident 23's MDS, dated [DATE], the MDS indicated a BIMS score of 9 which indicated Resident 23 had moderate cognitive impairment. During an observation on 5/20/24 at 9:58 a.m. in Resident 6 and 23's room, red tape was attached to the call light wall socket and to the call light cord. The call light was approximately two feet above the bed. During a concurrent observation and interview on 5/20/24 at 10:02 a.m. with the Activities Assistant (AA), in Resident 6 and 23's room, the AA validated the red tape was attached to the call light socket and call light cord. The AA stated tape should not be on the socket . it could catch fire and harm the residents . During a concurrent observation and interview on 5/20/24 at 10:06 a.m. with the Maintenance Staff (MAINS), in Resident 6 and 23's room, the MAINS stated . the tape was to hold the call light cord to the call light socket . the tape is electrical tape and is not flammable . During a concurrent observation and interview on 5/20/24 at 10:12 a.m. with the MAINS, the MAINS provided the red tape, that was used on the call light socket, the red tape was labeled on the inside of the tape was labeled Duct Tape - a multi-purpose duct tape used for discreet repairs, crafts and decorating projects.) the MAINS sated the red tape should not be used to hold the call light in place. The tape should have been removed it could be a safety hazard and does not provide a homelike environment. During a review of the facility's policy and procedure (P&P) titled Homelike Environment, dated 1/2018, indicated . 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. These characteristics include: a period clean, sanitary, and orderly environment . During a review of the facility's Maintenance Director job description, dated 10/19/2015, the job description indicated, . the maintenance director is responsible for the overall maintenance operation of the center, and he/she is responsible for performing repairs and maintenance on equipment . Responsibilities/Accountabilities 1. Performs overall supervision of the maintenance department including hands on performance of maintenance and repair work . 3. maintains the building and grounds in compliance with federal, state, and local laws . 15. performs other responsibilities, as may be required, and as directed by the administrator . 20. performs other duties as requested .

Based on observation, staff and resident interview, clinical record and administrative document review, the facility failed to implement policies and procedures to prohibit misappropriation of resident property when the personal bank account of 1 of 4 sampled residents (Resident 1) was deliberately and wrongfully accessed by the Business Office Manager (BOM) and a total amount of $17,610.72 was spent from Resident 1's personal bank account without authorization or consent. This failure resulted in the misappropriation of Resident 1's personal finances and in Resident 1 feeling exploited, confused and fearful of not having a safe place to live in the skilled nursing facility. Findings: On 12/2/15 at 3:50 p.m., during an interview, the facility Administrator (Admin) stated on 11/18/15 the Social Service Designee (SSD) 2 unlocked and opened a desk drawer that had been previously used by the former SSD, (SSD 1). An ATM (automated teller machine) card belonging to Resident 1 and an unmarked envelope containing $500 in cash was found inside the desk drawer. SSD 2 notified the Business Office Manager (BOM) and was told to turn in the ATM card and money to the BOM on 11/18/15. The Admin stated retail store receipts with Resident 1's name were found in the drawer that had been previously used by the former SSD 1, along with the money and ATM card. The Admin stated an investigation was conducted and determined the $500 dollars belonged to Resident 1. The Admin stated the money that was found in SSD 1's desk drawer had not been given to the BOM. The $500 dollars that was found in the desk drawer was withdrawn by SSD 1 as payment for Resident 1's share of cost (SOC) (insurance monthly deductible). The Admin stated the Chief Clinical Officer (CCO) for the corporation discovered the Share of Cost for Resident 1 had not been paid from October 2014 through November 2015. The Admin stated the Quality Assurance (QA) nurse interviewed SSD 1 regarding the ATM card transactions, withdrawals from Resident 1's checking account, and the unpaid SOC. The Admin stated during the investigation by the QA nurse she discovered that SSD 1 had been making $500 dollar cash withdrawals and hand delivered the money to the BOM as payment for Resident 1's monthly share of cost. The Admin stated SSD 1 had made cash withdrawals in the amount of $500 dollars with Resident 1's ATM card beginning 10/20/14 through 11/19/15. The Admin stated there were no records of receipt for the SOC cash payment delivered to the BOM. The Admin stated the facility obtained bank statements which indicated dates, locations and withdrawals from Resident 1's personal bank account. The Admin stated, There was an ATM withdrawal at a gas station using (Resident 1's) ATM card on 11/19/15; the only one that had access to the ATM card was the BOM. The Admin stated the facility obtained a filmed recording dated, 11/19/15 of the BOM making a cash withdrawal from an ATM machine located inside a gas station which was the same location identified on Resident 1's bank statements for the same date and time of the withdrawal. The Admin stated the BOM had not had authorization to use Resident 1's ATM card. This is on me. When asked if there had been oversight of the activities of the BOM and SSD 1, the Admin stated she was responsible for the oversight of the employees and she had trusted the employees to do the right thing. Resident 1's Minimum Data Set (MDS)(a resident assessment tool for cognitive and physical abilities) assessment, dated 11/11/15, indicated the Brief Interview for Mental Status summary score was 15, which indicated there were no cognitive deficits and the resident was able to make own decisions. On 12/2/15 at 1:55 p.m., during an interview, Resident 1 stated she could not recall anyone discussing her finances with her. Resident 1 stated SSD 1 had bought her candy and sodas. Resident 1 stated SSD 1 had not purchased clothes, shoes, or any other articles for her. Resident 1 stated she had not given SSD 1 permission to use her ATM card. When asked how Resident 1 felt about the misuse of the ATM card, Resident 1 stated, It made me feel like I was being used. You trust someone and they do that to you? Resident 1 stated she felt worried, there was a frown on her face while she wrung her hands as she talked. Resident 1 stated she was frightened that she may have been asked by the facility to move out of the facility since the SOC had not been paid for over a year. On 12/3/15 at 10:20 a.m., during an interview, the Admin stated SSD 1 began withdrawal of Resident 1' s money from Resident 1's checking account on 10/14/14. The Admin stated SSD 1 should not have been allowed and should not have taken control of Resident 1's finances. The Admin stated facility staff are not authorized to control residents' finances. On 12/15/15 at 8:27 a.m., during an interview Resident 1 stated, It (removal of the resident monies) made me feel like I was nothing; I had no control over it. I felt violated, as if I was a dog with a bone. You can easily come and take his bone, I felt like that. I don't know how much they took from me, they never really told me. On 1/14/16 at 4:16 p.m. during a concurrent interview and document review with the Clinical Consultant (CC), titled, (Resident 1's) ATM Withdrawals 11/17/14 - 11/19/15, undated, indicated four diagonal columns which contained the receipt dates as follows: 10/20/14, 11/17/14, 12/15/14, 12/18/14, 12/22/14, 12/29/14, 1/12/15, 1/20/15, 02/09/15, 03/02/15, 03/09/15, 03/30/15, 04/13/15, 05/04/15, 05/11/15, 05/18/15, 05/21/15, 06/05/15, 06/08/15, 06/15/15. 07/13/15, 07/20/15, 08/10/15, 08.17/15, 08/24/15, 08/31/15, 09/08/15, 09/14/15, 09/21/15, 09/28/15, 10/05/15, 10/14/15, 11/09/15, 11/19/15, 11/19/15 . The second diagonal column indicated, Amount and listed monies withdrawn monthly from a range of $202.25 to $503 over a 13 month period totaling $16,910. 50. The CC verified the document review. On 12/03/15 at 10:20 a.m., during a concurrent interview and administrative document review, the Admin verified Resident 1's personal bank account statement totaled 31 withdrawals of $500 dollars for the following dates: 10/20/14, 11/17/14, 12/15/14, 12/18/14, 12/22/14, 12/29/14, 1/12/15, 1/20/15, 02/09/15, 03/02/15, 03/09/15, 03/30/15, 04/13/15, 05/04/15, 05/11/15, 05/18/15, 05/21/15, 06/08/15, 06/15/15, 07/13/15, 07/20/15, 08/10/15, 08/17/15, 08/24/15, 08/31/15, 09/08/15, 09/14/15, 09/21/15, 09/28/15, 10/05/15, 11/09/15 totaling $15,500. There was documentation which indicated two withdrawals of $503.00 on 06/05/15, and 10/14/15 which totaled $1006.00. There were also two withdrawals of $202.25 on 11/19/15 which totaled $404.50. The total amount of money withdrawn totaled $16,910.50 from Resident 1 ' s bank account. On 1/15/16 at 5:30 p.m., during a concurrent interview and administrative document review, the Admin review of various retail register receipt in Resident 1's name that were found in the desk drawer of SSD 1 beginning from May 2014 to November 2015 totaled $ 702.22. Review of Resident 1's Transaction Journal from ( .) bank, indicated $16,910.50 dates beginning 10/20/14 to 11/19/15 had been withdrawn from Resident 1's checking account. Review of the various retail store receipts that the facility had submitted for review totaled $702.22. The total amount that was withdrawn without consent from Resident 1's bank account was $17,610.72. The facility Policy and Procedure titled, Abuse Prohibition Policy, undated indicated, POLICY: The Facility will prohibit ., mistreatment .and misappropriation of property for all patients through the following .Prevention of occurrence .Definitions .Exploitation is defined as the act or process of taking advantage of an elderly person by another person or caretaker whether for monetary, personal, or other benefit, gain, or profit.