Every finding on record at Channel Islands Post Acute

Based on observation, interview and record review, the facility failed to ensure food and ice were stored, prepared and served in accordance with professional standards for food safety when: Kitchen equipment were stored wet with water inside. A Dietary Aide 2 (DA 2) was observed using the sanitation bucket to sanitize the food preparation counter that did not contain the recommended concentration levels of quaternary ammonium (a group of chemicals used for killing bacteria, fungi, and viruses) for sanitization (to reduce the number of disease-causing pathogens).Green, brown, black, and pink substances were inside the ice machine where the water dripped into the drip pan.Undated oat milk past the best if used by was found in resident refrigerator located at nursing station 3/4.The dishwasher's actual temperature did not match the temperature written on the log.These failures had the potential to promote the growth of microorganisms and increase the risk of foodborne illness among the facility's medically vulnerable resident population. Findings:1. During a concurrent observation interview on 8/3/26 at 8:46 AM in the kitchen with the Kitchen Manager (KM) and the Registered Dietitian (RD), the blender and Robot Coupe (food processor) were stored while wet with water pooling inside the bottom. The RD acknowledged the water in the equipment. The KM stated she expected the equipment to be dry.A review of facility's Policy and Procedure (P&P) titled, Dishwashing, dated 2023, indicated, .dishes are to be air dried in racks before stacking and storing.2. During a concurrent observation of the kitchen and interview on 8/4/26 at 9:33 AM with the DA 2 in the presence of KM, DA 2 wiped down the food preparation counter with a towel from the green bucket, then wiped it down with a towel from the red sanitation bucket. DA 2 tested the concentration of the quaternary ammonium solution which measured 100 parts per million ([ppm] - a unit used to describe very small concentrations of a substance in a larger solution). DA 2 stated the concentration needed to be between 200 to 300 ppm and stated 100 or 400 ppm was not acceptable. DA 2 stated that chemical in the sanitizer bucket should have been changed every 2 hours and the bucket had last been filled at 6:30 am.A review of the facility's P&P titled, Quaternary Ammonium Policy, dated 2023, indicated, The Food & Nutrition Services worker will place the solution in the appropriate bucket labeled for its contents and will test the concentration of the sanitation solution. The concentration will be tested at least every shift or when the solution is cloudy. The solution will be replaced when the reading is below 200 ppm. The replacement will be tested prior to usage.A review of the facility's document of the manufacturer information, undated, indicated the proper sanitizing solution must read minimum 200ppm for proper sanitizing. A review of the facility's Quaternary Ammonium Log, dated 8/1/26, indicated, Instructions: Test the ammonium concentration in the quaternary sanitizer per policy using the proper strips. Record the concentration reading on two of these tests on the form below. Record the reading once in the AM and once in the PM. Ammonium reading should be at least 200 ppm, or manufacturer's recommendation. Alert the FNS Director if ammonium levels are below minimum.3. During a concurrent observation of the ice machine and interview on 8/4/26 at 9:41 AM with the Maintenance Director (MD) with the presence of the RD, the ice machine had green, brown, black, and pink residue inside the bin near the drip pan (where water drips to form ice). The MD stated the facility had an outside vendor clean and sanitize the ice machine monthly. The RD stated the ice produced by the ice machine was used in resident beverages and provided to residents upon request. During an interview with the MD on 8/4/26 at 9:57 AM, the MD acknowledged the colored residue observed inside the ice machine and stated he would discard the ice.A review of the facility's P&P titled, Ice Machine Cleaning Procedures, dated 2025, indicated, The ice machine needs to be cleaned routinely. The internal components cleaned monthly or per manufacturer's recommendations, and the date recorded when cleaned. During a review of the Instruction Manual, dated revised 2/23/23, indicated under .B. Cleaning and Sanitizing Instructions, more frequent cleaning and sanitizing may be required in some water conditions.4. During an observation of the resident refrigerator located at Nursing Station 3/4 on 8/5/26 at 9:43 AM, one carton of oat milk for Resident 88 with a best if used by date of 5/11/25 was found inside the resident refrigerator.During concurrent observation and interview on 8/5/26 at 9:52 AM with LVN 2, LVN 2 confirmed the best if used by date of 5/11/25 on the oat milk carton and stated that although it was unopened, it needed to be discarded because the date had passed.A review of facility's P&P titled, Foods Brought by Family or Visitor with revised date 01/2026, indicated Perishable prepared foods will be checked by the designee daily and discarded after 3 days of storage. Perishable manufactured foods stored in the manufacturer packaging will be discarded as per the best by or use by date. If no date, follow facility refrigerated storage guidelines.5. During a concurrent observation and interview on 8/3/26 at 9:40 AM in the kitchen with DA 1, the dish machine temperature gauge displayed 100 degrees Fahrenheit (F) while the machine was operating. DA 1 stated the dish machine wash temperature needed to be 120 degrees F and the rinse temperature needed to be at 140 degrees F. During a concurrent interview and record review on 8/3/26 at 10:03 AM with the KM, the facility's Dish Machine Temperature Log, dated July 2026 and August 2026, was reviewed. The wash temperature was documented as 100 F on the following dates: 7/1/26 - 7/31/26, and 8/1/26 - 8/3/26. Further review of the log indicated the rinse temperature was documented as 120 F on the following dates: 7/1/26 - 7/31/26, and 8/1/26 - 8/3/26. The KM verified the above findings and stated the wash temperature should be at least 120 F and the rinse temperature should be at least 140 F.A review of the facility's Dish Machine Temperature Log, dated July and August 2026, indicated, Instructions: Wash temperatures must be at least 120 F. (Use manufacturer's guidelines on machine for range of wash and rinse temperatures.)A review of the facility's Policy & Procedure (P&P) titled, Dishwashing dated 2023 indicated, The dishwasher will run the dish machine until temperature is within the manufacturer's recommendations. Low-temperature machine: If you do not have the manufacturer's recommendations, use the machine at a range of 120 F to 140 F. High-temperature machine: If you do not have the manufacturer's recommendations, use the machine at a temperature of 150 F to 165 F or higher for the wash and 180 F or above for the rinse.

Based on interview and record review, the facility failed to ensure required Payroll-Based Journal ([PBJ] a mandated reporting system used by the Centers for Medicare & Medicaid Services [CMS] to collect auditable, employee-level staffing data from long-term care facilities) staffing data was accurately submitted to CMS for Fiscal Year (FY) 2026, Quarter 1, (October 1-December 31, 2025).This failure resulted in the facility's failure to provide required information regarding staffing levels necessary to ensure the provision of safe and comprehensive care for all residents in accordance with federal regulations.Findings:A review of the facility's, PBJ Staffing Data Report, dated 7/24/26, the PBJ report for Quarter 1 2026 (October 1 - December 31, 2025) indicated the facility was triggered for failed to submit data for the quarter.During a concurrent interview and record review, with the Administrator on 8/5/26, at 3:05 PM, the Administrator stated the facility used an outside vendor to process and transmit PBJ staffing hours to CMS. The Administrator reviewed the facility's CMS Submission Report, for FY 2026 Quarter 1, dated 2/14/26, and verified the employee hours submitted to the CMS PBJ system did not match the existing value. The Administrator stated the facility's vendor incorrectly coded the hours and the PBJ was not accepted.

Based on observation and interview, the facility failed to ensure menus were followed when incorrect scoop sizes were used to portion vegetables, minced and moist meat, and soft and bite sized meat. This deficient practice resulted in nine residents (Residents 44, 54, 94, 98, 90, 87, 126, 137, 138) receiving portions that did not match Registered Dietitian (RD) approved facility menu and had the potential to affect the nutritional adequacy and medical status of the residents.Findings:A review of the facility's Lunch Menu, dated 8/3/26, indicated the following items were to be served: four ounces of old fashioned meatloaf and 1/2 (half) cup of seasoned vegetables.During an observation of the lunch meal service on 8/3/2026 starting at 11:15 AM, [NAME] 1 was using a 3-ounce spoodle to scoop the minced and moist broccoli, # 12 scoop (1/3 cup or 3 ounces) for the broccoli, a 3-ounce spoodle used for the carrots, #12 scoop for the zucchini, 3-ounce spoodle for minced and moist meatloaf and chopped meatloaf. It was observed during the lunch meal service, the following:Resident 54's tray contained three ounces of minced and moist meatloaf and three ounces of minced broccoli. A concurrent review of Resident 54's meal ticket showed a minced and moist diet. Resident 94's tray contained three ounces of carrots. A concurrent review of Resident 94's meal ticket showed a regular diet. Resident 44's tray contained three ounces of carrots and chopped meatloaf. A concurrent review of Resident 44's meal ticket showed an easy to chew, renal diet.Resident 98's tray contained three ounces of carrots. A concurrent review of Resident 98's meal ticket indicated a regular diet.Resident 90's tray contained three ounces of carrots, two slices of meatloaf and rice. A concurrent review of Resident 90's meal ticket showed a regular diet with double protein, renal, consistent carbohydrate, no added salt diet.Resident 87's tray contained two scoops of the three-ounce spoodle of chopped meatloaf, three ounces of carrots. A concurrent review of Resident 87's meal ticket showed easy to chew, double protein, fortified diet.Resident 126's tray contained a three-ounce spoodle of broccoli, three-ounce spoodle of mince and moist meatloaf, mashed potatoes, minced bread with a fortified sauce. A concurrent review of Resident 126's meal ticket showed Minced and moist level 5, fortified diet.Resident 138's tray contained three ounces of minced meatloaf and three ounces of minced broccoli. A concurrent review of Resident 138's meal ticket showed a minced and moist level 5, consistent carbohydrate diet. Resident 137's tray contained three ounces of chopped meatloaf. A concurrent review of Resident 137's meal ticket showed soft and bite sized, consistent carbohydrate diet and the resident disliked vegetables. During a concurrent interview and lunch menu review on 8/4/2026 at 12:52 PM with [NAME] 1 in the presence of Kitchen Manager (KM), [NAME] 1 confirmed he used 3-ounce spoodles and #12 scoops for the vegetables and minced and moist and soft bite (chopped) meatloaf. [NAME] 1 acknowledged the residents should have received 1/2 cup or 4 ounces (# 8 scoop) of the vegetables and the minced and moist meatloaf and soft bite meatloaf.During an interview with the RD on 8/4/26 at 3:23 PM, the RD stated her expectation is that menus are followed and scoop sizes are used and followed correctly. A review of the facility's Portioning Guide, dated 2024, indicated portioning utensils are as follows: #12 scoop was 1/3 cup and 3 ounces.During a review of the facility's Policy & Procedures (P&P) titled, Portion Control, dated 2023, indicated, To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used.1. Scoops are sized by number (the number of scoopfuls needed to equal one quart). The smaller the number, the larger the size. Scoop numbers and amounts are listed within the Healthcare Menus Direct, LLC. Recipe books and on menu spreadsheet.

Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications according to the facility's practice and manufacturer's specifications in two of four reviewed medication carts (Medication Carts A and B) when:1. One box of expired glucometer control solution (chemical used to calibrate a glucometer [device to measure blood sugar]) was stored in one of four reviewed medication carts (Medication Cart A);2. One bottle of medication with an illegible label was stored in one of four reviewed medication carts (Medication Cart A);3. Two insulin pens (pre-filled injectable pen containing insulin [medication to lower blood sugar]) were stored at room temperature in one of four reviewed medication carts (Medication Cart B) without a labeled date; and4. One opened bottle of eye drops was stored in one of four reviewed medication carts (Medication Cart B) without a labeled resident's name.These failures had the potential to expose residents to deteriorated or ineffective medications, which could lead to the use of unsafe and ineffective medications for the residents.Findings:1. During a concurrent observation and interview on 8/4/26 at 10:24 AM with Licensed Vocational Nurse 7 (LVN 7), Medication Cart A was reviewed. The medication cart contained one box of EvenCare G3 Glucose [sugar] Control Solutions labeled D.O. 3/13/26 in black marker with two opened bottles inside. LVN 7 stated the solution was used to calibrate the glucometer. LVN 7 stated the label meant the two bottles inside the box were opened on 3/13/26. LVN 7 stated the manufacturer labeling on the bottle indicated the solutions inside expired three months after opening. LVN 7 stated the bottles were expired and were not supposed to be in the medication cart. During an interview on 8/6/26 at 12:49 PM with the Director of Nursing In Training 1 (DIT 1) and the Director of Nursing (DON), the DIT 1 stated the glucose control solutions had expired on 6/13/26 and were not supposed to be in the cart. The DON stated the solutions needed to be discarded. A review of the EvenCare G3 Blood Glucose Test Strips manufacturer labeling, revised July 2022 and provided by the facility, indicated, Control solution test results should fall within the control ranges printed on the test strip bottle.Results may fall out of range due to.Expired or contaminated control solution. 2. During a continued concurrent observation and interview on 8/4/26 at 10:32 AM with Licensed Vocational Nurse L (LVN L), Medication Cart A was reviewed. The medication cart contained one white medication bottle with a scratched and faded green label and contained medication tablets. LVN L stated she was unable to read the label. LVN L stated the medication was not acceptable to administer to residents due to the bottle's condition. During an interview on 8/6/26 at 12:45 PM with the DON and DIT 1, the DON stated medications in the medication cart were available for use. The DIT 1 stated the medication bottle was not legible. A review of the facility's policy and procedure (P&P) titled, Medication Administration - Oral, revised January 2026, indicated, Drugs are not to be used from a container if label is illegible or missing. Return them to the pharmacy. 3. During a concurrent observation and interview on 8/5/26 at 2:56 PM with LVN 8, Medication Cart B was reviewed. The medication cart contained seven insulin pens. There was one unopened Lantus SoloStar (brand name injectable pen containing insulin glargine, type of long-acting insulin) insulin pen and one unopened Novolog FlexPen (brand name injectable pen containing insulin aspart, type of rapid-acting insulin) without a labeled date. LVN 8 stated the insulin pens were not opened and needed to be labeled with a date when removed from the refrigerator. LVN 8 stated Lantus SoloStar and Novolog FlexPen had a beyond use date of 28 days after removal from the refrigerator. During a telephone interview on 8/6/26 at 9:30 AM with the Consultant Pharmacist (CP), the CP stated insulin pens could be stored at room temperature for 28 days after removal from the refrigerator. The CP stated the 28 day beyond use date applied for opened and unopened insulin pens. The CP stated there was a concern that insulin pens stored at room temperature without a labeled date could expire without the facility knowing. The CP stated all insulin pens needed to be labeled and dated once removed from the refrigerator. During an interview on 8/6/26 at 12:42 PM with the DIT 1, the DIT 1 stated insulin pens stored in the medication cart needed to be labeled with the date opened or removed from the refrigerator. The DIT 1 stated insulin pens had a 28-day expiration when stored at room temperature. During an interview on 8/6/26 at 3:17 PM with the DON, the DON stated the facility did not have a policy addressing the labeling of insulin pens. A review of the facility's P&P titled, Storage and Labeling of Medications, revised January 2026, indicated, Medications will be stored under conditions that enhance stability. Elements to be considered include: Appropriate storage temperatures. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for Novolog FlexPen, dated 2/28/23, retrieved from DailyMed (a website operated by the U.S. National Library of Medicine to publish up-to-date and accurate drug labels to health care providers and the general public, provided and updated daily by the U.S. Food and Drug Administration), indicated, Store unused NOVOLOG in a refrigerator between 2 C to 8 C (36 F to 46 F). The record further indicated, Not in-use (unopened) Room Temperature.28 days and In-use (opened) Room Temperature.28 days (Do not refrigerate). A review of the PI for Lantus SoloStar, dated 6/2/25, retrieved from DailyMed, indicated, Store unused LANTUS in a refrigerator between 36 F and 46 F (2 C and 8 C). The record further indicated, Not in-use (unopened) Room Temperature.28 days and In-use (opened) Room Temperature.28 days Room temperature only (Do not refrigerate). 4. During a continued concurrent observation and interview on 8/5/26 at 3:00 PM with LVN 8, Medication Cart B was reviewed. The medication cart contained one box of Sterile Eye Drops Irritation Relief (medication used to treat dry eyes) with a bottle of eye drops inside. LVN 8 stated the bottle had been opened and the box was not labeled with a resident's name. During an interview on 8/5/26 at 3:27 PM with LVN 8, LVN 8 stated eye drops were supposed to be labeled with a specific resident's name. LVN 8 stated eye drops were not allowed to be shared between residents for infection control. During an interview on 8/6/26 at 12:48 PM with the DIT 1, the DIT 1 stated opened eye drops were supposed to be labeled with a specific resident's name. The DIT 1 stated the concern was unlabeled eye drops being used for multiple residents. During a telephone interview on 8/6/26 at 9:32 AM with the CP, the CP stated eye drops were for one resident only for infection control. The CP stated eye drops were supposed to be labeled with a resident's name. The CP stated unlabeled eye drops were supposed to be removed and discarded. During an interview on 8/6/26 at 3:18 PM with the DON, the DON stated the facility did not have a policy addressing the labeling of eye drops or eye drops used for one resident only. The DON confirmed the nurses were supposed to label eye drops with a resident's name and only use the eye drops for one resident. A review of the facility's P&P titled, Storage and Labeling of Medications, revised January 2026, indicated, Medications will be properly stored and labeled for use. The policy indicated, All medications.will be labeled for contents, with expiration dates clearly identified. No expired medication will be used. Expired medications will be removed from use, for appropriate disposal.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of residents, when: 1. The facility failed to ensure accurate accountability of controlled drugs (controlled substances [CS], those with high potential for abuse and addiction) when the Controlled Drug Records (CDR, accountability records) for six of eleven randomly selected residents (Residents 30, 159, 39, 23, 11, and 164) did not reconcile with the Medication Administration Records ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). This failure resulted in inaccurate accountability of controlled substances and the potential for unidentified discrepancies and possible abuse or diversion of controlled substances; and 2. The facility administered a slow, long-acting antipsychotic (medication to treat mental illness like schizophrenia) during an emergency for one of five sampled residents (Resident 30) reviewed for unnecessary medications. This failure had the potential for Resident 30 to experience side effects such as abnormal body movements. 3. Resident 57 was observed with anesthetic lozenges (medicated tablets or hard candies that dissolve slowly in the mouth to ease throat pain) at the bedside without a physician's order. This failure had the potential to result in appropriate medication use and adverse medication effects. Findings: 1a. A review of Resident 30's Order Listing Report, dated 8/5/26, indicated Resident 30 had a physician's order, dated 8/2/26, for lorazepam (generic for Ativan, a controlled medication to treat anxiety [feeling of fear, dread, or unease when stressed or anticipating a problem]) 0.5 milligrams (mg), Give 1 tablet by mouth every 8 hours as needed for anxiety. During a concurrent interview and record review on 8/5/26 at 10:58 AM with Licensed Vocational Nurse (LVN) 5, Resident 30's lorazepam 0.5 mg CDR, dated 8/1/26, and MAR, dated 8/1/26 – 8/5/26, were reviewed. LVN 5 confirmed the CDR indicated the licensed nurse signed out one dose on 8/4/26 at 1945 (7:45 PM) and did not document the administration of as needed lorazepam on the MAR. 1b. A review of Resident 159's Order Listing Report, dated 8/5/26, indicated Resident 159 had a physician's order, dated 7/25/26, for oxycodone (a potent controlled drug and narcotic for moderate to severe pain) 5 mg, Give 1 tablet by mouth every 4 hours as needed for Moderate to Severe pain. During a concurrent interview and record review on 8/5/26 at 10:58 AM with LVN 5, Resident 159's oxycodone 5 mg CDR, dated 7/25/26, and MAR, dated 8/1/26 – 8/5/26, were reviewed. LVN 5 confirmed the CDR indicated the licensed nurse signed out one dose on 8/4/26 at 0325 (3:25 AM) and did not document the administration of as needed oxycodone on the MAR. During a continued concurrent interview and record review on 8/5/26 at 10:58 AM with LVN 5, Resident 159's oxycodone 5 mg CDR, dated 7/26/26, and MAR, dated 7/1/26 – 7/31/26, were reviewed. LVN 5 confirmed the CDR indicated the licensed nurse signed out one dose on 7/30/26 at 0100 (1:00 AM) and did not document the administration of as needed oxycodone on the MAR. During an interview on 8/5/26 at 11:00 AM with LVN 5, LVN 5 stated nurses were supposed to sign the medication out on the CDR, then administer to the resident, and then document administration on the MAR. LVN 5 stated if administration was not documented on the MAR, the medication was considered not given. 1c. A review of Resident 39's Order Listing Report, dated 8/5/26, indicated Resident 39 had a physician's order, dated 3/9/26, for Percocet 5-325 mg (oxycodone 5 mg with acetaminophen 325 mg, a potent controlled drug and narcotic for severe pain), Give 1 tablet by mouth every 8 hours as needed for MODERATE to SEVERE Pain. During a concurrent interview and record review on 8/5/26 at 3:07 PM with LVN 8, Resident 39's Percocet 5-325 mg CDR, dated 4/14/26, and MAR, dated 7/4/26 – 8/5/26, were reviewed. LVN 8 confirmed the CDR indicated the licensed nurse signed out a dose and did not document the administration of as needed Percocet on the MAR on the following dates and times: 7/5/26 at 0805 (8:05 AM) 7/10/26 at 0835 (8:35 AM) 7/11/26 at 0850 (8:50 AM) 7/12/26 at 0710 (7:10 AM) 7/17/26 at 0840 (8:40 AM) 7/18/26 at 0705 (7:05 AM) 7/19/26 at 0850 (8:50 AM) 7/26/26 at 0830 (8:30 AM) 7/31/26 at 0840 (8:40 AM) 8/1/26 at 0710 (7:10 AM) 8/2/26 at 0820 (8:20 AM) LVN 8 stated it was the same nurse, LVN 9, who did not document the CS administration on Resident 39's MAR. LVN 8 stated it looked like the weekend nurse was not documenting on the MAR. LVN 8 stated it looked like the Percocet was not administered because it was not documented on the MAR. LVN 8 stated nurses were supposed to document in both the CDR and the MAR. During a concurrent interview and record review on 8/5/26 at 4:02 PM with Registered Nurse 3 (RN 3), Resident 39's Percocet 5-325 mg CDR, dated 4/14/26, MAR, dated 7/1/26 – 7/31/26, and MAR, dated 8/1/26 – 8/5/26 were reviewed. RN 3 confirmed nine of 11 documented entries on the Percocet CDR were not charted on Resident 39's MAR in July 2026. RN 3 also confirmed two of three documented entries on the Percocet CDR were not charted on Resident 39's MAR in August 2026. During an interview on 8/5/26 at 4:06 PM with RN 3, RN 3 stated nurses were supposed to document administration of all medications in a resident's MAR. RN 3 stated controlled substances signed out of the CDR but not charted in the MAR were considered medication errors.= During an interview on 8/5/26 at 4:40 PM with Resident 39, Resident 39 stated he did not often need pain medication. Resident 39 stated he took one dose of the Percocet in the morning and did not need any of the medication over the previous weekend (8/1/26 – 8/2/26). Resident 39 stated prior to 8/5/26, his last dose of Percocet was about three weeks ago. Resident 39 stated he rarely experienced pain and he never needed pain medications over the weekend. During a concurrent interview and record review on 8/6/26 at 12:56 PM with the Director of Nursing in Training 1 (DIT 1), Resident 39's Percocet 5-325 mg CDR, dated 4/14/26, MAR, dated 7/1/26 – 7/31/26, and MAR, dated 8/1/26 – 8/5/26, were reviewed. The MAR indicated Resident 39 received a dose of as needed Percocet on 7/20/26 at 0939 (9:39 AM) and a dose on 8/5/26 at 0934 (9:34 AM), with no doses documented in between. The DIT 1 stated Resident 39's record indicated a three-week gap between Resident 39's Percocet administrations. The DIT 1 acknowledged this indicated Resident 39 did not recall getting any of the following four doses LVN 9 documented as removed on the CDR: 7/26/26 at 0830 (8:30 AM) 7/31/26 at 0840 (8:40 AM) 8/1/26 at 0710 (7:10 AM) 8/2/26 at 0820 (8:20 AM) 1d. A review of Resident 23's Order Listing Report, dated 8/5/26, indicated Resident 23 had a physician's order, dated 6/10/26, for oxycodone 5 mg, Give 1 tablet via PEG-tube [percutaneous endoscopic gastrostomy tube, a small tube placed through the abdominal wall into the stomach, used to provide feeding formula and/or administer medications] every 4 hours as needed for Mod [moderate] – Severe pain. During a concurrent interview and record review on 8/5/26 at 3:15 PM with LVN 8, Resident 23's oxycodone 5 mg CDR, dated 6/10/26, and MAR, dated 7/1/26 – 7/31/26, were reviewed. LVN 8 stated the CDR indicated the licensed nurse signed out one tablet on 7/25/26 at 2006 (8:06 PM) and did not document the administration of as needed oxycodone on the MAR. 1e. A review of Resident 11's Order Listing Report, dated 8/5/26, indicated Resident 11 had a physician's order, dated 4/22/26, for oxycodone 5 mg Give 0.5 [half] tablet by mouth every 6 hours as needed for Moderate Pain. During a concurrent interview and record review on 8/5/26 at 3:18 PM with LVN 8, Resident 11's oxycodone 5 mg CDR, dated 6/8/26, and MAR, dated 7/25/26 – 8/5/26, were reviewed. LVN 8 confirmed the CDR indicated the licensed nurse signed out a dose and did not document the administration of as needed oxycodone on the MAR on the following dates and times: 7/26/26 at 0730 (7:30 AM) 7/26/26 at 1600 (4:00 PM) 8/1/26 at 0830 (8:30 AM) 8/1/26 at 1500 (3:00 PM) LVN 8 stated she was not able to review records from prior to 7/25/26. LVN 8 stated the same nurse from Resident 39's Percocet review, LVN 9, did not chart administration of Resident 11's oxycodone. During an interview on 8/5/26 at 3:20 PM with LVN 8, LVN 8 stated a nurse was supposed to fill out both the CDR and the MAR so all nurses would know whether as needed medications were due. LVN 8 stated they followed this process to make sure nurses did not administer the dose too early according to the doctor's orders. During a concurrent interview and record review on 8/5/26 at 4:07 PM with RN 3, Resident 11's oxycodone 5 mg CDR, dated 6/8/26, and MAR, dated 7/1/26 – 7/31/26, were reviewed. RN 3 confirmed the CDR indicated the licensed nurse signed out a dose and did not document the administration of as needed oxycodone on the MAR on the following dates and times: 7/3 at 0800 7/3 at 1500 7/4 at 0800 7/4 at 1530 7/5 at 0730 7/5 at 1500 7/10 at 1130 7/11 at 0830 7/11 at 1600 7/12 at 0715 7/26 at 0730 7/26 at 1600 RN 3 confirmed 12 of 19 documented entries on the oxycodone CDR were not charted on Resident 11's MAR in July 2026. During a concurrent interview and record review on 8/5/26 at 4:10 PM with RN 3, Resident 11's oxycodone 5 mg CDR, dated 6/8/26, and MAR, dated 8/1/26 – 8/5/26, were reviewed. RN 3 confirmed the CDR indicated the licensed nurse signed out a dose and did not document the administration of as needed oxycodone on the MAR on the following dates and times: 8/1/26 at 0830 (8:30 AM) 8/1/26 at 1500 (3:00 PM) RN 3 confirmed two of three documented entries on the oxycodone CDR were not charted on Resident 11's MAR in August 2026. During a concurrent interview and record review on 8/5/26 at 4:11 PM with RN 3, Resident 11's oxycodone 5 mg CDR, dated 6/8/26, and MAR, dated 6/1/26 – 6/30/26, were reviewed. RN 3 confirmed the CDR indicated the licensed nurse signed out a dose and did not document the administration of as needed oxycodone on the MAR on the following dates and times: 6/13/26 at 1500 (3:00 PM) 6/14/26 at 1000 (10:00 AM) 6/19 at 0700 (7:00 AM) 6/19 at 1500 (3:00 PM) 6/19 at 2111 (9:11 PM) 6/20 at 0810 (8:10 AM) 6/21 at 0715 (7:15 AM) 6/21 at 1710 (5:10 PM) 6/22 at 0826 (8:26 AM) 6/26 at 0730 (7:30 AM) 6/26 at 1500 (3:00 PM) 6/27 at 0820 (8:20 AM) 6/27 at 1600 (4:00 PM) 6/28 at 0740 (7:40 AM) 6/28 at 1500 (3:00 PM) RN 3 confirmed 15 of 18 documented entries on the oxycodone CDR were not charted on Resident 11's MAR in June 2026. RN 3 acknowledged the same nurse, LVN 9, did not document narcotic drug administration on both Resident 39 and Resident 11's records. 1f. A review of Resident 164's Order Listing Report, dated 8/5/26, indicated Resident 164 had a physician's order, dated 5/27/26, for tramadol (generic for Ultram, a controlled drug and narcotic for pain) 50 mg Give 1 tablet by mouth every 6 hours as needed for SEVERE PAIN. During a concurrent interview and record review on 8/5/26 at 3:36 PM with LVN 2, Resident 164's tramadol 50 mg CDR, dated 5/27/26, and MAR, dated 7/8/26 – 8/5/26, were reviewed. LVN 2 confirmed the CDR indicated the licensed nurse signed out a dose and did not document the administration of as needed tramadol on the MAR on the following dates and times: 7/10/26 at 0730 (7:30 AM) 7/10/26 at 1730 (5:30 PM) 7/11/26 at 0740 (7:40 AM) 7/12/26 at 0735 (7:35 AM) LVN 2 stated she was not able to review administration records from prior to 7/8/26. LVN 2 stated Resident 164 had moved to this unit in August 2026 and had not asked for tramadol since arrival. During a concurrent interview and record review on 8/5/26 at 3:52 PM with RN 3, Resident 164's tramadol 50 mg CDR, dated 5/27/26, and MAR, dated 5/1/26 – 5/31/26, were reviewed. RN 3 confirmed the CDR indicated the licensed nurse signed out a dose and did not document the administration of as needed tramadol on the MAR on the following dates and times: 5/29/26 at 0850 (8:50 AM) 5/30/26 at 0820 (8:20 AM) RN 3 confirmed two of of two documented entries on the tramadol CDR were not charted on Resident 164's MAR in May 2026. During a concurrent interview and record review on 8/5/26 at 3:56 PM with RN 3, Resident 164's tramadol 50 mg CDR, dated 5/27/26, and MAR, dated 6/1/26 – 6/30/26, were reviewed. RN 3 confirmed the CDR indicated the licensed nurse signed out a dose and did not document the administration of as needed tramadol on the MAR on the following dates and times: 6/5/26 at 0815 (8:15 AM) 6/5/26 at 1300 (1:00 PM) 6/6/26 at 0820 (8:20 AM) 6/7/26 at 0815 (8:15 AM) 6/8/26 at 1530 (3:30 PM) 6/12/26 at 0930 (9:30 AM) 6/13/26 at 0840 (8:40 AM) 6/14/26 at 0825 (8:25 AM) 6/19/26 at 0830 (8:30 AM) 6/20/26 at 0835 (8:35 AM) 6/21/26 at 0820 (8:20 AM) 6/26/26 at 0830 (8:30 AM) 6/27/26 at 0945 (9:45 AM) 6/28/26 at 0850 (8:50 AM) RN 3 confirmed 14 of 14 documented entries on the tramadol CDR were not charted on Resident 164's MAR in June 2026. During a concurrent interview and record review on 8/5/26 at 3:56 PM with RN 3, Resident 164's tramadol 50 mg CDR, dated 5/27/26, and MAR, dated 7/1/26 – 7/31/26, were reviewed. RN 3 confirmed the CDR indicated the licensed nurse signed out a dose and did not document the administration of as needed tramadol on the MAR on the following dates and times: 7/3/26 at 0825 (8:25 AM) 7/4/26 at 0850 (8:50 AM) 7/5/26 at 0840 (8:40 AM) 7/10/26 at 0730 (7:30 AM) 7/10/26 at 1730 (5:30 PM) 7/11/26 at 0740 (7:40 AM) 7/12/26 at 0735 (7:35 AM) RN 3 confirmed seven of 11 documented entries on the tramadol CDR were not charted on Resident 164's MAR in July 2026. RN 3 stated, That's a lot. During an interview on 8/5/26 at 4:04 PM with RN 3, RN 3 stated Resident 39 and Resident 164's narcotic records contained a repetitive mistake. RN 3 stated the missing entries were from the same nurse, LVN 9. During an interview on 8/5/26 at 4:22 PM with RN 3, RN 3 stated the concern with unsecured controlled drugs was residents, staff, or visitors could access the medications without authorization and overdose. RN 3 stated the CDR and the MAR needed to match. During an interview on 8/5/26 at 5:03 PM with the Assistant Director of Nursing (ADON), the ADON stated nurses were accountable to the facility's controlled drug accountability process. The ADON stated the concern with controlled drug discrepancies was diversion and to ensure residents received their medications. The ADON stated if a controlled drug was documented as removed on the CDR, it needed to be documented in the MAR to ensure accurate records. The ADON agreed if medication administration was not documented on the MAR, it meant the medication was not given. During a telephone interview on 8/6/26 at 9:26 AM with the Consultant Pharmacist (CP), the CP stated controlled drug records were checked to ensure no diversion and to prevent diversion. The CP stated controlled drug administration was supposed to be documented in the CDR and the MAR. The CP stated the expectation was nurses to document administration in the MAR for all medications and to also document on the CDR for controlled drugs. During an interview on 8/6/26 at 12:52 PM with the Director of Nursing (DON), the DON stated nurses were expected to document the administration of as needed controlled substances right away. The DON stated the missing documentation in the records was hard to explain. The DON stated it was required for the CDR and the MAR to match, and for nurses to document accurately. The DON further stated the facility evaluated controlled drug records for patterns, such as an individual nurse's patterns, and investigated as part of the facility's narcotic accountability processes. During a concurrent interview and record review on 8/6/26 at 3:56 PM with the DON, Resident 39's Percocet 5-325 mg CDR, dated 4/14/26, Resident 11's oxycodone 5 mg CDR, dated 6/8/26, and Resident 164's tramadol 50 mg CDR, dated 5/27/26, were reviewed. The DON stated the initials found on the three residents' records belonged to LVN 9. A review of the facility's policy and procedure (P&P) titled, Medication Administration - Oral, revised January 2026, indicated, Administering.Drugs.Document administration of medication. A review of the facility's P&P titled, Controlled Medications, revised January 2026, indicated: When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record [CDR]: Date and time of administration. Amount administered. Signature of the nurse administering the dose, completed after the medication is actually administered. 2. A review of Resident 30's Face Sheet (document showing a summary of the resident's information), dated 8/5/26, indicated Resident 30 was admitted to the facility on [DATE]. The record indicated an active diagnosis, dated 6/3/26 on admission, of dementia (loss of mental function such as thinking, memory, and reasoning skills) with other behavioral disturbance. There was no documented diagnosis of schizophrenia (severe brain disorder in which people interpret reality abnormally) in the record. A review of Resident 30's Order Listing Report, dated 8/6/26, indicated Resident 30 had a physician's order, dated 6/8/26, for Haldol Decanoate (brand name for haloperidol decanoate, long-acting injectable antipsychotic), Inject 4 mg intramuscularly [into the muscle] one time only for Physical aggression toward staff for 1 Day. A review of Resident 30's MAR, dated 6/1/26 – 6/30/26, indicated Resident 30 received one 4 mg dose of Haldol Decanoate on 6/7/26 at 2110 (9:10 PM). During a telephone interview on 8/6/26 at 9:34 AM with the CP, the CP stated Haldol Decanoate was a long-acting routine medication administered once a month. The CP stated haloperidol lactate (generic for Haldol Lactate, short-acting injectable antipsychotic medication used to treat acute agitation) was immediate-release and used in emergency situations. The CP stated it was unusual for Haldol Decanoate to be administered in an emergency. The CP stated the order did not seem right. During a concurrent interview and record review on 8/6/26 at 10:12 AM with the Medical Records Director (MRD), Resident 30's Progress Note, dated 6/7/26 at 9:25 PM, was reviewed. The record indicated, At approximately 20:50 [8:50 PM] MD [redacted] was notified of the resident's acute behavioral change and provided a one-time order for Haldol 4mg IM [intramuscular, into the muscle] for behavioral management. The MRD confirmed the Haldol was administered as a one-time emergency dose. The MRD further stated Resident 30 did not have a documented history of receiving any form of haloperidol besides the emergency dose on 6/7/26. During a concurrent interview and record review on 8/6/26 at 12:00 PM with LVN 4, Resident 30's Progress Note, dated 6/7/26 at 9:25 PM, was reviewed. LVN 4 stated Haldol was available in two injectable formulations, short-acting and long-acting. LVN 4 stated the progress note did not specify whether the physician ordered the short-acting or long-acting Haldol injection. LVN 4 stated the progress note did not include justification for why Resident 30 received long-acting Haldol decanoate. During an interview on 8/6/26 at 12:06 PM with LVN 4, LVN 4 stated nurses were supposed to clarify which medication the physician ordered when there were multiple different formulations available, such as Haldol injection. LVN 4 stated residents should get a short-acting Haldol injection in an emergency. When asked if there were risks to residents if nurses did not clarify the physician's orders before giving the medication, LVN 4 nodded. During an interview on 8/6/26 at 1:00 PM with the DON, the DON stated Haldol Decanoate was used as a long-term monthly injectable therapy. The DON stated haloperidol lactate was administered as a single dose. During an interview on 8/6/26 at 1:05 PM with the DIT 1, the DIT 1 stated the facility administered injectable Haldol to Resident 30 due to an emergency. The DIT 1 stated haloperidol lactate was supposed to be ordered for Resident 30. The DIT 1 stated Resident 30's record indicated she received Haldol Decanoate instead of haloperidol lactate. The DIT 1 further stated Haldol Decanoate was a monthly injection that stayed in the body for 28 to 30 days. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for Haldol Decanoate, dated 11/11/25, retrieved from DailyMed (a website operated by the U.S. National Library of Medicine to publish up-to-date and accurate drug labels to health care providers and the general public, provided and updated daily by the U.S. Food and Drug Administration), indicated: HALDOL DECANOATE is indicated for the treatment of schizophrenia in adults who were previously taking a stable dosage of an immediate-release oral [by mouth] haloperidol product, Administer HALDOL DECANOATE by deep intramuscular injection every 4 weeks, The plasma [blood] concentrations of haloperidol gradually rise, reaching a peak at about 6 days after the HALDOL DECANOATE injection, and Adverse Reactions.Parkinsonism [condition caused by antipsychotic medications marked by tremor, muscular rigidity, and slow, imprecise movements] and oculogyric crisis [sudden, involuntary eye spasms forcing the eyes into a fixed position]. A review of the PI for haloperidol lactate, dated 12/12/24, retrieved from DailyMed, indicated, Parenteral [directly into the body] medication, administered intramuscularly in doses of 2 to 5 mg, is utilized for prompt control of the acutely agitated schizophrenic patient with moderately severe to very severe symptoms. A review of the facility's P&P titled, Psychotropic [medication affecting brain activities associated with mental processes and behavior, such as antipsychotics] Drug Use, reviewed January 2026, indicated, Residents do not receive psychotropic drugs pursuant to a PRN [as needed] order unless medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. The policy further indicated, The Licensed Nurses shall review the classification of the drug, its indication/behavior monitors and related adverse side effects. 3. During a concurrent observation and interview on 8/4/26 at 7:55 AM, with Resident 57 inside of Resident 57's room, Resident 57 was observed sitting up in bed with one blister pack (a type of medicine packaging where individual doses of medication are sealed in small, clear plastic bubbles (blisters) and attached to a rigid card or foil backing) of anesthetic lozenges on top of the bedside table. The blister pack contained one remaining lozenge, with eight blister cavities observed empty. Resident 57 was observed with one lozenge in their mouth and stated they had taken the lozenge due to coughing and a sore throat. A review of Resident 57's Face Sheet, (front page of the chart that contains a summary of basic information about the resident) dated 8/4/26, indicated Resident 57 was readmitted to the facility on [DATE]. A review of Resident 57's Order Summary Report, dated 8/4/26, indicated Resident 57 did not have a physician's order for anesthetic lozenges. During a concurrent observation and interview on 8/4/26 at 3:50 PM with Licensed Vocational Nurse (LVN) 7 inside of Resident 57's room, Resident 57 was observed sitting up in bed with one blister pack of anesthetic lozenges on top of the bedside table. LVN 7 acknowledged the findings and stated they did not know where Resident 57 obtained the blister pack of anesthetic lozenges. During a concurrent observation and interview on 8/4/26 at 3:52 PM, with LVN 7 outside of the medication room in station 1, LVN 7 retrieved a box labeled Sore Throat Lozenges Menthol/Benzocaine – Oral Anesthetic. LVN 7 opened the box and verified the anesthetic lozenges contained in the box were the same type of lozenges observed in Resident 57's room. During a concurrent interview and record review on 8/4/26 at 4:11 PM with the Assistant Director of Nursing (ADON), the ADON stated anesthetic lozenges required a physician's order and should not have been at Resident 57's bedside without a physician's order.A review of the facility's policy and procedure (P&P)t titled, Medication Administration, revised 1/2026, indicated No medication is to be administered without a physician's written order. Cross reference to F554.

Based on observation, interview and record review, the facility failed to follow Infection Prevention and Control practices when:1. Shared equipment was not disinfected between uses during the medication administration observation for two of six residents (Residents 74 and 96); 2. Enhanced barrier precautions (EBP, infection control practices used in nursing homes to prevent the spread of bacteria) were not followed during the medication administration observation for two of six residents (Residents 96 and 100); 3. An insulin pen (pre-filled injectable pen containing insulin, a medication to lower blood sugar) was not disinfected prior to use during the medication administration observation for one of six residents (Resident 96);4. A Housekeeping Aide (HA) did not perform hand hygiene before and after wearing gloves inside a resident room.These deficient practices have the potential for transmission of communicable diseases and infections to residents in the facility.5. Beverages were not properly stored and discarded in accordance with food safety and sanitation practices when six cups of coffee found inside Resident 126's bedside drawer were left overnight.These deficient practices have the potential for transmission of communicable diseases and infections to residents in the facility.Findings: 1a. During a medication pass observation on 8/3/26 at 8:53 AM outside of Resident 74's room, Licensed Vocational Nurse 3 (LVN 3) was observed removing an automatic blood pressure (BP) cuff from the medication cart. LVN 3 did not clean or disinfect the BP cuff. LVN 3 entered Resident 74's room and asked Resident 74 to remove his jacket to expose his arm. LVN 3 placed the BP cuff on Resident 74's left arm and checked his blood pressure. LVN 3 then returned to the medication cart, put the BP cuff in the medication cart without cleaning or disinfecting the BP cuff, and then continued Resident 74's morning medication pass. During an interview on 8/3/26 at 4:33 PM with LVN 4, LVN 4 stated shared equipment like BP cuffs and glucometers (device to measure blood sugar) needed to be disinfected before and after use on a resident. LVN 4 stated nurses were supposed to use the Micro-Kill One disinfecting wipes to clean and disinfect shared equipment. 1b. During a medication pass observation on 8/3/26 at 9:11 AM outside of Resident 96's room, LVN 3 was observed removing an EvenCare G3 (brand name) glucometer from the medication cart. LVN 3 did not clean or disinfect the glucometer. LVN 3 entered Resident 96's room, pricked Resident 96's right index finger, and used the glucometer to read Resident 96's blood sugar. LVN 3 then returned to the medication cart, put the glucometer in the medication cart without cleaning or disinfecting the glucometer, and then continued Resident 96's morning medication pass. During an interview on 8/3/26 at 3:57 PM with LVN 3, LVN 3 stated nurses were expected to disinfect shared equipment like BP cuffs and glucometers before and after use. LVN 3 stated she did not disinfect the BP cuff before or after use for Resident 74, and she did not disinfect the glucometer before or after use for Resident 96. LVN 3 stated nurses were supposed to use the wipes in the medication cart to disinfect shared equipment. During an interview on 8/4/26 at 10:58 AM with LVN 3, LVN 3 stated she checked blood sugar on 8/3/26 for Residents 82, 28, 138, and 13 with the same glucometer used for Resident 96. LVN 3 confirmed she did not clean or disinfect the glucometer between residents until after the 3:57 PM interview on 8/3/26. A review of Resident 96's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 8/1/26 – 8/4/26, indicated LVN 3 checked Resident 96's blood sugar during the 8:00 AM and 12:00 PM medication pass on 8/3/26. A review of Resident 82's Medication Administration Record, dated 8/1/26 – 8/6/26, indicated LVN 3 checked Resident 82's blood sugar during the 8:00 AM and 12:00 PM medication pass on 8/3/26. A review of Resident 28's Medication Administration Record, dated 8/1/26 – 8/6/26, indicated LVN 3 checked Resident 28's blood sugar during the 8:00 AM and 12:00 PM medication pass on 8/3/26. A review of Resident 138's Medication Administration Record, dated 8/1/26 – 8/6/26, indicated LVN 3 checked Resident 138's blood sugar during the 8:00 AM and 12:00 PM medication pass on 8/3/26. A review of Resident 13's Weights and Vitals Summary, dated 8/6/26, indicated Resident 13's blood sugar was checked at 11:44 AM on 8/3/26. During an interview on 8/4/26 at 12:24 PM with the Infection Preventionist (IP), the IP stated shared equipment was supposed to be disinfected before and after every use for infection control. The IP stated nurses were supposed to use the Micro-Kill One disinfecting wipes on shared equipment like BP cuffs and glucometers. The IP stated the disinfecting wipes needed to be effective against blood-borne pathogens (infections carried in and spread through blood). During an interview on 8/4/26 at 12:28 PM with the IP, the IP stated if a resident had a blood-borne pathogen, the concern with not disinfecting a shared glucometer was infecting others or an outbreak. During an interview on 8/5/26 at 9:44 AM with the Director of Nursing (DON), the DON stated the facility did not have a policy specific to cleaning and disinfection of point of care devices, such as glucometers. During an interview on 8/6/26 at 12:59 PM with the DON, the DON stated the expectation was for nurses to clean the glucometer and BP cuff every time it's used for a resident. A review of the EvenCare G3 Blood Glucose [sugar] Test Strips manufacturer labeling, revised July 2022 and provided by the facility, indicated, All parts of the glucose monitoring system [glucometer] should be considered potentially infectious and are capable of transmitting blood-borne pathogens between patients and healthcare professionals. The labeling indicated, The meter should be disinfected after use on each patient. This blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. A review of the facility's policy and procedure (P&P) titled, IPCP Standard and Transmission-Based Precautions, revised January 2026, indicated, .Patient-care equipment (e.g., blood pressure cuffs). It is preferred dedicated or disposable patient-care equipment be used. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient . 2a. During a medication pass observation on 8/3/26 at 9:12 AM in Resident 96's room, LVN 3 entered Resident 96's room and wore gloves while pricking Resident 96's right index finger to check Resident 96's blood sugar. LVN 3 did not wear a gown during the blood sugar check. LVN 3 then returned to the medication cart to prepare Resident 96's insulin injection. During a continued medication pass observation on 8/3/26 at 9:21 AM in Resident 96's room, LVN 3 was observed administering a subcutaneous (under the skin) insulin injection to Resident 96's right arm. LVN 3 wore gloves and did not wear a gown during the insulin injection. LVN 3 then returned to the medication cart to prepare Resident 96's other medications. During an interview on 8/3/26 at 4:00 PM with LVN 3, LVN 3 stated Resident 96 was on enhanced barrier precautions (EBP). LVN 3 stated she was supposed to wear a gown and gloves when checking blood sugar and administering insulin. LVN 3 stated she was supposed to wear a gown during Resident 96's medication pass. LVN 3 stated she did not wear a gown during the medication pass. A review of Resident 96's Order Summary Report, dated 8/4/26, indicated Resident 96 had a physician's order, dated 5/1/26, for Enhanced Barrier Precautions r/t [related to] LEFT AV FISTULA [arteriovenous fistula, surgically created connection between an artery and vein for dialysis (treatment for removing waste and excess water from the blood due to failing kidney function)]. During an interview on 8/3/26 at 3:35 PM with LVN 7, LVN 7 stated nurses were supposed to follow EBP by wearing a gown and gloves when drawing blood or if touching the resident. LVN 7 stated nurses were supposed to wear a gown during medication pass for residents on EBP. During an interview on 8/4/26 at 4:50 PM with the DON and the Director of Nursing In Training 2 (DIT 2), DIT 2 stated there was a potential for fluid exposure with blood sugar checks. The DON agreed nurses needed to wear gowns when checking blood sugar and administering insulin. 2b. During a medication pass observation on 8/3/26 at 4:15 PM in Resident 100's room, LVN 4 was observed checking the placement of Resident 100's gastrotomy tube (G-tube, a small tube placed through the abdominal wall into the stomach, used to provide feeding formula and/or administer medications) by using a stethoscope on the resident's abdomen. LVN 4 then administered one medication into Resident 100's G-tube. LVN 4 wore gloves and did not wear a gown during the G-tube placement verification or medication administration. During a concurrent interview and record review on 8/3/26 at 4:33 PM with LVN 4, the Enhanced Barrier Precautions sign, undated and provided by the facility, was reviewed. LVN 4 stated residents with G-tubes were on EBP. LVN 4 stated she referred to the EBP sign posted on the resident's door to know what infection control practices to follow during resident care. The EBP sign indicated, Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities.Device care or use.feeding tube. LVN 4 stated the sign meant nurses were supposed to wear a gown and gloves when checking G-tube placement and administering G-tube medications to residents. LVN 4 stated she forgot to wear a gown during Resident 100's G-tube medication pass observation. A review of Resident 100's Order Summary Report, dated 8/4/26, indicated Resident 100 had a physician's order, dated 9/26/25, for Enhanced Barrier Precaution: Indication: (Indwelling [placed in the body] Medical Device) G-Tube Feeding. During an interview on 8/4/26 at 12:14 PM with the IP, the IP stated EBP provided extra protection for residents with G-tubes, chronic wounds, MDROs (multidrug resistant organisms, bacteria that cannot be killed by most antibiotics), and on dialysis. The IP stated staff needed to wear gown and gloves during high contact resident care such as G-tube medication administration. The IP stated staff were encouraged to follow EBP when checking blood sugar and administering insulin. The IP stated the purpose of EBP was to provide extra protection from infections for residents and staff. During an interview on 8/4/26 at 5:00 PM with the DON, the DON stated nurses were definitely required to wear gloves and a gown when administering medications through a resident's G-tube. A review of the facility's P&P titled, IPCP Standard and Transmission-Based Precautions, revised January 2026, indicated: .Enhanced Barrier Protection (EBP): expand the use of PPE [personal protective equipment] and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident.indwelling medical devices are at especially high risk of both acquisition and colonization with MDROs .PPE: The use of gown and gloves for high-contact resident care activities is indicated .Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include.Device care or use.feeding tube . 3. During a medication pass observation on 8/3/26 at 9:17 AM outside of Resident 96's room, LVN B was observed preparing insulin for Resident 96's morning medication pass. LVN B removed a Novolog FlexPen (brand name injectable pen containing insulin aspart, type of rapid-acting insulin) 100 units per milliliter (u/ml) from the medication cart. LVN B did not clean or wipe the rubber stopper of the insulin pen before attaching the pen tip needle. LVN B then administered the insulin to Resident 96. During an interview on 8/3/26 at 3:46 PM with LVN 6, LVN 6 stated nurses preparing insulin pens needed to wipe the rubber stopper with an alcohol swab before attaching the needle. During an interview on 8/3/26 at 4:04 PM with LVN 3, LVN 3 stated she did not wipe Resident 96's insulin pen with an alcohol wipe before attaching the needle. LVN 3 stated she was supposed to wipe the rubber stopper with an alcohol swab before attaching the needle. During an interview on 8/4/26 at 12:22 PM with the IP, the IP stated nurses were supposed to wipe the rubber stopper of the insulin pen before attaching the needle to disinfect the surface. The IP confirmed this practice was part of infection control at the facility. During a concurrent interview and record review on 8/5/26 at 9:45 AM with the DON, the facility's P&P titled, IIB16: Subcutaneous Medication Administration, undated, was reviewed. The policy indicated, Swab rubber cap with alcohol swab. The DON stated this section of the policy applied to Resident 96's medication pass observation. During a telephone interview on 8/6/26 at 9:22 AM with the Consultant Pharmacist (CP), the CP stated insulin pen tips needed to be wiped with an alcohol swab before attaching the needle for infection control. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for Novolog FlexPen, dated 2/28/23, retrieved from DailyMed (a website operated by the U.S. National Library of Medicine to publish up-to-date and accurate drug labels to health care providers and the general public, provided and updated daily by the U.S. Food and Drug Administration), indicated, Preparing your NovoLog FlexPen.Pull off the pen cap.Wipe the rubber stopper with an alcohol swab.Screw the needle tightly onto your FlexPen. 4. During an observation on 8/4/26 at 7:53 AM, along the hallway, the HA wore gloves while inside a resident's room and received a wet floor signage handed over by another staff. The HA walked out of the resident's room wearing the same contaminated gloves on both hands and placed the wet floor signage inside a storage room. The HA then proceeded to remove the contaminated gloves and donned (to dress or put on an item of clothing or gear in healthcare) a clean pair of gloves without performing hand hygiene before reentering into the resident's room. During an interview on 8/4/25 at 8:00 AM, with the HA, the HA stated before leaving the resident's room, he should have removed the gloves and performed hand hygiene. The HA further stated he should have done the same hand hygiene before putting on a new pair of gloves prior to entering the resident room. During a concurrent interview and record review on 8/6/26 at 10:12 AM, with the Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Hand Hygiene revised 1/2026, was reviewed. The P&P indicated, .Purpose.Hand hygiene is one of the most effective measures to prevent the spread of infection.Procedure. 2. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:. f. before donning gloves. m. after removing gloves. r. After removing and disposing of personal protective equipment. The IP stated the facility's policy on Infection Control was not followed. 5. A review of Resident 126's Face Sheet (front page of the chart that contains a summary of basic information about the resident), indicated Resident 126 was readmitted to the facility on [DATE]. During an observation on 8/3/26 at 9:04 AM inside Resident 126's room, six cups containing a dark black liquid beverage were inside Resident 126's bedside drawer. The cups containing the dark black liquid beverage were stained and the spilled liquid was observed inside the drawer. During an interview, on 8/3/26, at 9:20 AM, with Certified Nursing Assistant (CNA) 3, the CNA 3 stated Resident 129 would ask for a cup of coffee after dinner and verified the stored beverages in Resident 129's bedside drawer were cups of coffee. CNA 3 further stated the morning shift staff should inspect the bedside drawer and bedside table to determine whether Resident 129 consumed the coffee. If the coffee was unconsumed staff should remove the cups and any remaining beverages from Resident 129's bedside table and drawer. CNA 3 stated beverages left for an extended period should be discarded to prevent potential food contamination. During an interview and record review on 8/5/26 at 11:18 AM, with the Director of Staff Development (DSD), the DSD stated when a cup of coffee was provided to Resident 126 after dinner, the CNA should discard unconsumed beverages. The DSD confirmed unconsumed beverages should not be left or stored in the residents' bedside drawer for an extended or unknown period of time. A review of facility's policy and procedure (P&P) titled Infection Prevention-Foodborne Illness, undated, indicated.11. Food left out at room temperature for more than two hours will be discarded. A review of the FDA Federal Food Code 2022, 3-701.11 titled Discarding or Reconditioning Unsafe, Adulterated, or Contaminated Food, indicated, (A) A FOOD that is unsafe, ADULTERATED, or not honestly presented as specified under 3-101.11 shall be discarded or reconditioned according to an APPROVED procedure.

Based on observation, interview, and record review, the facility had a medication error rate of 13.16% when five medication errors occurred out of 38 opportunities during the medication administration observation for three of six residents (Residents 87, 96, and 121). These failures resulted in medications not given according to the physician's orders and had the potential for residents to experience side effects such as upset stomach, as well as incorrect medication doses and inadequate management of conditions.Findings:1. During a medication pass observation on 8/3/26 at 8:18 AM in Resident 87's room, Licensed Vocational Nurse 3 (LVN 3) was observed administering eleven medications for Resident 87. The medications included one tablet of chewable aspirin (blood thinner) 81 milligrams (mg). LVN 3 gave Resident 87 a cup of pink liquid to take with her medications. A review of Resident 87's Order Listing Report, dated 8/4/26, indicated Resident 87 had a physician's order, dated 3/20/26, for chewable aspirin 81 mg, Give 81 mg by mouth one time a day for DVT/PE [deep vein thrombosis/pulmonary embolism, types of blood clots] treatment. Administer with food. During a concurrent interview and record review on 8/3/26 at 3:55 PM with LVN 3, Resident 87's chewable aspirin orders were reviewed. LVN 3 stated the orders indicated to administer with food. LVN 3 stated Resident 87 did not take the aspirin with food. When asked if Resident 87's aspirin orders were followed, LVN 3 stated no. During an interview on 8/4/26 at 4:14 PM with the Director of Nursing (DON), the DON stated Resident 87's aspirin was supposed to be administered with food. The DON stated the medication could cause possible side effects such as irritation to the lining of the stomach (upset stomach) if given without food. 2a. During a medication pass observation on 8/3/26 at 9:17 AM outside of Resident 96's room, LVN 3 was observed preparing insulin (a medication to lower blood sugar) for Resident 96's morning medication pass. LVN 3 removed a Novolog FlexPen (brand name injectable pen containing insulin aspart, type of rapid-acting insulin) 100 units per milliliter (u/ml) from the medication cart. LVN 3 set the insulin pen dosing dial to one unit and then attached a pen tip needle to the device. LVN 3 did not prime the insulin pen. LVN 3 then administered the insulin to Resident 96. A review of Resident 96's Order Summary Report, dated 8/4/26, indicated Resident 96 had a physician's order, dated 1/23/26, for insulin aspart injector pen (generic for Novolog FlexPen), to Inject as per sliding scale.subcutaneously [under the skin] four times a day for Type 2 DM [diabetes mellitus, a long-term condition that causes high blood sugar levels]. During an interview on 8/3/26 at 3:46 PM with LVN 6, LVN 6 stated insulin pens needed to be primed before use. LVN 6 stated nurses were supposed to attach the pen tip needle, set the dial to two units, and prime (a method to remove air and verify the pen functions properly) the insulin pen by pushing out the two units. LVN 6 stated after priming the insulin pen, nurses would then set the dial to the insulin dose and administer to residents. During an interview on 8/3/26 at 4:02 PM with LVN 3, LVN 3 stated she was supposed to prime the insulin pen before administering to a resident. LVN 3 confirmed she did not prime Resident 96's insulin pen before administration. During an interview on 8/4/26 at 4:48 PM with the DON, the DON stated insulin pens were supposed to be primed before administration to remove air bubbles from the injection. The DON stated the manufacturer's guideline required priming of the insulin pen before use. During a telephone interview on 8/6/26 at 9:22 AM with the Consultant Pharmacist (CP), the CP stated insulin pens needed to be primed every time before use. The CP stated this was to verify the pen tip needle was attached correctly and to ensure the entire dose was correctly administered. The CP stated the concern was if medication did not come out of the insulin pen while priming, the resident may not get the entire insulin dose. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for Novolog FlexPen, dated 2/28/23, retrieved from DailyMed (a website operated by the U.S. National Library of Medicine to publish up-to-date and accurate drug labels to health care providers and the general public, provided and updated daily by the U.S. Food and Drug Administration), indicated: Small amounts of air may collect in the cartridge during normal use. You must do an airshot [prime] before each injection to avoid injecting air and to make sure you receive the prescribed dose of your medicine, then, Do the airshot as described.Keep testing.until you see insulin at the needle tip. If you still do not see a drop of insulin after 6 times, change the needle and repeat this step. This makes sure that any air bubbles are removed and that insulin is getting through the needle, and then, Select your dose. 2b. During a continued medication pass observation on 8/3/26 at 9:25 AM outside of Resident 96's room, LVN 3 was observed preparing six medications for Resident 96's morning medication pass. LVN 3 stated she needed to order sevelamer carbonate (generic for Renvela, phosphate binder, medication to control high blood level of phosphorus, a mineral found in food, in people with kidney disease on dialysis [a treatment for removing waste and excess water from the blood due to failing kidney function]) for Resident 96 because the facility was out of the medication. A review of Resident 96's Order Summary Report, dated 8/4/26, indicated Resident 96 had a physician's order, dated 4/22/26, for sevelamer carbonate 800 mg, Give 1 tablet by mouth with meals for High Phosphate [phosphorous] Levels d/t [due to] CKD [chronic kidney disease, progressive loss of kidney function over time] on dialysis. A review of Resident 96's Progress Notes, dated 8/3/26 at 9:42 AM, indicated, Sevelamer Carbonate Oral Tablet 800 MG.Awaiting from pharmacy. During a telephone interview on 8/6/26 at 9:24 AM with the CP, the CP stated residents should not miss a dose of sevelamer. The CP stated there could be clinical concerns with missed medication doses and the physician needed to be informed. The CP stated missing even one dose of medication was a medication error. A review of the facility's policy and procedure (P&P) titled, Medication Administration - Oral, revised January 2026, indicated, It is the policy of this facility to accurately prepare, administer and document oral medications. 2c. During a continued medication pass observation on 8/3/26 at 9:37 AM in Resident 96's room, LVN 3 prepared to administer one lidocaine (a numbing medication to treat pain) 4% (strength) patch to Resident 96. Resident 96 told LVN 3 he wanted the patch applied to his back and lifted his shirt to expose the area. LVN 3 applied the lidocaine patch to the resident's upper back. A review of Resident 96's Order Summary Report, dated 8/4/26, indicated Resident 96 had a physician's order, dated 7/26/26, for lidocaine 4% patch, Apply to right shoulder topically [to the skin] every 24 hours as needed for Pain Management. A review of Resident 96's Progress Notes, dated 8/3/26 at 9:43 AM, indicated, Lidocaine External Patch 4% .Resident requested for patch to be applied to upper back. During a concurrent interview and record review on 8/3/26 at 4:05 PM with LVN 3, Resident 96's lidocaine patch orders were reviewed. LVN 3 stated the orders indicated to apply the lidocaine patch to Resident 96's right shoulder. LVN 3 stated she applied the lidocaine patch to Resident 96's upper mid-back. During an interview on 8/4/26 at 4:10 PM with the DON, the DON stated a medication error was not following exactly the order of the doctor. The DON stated a lidocaine patch applied to a different body part than the physician's order was a medication error. 3. During a medication pass observation on 8/3/26 at 10:12 AM in Resident 121's room, LVN 6 prepared to administer one lidocaine 4% patch to Resident 121. LVN 6 asked Resident 121 where she wanted the lidocaine patch to be placed. Resident 121 stood up and exposed her left hip and pointed to the area. LVN 6 applied the lidocaine patch to the resident's left hip. A review of Resident 121's Order Listing Report, dated 8/4/26, indicated Resident 121 had a physician's order, dated 2/15/25, for lidocaine 4% patch, Apply to lateral [away from the middle of the body] side of chest topically one time a day for Pain Management. A review of Resident 121's Location of Administration Report, dated 8/4/26, indicated LVN 6 applied one lidocaine patch to Resident 121's Thigh - left on 8/3/26 at 10:21 AM. During an interview on 8/3/26 at 3:10 PM with Resident 121, Resident 121 stated she wanted the lidocaine patch on her left hip because her hip was super tight. During a concurrent interview and record review on 8/3/26 at 3:44 PM with LVN 6, Resident 121's lidocaine patch orders were reviewed. LVN 6 stated he applied the lidocaine patch to Resident 121's left thigh during the morning medication pass administration observation. LVN 6 stated the physician's orders indicated to apply the lidocaine patch to the lateral side of the chest. LVN 6 stated the orders were for the patch to be applied to the chest, not the thigh. LVN 6 stated he did not follow the physician's orders. During an interview on 8/4/26 at 4:18 PM with Director of Nursing-In-Training 2 (DIT 2) and the DON, DIT 2 stated nurses were supposed to get new orders from the physician before applying lidocaine patches to a different body part than ordered. The DON stated physician's orders were supposed to be followed. During an interview on 8/6/26 at 8:27 AM with the DON, the DON stated there was no facility policy defining medication errors or the six rights of medication administration. The DON stated medications needed to be administered to the right resident, with the right dose, at the right time, with the right frequency, and the right route of administration and right documentation. The DON agreed medication orders were expected to be followed as written. The DON further agreed nurses were supposed to follow the manufacturer's labeling for correct administration of medication. During a telephone interview on 8/6/26 at 9:20 AM with the CP, the CP stated the physician's orders needed to be followed completely. A review of the facility's P&P titled, Medication Administration - Oral, revised January 2026, indicated, No medication is to be administered without a physician's written order. Accurate and timely administration according to MD order is essential.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 8 and 57), who were assessed as unable to safely self-administer medications, did not independently possess and self-administer medications when:1. Resident 57 was observed with one blister pack (a type of medicine packaging where individual doses of medication are sealed in small, clear plastic bubbles (blisters) and attached to a rigid card or foil backing) of anesthetic lozenges (medicated tablets or hard candies that dissolve slowly in the mouth to ease throat pain) at the bedside.2. Resident 8 was observed self-administering an inhaler during the medication pass observation. These failures had the potential to result in medication errors. Findings: 1. During a concurrent observation and interview on 8/4/26 at 7:55 AM, with Resident 57 inside of Resident 57's room, Resident 57 was sitting up in bed with one blister pack of anesthetic lozenges on top of the bedside table. The blister pack contained one remaining lozenge, with eight blister cavities observed empty. Resident 57 was observed with one lozenge in their mouth and stated they had taken the lozenge due to coughing and a sore throat. A review of Resident 57's Face Sheet, (front page of the chart that contains a summary of basic information about the resident) dated 8/4/26, indicated Resident 57 was readmitted to the facility on [DATE]. A review of Resident 57's Order Summary Report, dated 8/4/26, indicated Resident 57 did not have a physician's order for anesthetic lozenges. Further review of Resident 57's Order Summary Report indicated Resident 57 did not have an order to self-administer medications.A review of Resident 57's Self-Administration of Medications – Initial Evaluation, dated 7/17/24, indicated Resident 57 was .unable to demonstrate secure storage of medications kept in room. Resident 57's Self-Administration of Medications – Initial Evaluation further indicated, the . approval by the Interdisciplinary Team (IDT) to grant self-administration of medications was marked 'no.' During a concurrent observation and interview on 8/4/26 at 3:50 PM, with Licensed Vocational Nurse (LVN) 7 inside of Resident 57's room, Resident 57 was observed sitting up in bed with one blister pack of anesthetic lozenges on top of the bedside table. LVN 7 acknowledged the findings and stated they did not know where Resident 57 obtained the blister pack of anesthetic lozenges. During a concurrent observation and interview on 8/4/26 at 3:52 PM, with LVN 7 outside of the medication room in station 1, LVN 7 retrieved a box labeled Sore Throat Lozenges Menthol/Benzocaine – Oral Anesthetic. LVN 7 opened the box and verified the anesthetic lozenges contained in the box were the same type of lozenges observed in Resident 57's room. During a concurrent interview and record review on 8/4/26 at 4:06PM, with LVN 7, LVN 7 stated Resident 57 did not have a physician's order for the anesthetic lozenges. LVN 7 further stated they were unable to locate an assessment indicating Resident 57 was approved to self-administer medications. During a concurrent interview and record review on 8/4/26 at 4:11 PM with the Assistant Director of Nursing (ADON), the ADON stated anesthetic lozenges required a physician's order and should not have been at Resident 57's bedside without a physician's order. The ADON reviewed Resident 57's Order Summary Report, dated 8/4/26, and verified Resident 57 did not have a physician's order for lozenges. The ADON proceeded to Review Resident 57's Self-Administration of Medications – Initial Evaluation, dated 7/17/24, and verified Resident 57 was unable to self-administer medications. 2. During a medication pass observation on 8/3/26 at 10:09 AM outside of Resident 8's room, Licensed Vocational Nurse 6 (LVN 6) was observed preparing eleven medications for Resident 8's morning medication pass. The medications included a Symbicort (brand name for budesonide with formoterol fumarate, medication used for asthma) 160-4.5 micrograms (mcg, unit of measurement) inhaler. LVN 6 asked Resident 8 if she wanted him to give her the medication or if she preferred to administer herself. Resident 8 administered her own inhaler. A review of Resident 87's Order Listing Report, dated 8/4/26, indicated Resident 8 had a physician's order, dated 7/23/26, for budesonide-formoterol fumarate inhalation 160-4.5 mcg (generic for Symbicort), 2 puff inhale orally [by mouth] two times a day for Asthma [lung disease causing difficulty breathing]. During an interview on 8/3/26 at 3:46 PM with LVN 4, LVN 4 stated the facility assessed residents before allowing self-administration of medications. LVN 4 stated residents approved to self-administer medications needed a physician's order. During a concurrent interview and record review on 8/3/26 at 3:40 PM with LVN 6, Resident 8's physician orders were reviewed. LVN 6 stated residents needed physician orders to self-administer medications. LVN 6 confirmed Resident 8 had self-administered her Symbicort inhaler during the morning medication pass observation. LVN 6 confirmed Resident 8 did not have any orders to self-administer medications. During an interview on 8/4/26 at 4:23 PM with the Director of Nursing (DON), the DON stated residents who wanted to self-administer medications were assessed for mental and physical capability. The DON stated the physician could then provide orders for a resident to self-administer their own medications. During a concurrent interview and record review on 8/4/26 at 4:43 PM with the DON, the facility's (P&P) titled, Self Administration of Medications, revised January 2026, was reviewed. The policy indicated, PURPOSE: To determine the ability of alert residents to participate in self-administration of medications. The DON stated residents needed physician's orders to self-administer an inhaler according to the facility's policy. The DON confirmed Resident 8 needed orders to self-administer her Symbicort inhaler. During a concurrent interview and record review on 8/6/26 at 8:19 AM with the DON, Resident 8's Self-Administration of Medications - IDT [interdisciplinary team] Determination, dated 8/21/25, was reviewed. The record indicated a blank checkbox next to the statement, The IDT has determined that it is SAFE for the resident to self-administer medications. The DON stated the record indicated Resident 8 was not capable of self-administration of medications. A review of Resident 8's Self-Administration of Medications- Initial Evaluation, dated 7/2/23, was reviewed. The record indicated, Can administer inhalant medications according to proper procedure. The selected response was Unable. A review of the facility's policy and procedure (P&P) titled, Self Administration of Medications, revised January 2026, indicated: If the interdisciplinary team determines that this resident is unable to carry out this responsibility.the interdisciplinary team may withdrawal [sic] this right, and If the resident is a candidate for self-administration of medications, this will be indicated in the chart. The physician will be contacted to obtain order for self administration of medications. If physician does not approve order, this right will be rescinded.

Based on interview and record review, the facility failed to ensure two of five sampled residents (Residents 30 and 126) reviewed for unnecessary medications were free from unnecessary psychotropic medications (medications affecting brain activities associated with mental processes and behaviors), when:1. Resident 30 received quetiapine (generic for Seroquel, an antipsychotic [type of psychotropic] medication to treat mental illness) without an initial AIMS (abnormal involuntary movement scale, a rating scale designed to measure involuntary movements known as tardive dyskinesia, a disorder that sometimes develops as a side effect of long-term treatment with antipsychotic medications) assessment, and2. Resident 126 received quetiapine in the presence of increased AIMS score (higher score indicates more observed abnormal movements) without physician notification.These failures resulted in unnecessary medications for the residents, which had the potential for increased risks associated with psychotropic medication use that include, but are not limited to, abnormal involuntary movements.Findings:1. A review of Resident 30's Face Sheet (document showing a summary of the resident's information), dated 8/5/26, indicated Resident 30 was admitted to the facility on [DATE]. The record indicated an active diagnosis, dated 6/3/26 on admission, of dementia (loss of mental function such as thinking, memory, and reasoning skills) with other behavioral disturbance.A review of Resident 30's Order Summary Report, dated 8/6/26, indicated Resident 30 had an active physician's order, dated 6/8/26, for quetiapine, Give 12.5 mg [milligrams] by mouth two times a day for Psychotic Disorder. The Order Listing Report further indicated an additional active physician's order, dated 6/18/26, for quetiapine 25 mg, Give 1 tablet by mouth one time a day for Psychotic disorder.A review of Resident 30's Medication Administration Record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 6/1/26 - 6/30/26, indicated Resident 30 had a physician's order, dated 6/3/26, for quetiapine 25 mg, Give 1 tablet by mouth at bedtime for Psychotic Disorder for 5 days. The MAR indicated the order was discontinued on 6/8/26.During an interview on 8/6/26 at 10:12 AM with the Medical Records Director (MRD), the MRD stated there was no documented AIMS assessment in Resident 30's medical record.During an interview on 8/6/26 at 11:51 AM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated AIMS assessments were supposed to be done upon admission or within the first 72 hours of a resident's stay for residents who were admitted on antipsychotic medications.During an interview on 8/6/26 at 12:07 PM with LVN 4, LVN 4 stated Resident 30 needed an AIMS assessment done upon admission on [DATE] or before 6/6/26 at latest. LVN 4 stated the facility needed to follow up as to why an AIMS assessment was not done for Resident 30. LVN 4 stated the facility needed to initiate an AIMS assessment as soon as possible. LVN 4 stated the concern with not conducting the AIMS assessment was the facility could miss side effects of the medication.During an interview on 8/6/26 at 1:10 PM with the Director of Nursing (DON) and Director of Nursing In Training 1 (DIT 1), the DON stated the facility conducted AIMS assessments on residents upon admission and every six months. The DIT 1 stated if AIMS assessment was not conducted on admission, the facility would not know a resident's baseline condition for monitoring.During a concurrent interview and record review on 8/6/26 at 3:56 PM with the DON, the facility's policy and procedure (P&P) titled, Antipsychotic Drugs, revised January 2026, was reviewed. The policy indicated, AIMS assessment will be completed at least Q [every] 6 months as a tool to assist monitoring for side effects to Antipsychotic medications. The DON stated the policy did not include the requirement to conduct initial AIMS assessments for residents. The DON stated the initial AIMS assessment was required even though the policy did not address the requirement.2. A review of Resident 126's Face Sheet, dated 8/6/26, indicated Resident 126 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. The record indicated an active diagnosis, dated 12/10/25 on admission, of dementia with other behavioral disturbance.A review of Resident 126's MAR, dated 6/1/26 - 6/30/26, indicated Resident 30 had a physician's order, dated 12/10/25, for quetiapine, Give 125 mg by mouth at bedtime for Schizophrenia disorder. The MAR indicated an additional physician's order, dated 2/28/26, for quetiapine 100 mg, Give 1 tablet by mouth two times a day for Schizophrenia disorder.A review of Resident 126's MAR, dated 8/1/26 - 8/6/26, indicated Resident 30 received quetiapine 125 mg at 2100 (9:00 PM) and quetiapine 100 mg two times a day at 0900 (0:00 AM) and 1300 (1:00 PM) in August 2026.During a concurrent interview and record review on 8/6/26 at 10:31 AM with the MRD, Resident 126's AIMS Evaluation, dated 3/31/26, and AIMS Evaluation, dated 7/31/26, were reviewed. The MRD stated the AIMS score was six on 3/31/26. The MRD stated the AIMS score was nine on 7/31/26.A review of Resident 126's Abnormal Involuntary Movement Scale (AIMS) Evaluation, dated 3/31/26, indicated Movement Ratings: Rate highest severity observed. The assessment indicated None in response to the following movement ratings: Jaw: e.g. biting, clenching, chewing, mouth opening, lateral [sideways] movement. Tongue: Rate only increases in movement both in and out of mouth. NOT inability to sustain movement. Darting in and out of mouth. Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion [turned inwards] and eversion [turned outwards] of foot. Incapacitation due to abnormal movement.The assessment further indicated, AIMS TOTAL SCORE.6 and The higher the score (0-28), the greater the impact of observed movements on resident.A review of Resident 126's Abnormal Involuntary Movement Scale (AIMS) Evaluation, dated 7/31/26, indicated Minimal, may be extreme normal in response to the following movement ratings: Tongue: Rate only increases in movement both in and out of mouth. NOT inability to sustain movement. Darting in and out of mouth. Lower (legs, knees, ankles, toes) Lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot.The assessment indicated Mild in response to the following movement ratings: Jaw: e.g. biting, clenching, chewing, mouth opening, lateral [sideways] movement.The assessment indicated Minimal in response to the following movement ratings: Incapacitation due to abnormal movement.The assessment further indicated, AIMS TOTAL SCORE.9 and The higher the score (0-28), the greater the impact of observed movements on resident. The assessment indicated High Risk for Tardive Dyskinesia as evident by positive AIMS, and Intervention - Notify provider of possible tardive dyskinesia.Not Active.During an interview on 8/6/26 at 11:53 AM with LVN 4, LVN 4 stated the facility needed to immediately notify the resident's physician if the AIMS score increased. LVN 4 stated the physician would evaluate the resident to consider therapy for tardive dyskinesia or to change the dose of the antipsychotic medication. LVN 4 stated nurses needed to document the physician notification in the progress notes.During an interview on 8/6/26 at 12:11 PM with LVN 4 and the MRD, LVN 4 stated the facility was supposed to notify Resident 126's physician about the increased AIMS score. The MRD stated there was no documented physician notification in Resident 126's progress notes. When asked if the physician was notified about Resident 126's changed score, LVN 4 stated unfortunately, it wasn't done.During an interview on 8/6/26 at 1:12 PM with the DON and the DIT 1, the DIT 1 stated the facility needed to notify the physician if the AIMS score worsened (increased score). The DIT 1 stated the concern with not notifying the physician was the resident continuing to have the symptoms. The DIT 1 stated an additional concern was symptoms could progress with continued use of antipsychotics. The DON stated the physician or psychiatrist needed to be notified of a higher AIMS score to evaluate the resident for antipsychotic dose adjustment or other ways to counteract the symptoms.A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for quetiapine, dated 5/21/26, retrieved from DailyMed (a website operated by the U.S. National Library of Medicine to publish up-to-date and accurate drug labels to health care providers and the general public, provided and updated daily by the U.S. Food and Drug Administration), indicated: Tardive Dyskinesia. A syndrome of potentially irreversible, involuntary, dyskinetic [uncontrolled] movements may develop in patients treated with antipsychotic drugs, including quetiapine, and If signs and symptoms of tardive dyskinesia appear in a patient on quetiapine, drug discontinuation should be considered.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a federally mandated standardized assessment tool) accurately reflected the status for four of four sampled residents (Residents 7, 66, 30 and 120) when:1. Resident 7's bowel incontinence and toileting program assessment was not accurately reflected in the MDS assessment2. Resident 66's hearing ability and use of hearing assistive device assessment was not consistently reflected in the MDS assessment3. Resident 30's diagnosis of Psychotic Disorder (a severe mental condition in which thoughts and emotions are so affected that contact is lost with reality) was not accurately reflected in the MDS assessment4. Resident 120's use of oxygen was not accurately reflected in the quarterly MDS assessment.These failures had the potential for the residents' care and needs not accurately identified and addressed.Findings:1. A review of Resident 7's Face Sheet (front page of the chart that contains a summary of basic information about the resident), dated 8/5/26 indicated, Resident 7 was admitted to the facility on [DATE]. A review of Resident 7's Bowel and Bladder Evaluation, dated 4/27/26, the Evaluation indicated Resident 7 was incontinent of bowels (inability to control bowel movements, causing solid or liquid stool, mucus, or gas to leak unexpectedly from the rectum) and was a good candidate for bowel re-training (a behavioral method to help your body establish a predictable, regular schedule for bowel movements usually using scheduled toileting times). A review of Resident 7's Care Plan Report, dated 4/27/26, indicated Resident 7 had a care plan (an individualized outline of specific care, interventions, and goals for a resident/patient) Focus to address Resident 7's risk for a decline in bowel continence related to impaired mobility. and indicated Interventions initiated on 4/27/26, for brief use.incontinent. and on 5/1/26 a toileting program was initiated. A review of Resident 7's Documentation Survey Report, dated May 2026, indicated Resident 7 was provided with a toileting program. Further review of the Documentation Survey Report, indicated Resident 7 had episodes of bowel incontinence on 5/1/26 and on 5/2/26. During a concurrent interview and record review on 8/5/26 at 4:47 PM with the MDS Coordinator (MDSC), Resident 7's Bowel and Bladder Evaluation, dated 4/27/26, Resident 7's Documentation Survey Report, and Care Plan Report, dated 4/27/26, were reviewed. MDSC acknowledged the record review findings for Resident 7 as described above. MDSC proceeded to review Resident 7's MDS, Section H - Bowel and Bladder, dated 5/4/26, the MDS indicated Resident 7 was always continent (having normal voluntary control over your bladder and bowel functions) with bowel and Resident 7 did not have a bowel toileting program. MDSC acknowledged Resident 7's MDS assessment did not accurately reflect Resident 7's bowel care and function. 2. During an initial tour, a concurrent observation and interview 8/3/26 at 9:39 AM, with Resident 66, in Resident 66's bedroom, Resident 66 laid in bed and gestured with his right hand to move closer to the resident. Resident 66 stated he was unable to hear well. Resident 66 needed the questions repeated during the interview. There were no hearing aid devices observed in Resident 66's ear. A review of Resident 66's Face Sheet (front page of the chart that contains a summary of basic information about the resident), dated 8/5/26 indicated, Resident 66 was admitted to the facility on [DATE]. A review of Resident 66's MDS - Section C - Cognitive Patterns, dated 4/6/26, indicated Resident 66 had a Brief Interview for Mental Status (BIMS - measures a person's memory, attention, and basic thinking skills) score consistent with severe cognitive impairment. A review Resident 66's MDS assessment Section B - Hearing , Speech and Vision, indicated the following:- On 10/30/25, Resident 66 was coded for minimal difficulty with hearing ability – difficulty in some environments (e.g when person speaks softly or setting is noisy), and indicated Resident 66 had a hearing aid device in place during the assessment.- On 2/4/26, Resident 66 was coded for moderate difficulty – speaker has to increase volume and speak, and Resident 66 had a hearing aid device in place during the assessment. - On 6/6/26, Resident 66 was coded for adequate hearing ability – no difficulty in normal conversation, social interaction, listening to TV, and Resident 66 did not have a hearing aid device in place during the assessment. During an interview on 8/4/26 at 4:09 PM with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 66 was hard of hearing and required CNA 2 to speak loudly when conversing with Resident 66. CNA 1 stated he would have to repeat the statement or words for Resident 66 to understand what was said. CNA 2 acknowledged Resident 66 had a hearing aid device, however, the hearing aid device has been missing since May 2026. During an interview on 8/5/26 at 8:09 AM with the MDSC, the MDSC acknowledged the findings as described above and stated Resident 66's hearing ability was not consistently reflected in the MDS assessment. During a telephone interview on 8/5/26 at 12:06 PM with Family Member A, Family Member A stated, Resident 66 has been wearing hearing aid device for over 10 years. 3. A review Resident 30's Face Sheet, dated 8/6/26, indicated Resident 30 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (a progressive state of decline in mental abilities) with behavioral disturbance, with onset (beginning or start) date of 6/3/26. A review of Resident 30's Order Listing Report, dated 8/6/26, indicated the following: a. A physician's order for Quetiapine (an antipsychotic drug [prescription medicines used to treat mental health conditions that cause psychosis, such as hallucinations, delusions, and confused thinking]) 25 mg (milligram- a unit of weight measurement) for Psychotic Disorder, with a supply last order date of 6/3/26 and a revision date of 6/8/26. b. A physician's order to monitor for episodes of psychotic behavior, with a supply last order date of 6/5/26. A review of Resident 30's Psychiatric Note, dated 6/7/26, indicated Resident 30 had a diagnosis of psychosis. A review of Resident 30's MDS [MV2.1]Section N- Medications, dated 6/10/26, the MDS indicated Resident 30 was taking a High-Risk Drug Class.Antipsychotic, and received antipsychotic medications on a routine basis. Further review of Resident 30's MDS Section I- Active Diagnoses, dated 6/10/26, indicated Resident 30 did not have an active diagnosis of psychotic disorder.During a concurrent interview and record review on 8/6/26 at 8:05 AM with the MDSC, [MV3.1]Resident 30's medical records were reviewed. The MDSC stated the MDS Section I indicated Resident 30 was taking antipsychotic medications, as reflected by the physician order for Quetiapine for psychotic disorder. The MDSC stated Resident 30's Psychiatric Note, dated 6/7/26 indicated a diagnosis for psychosis, but Resident 30's MDS Section I did not to show a diagnosis for psychotic disorder was coded for Resident 30. The MDSC stated Resident 30's assessment for Section I should have been coded with diagnosis of psychotic disorder, further stating that all resident assessments should accurately reflect the resident's status. 4. During a concurrent observation and interview on 8/3/26 at 11:57 AM, with Resident 120 inside Resident 120's room, Resident 120 was sitting upright in bed with a nasal cannula (a light and flexible plastic device used to give oxygen into a person's nose) in place. Resident 120 stated he received continuous oxygen to help him breathe. Resident 120's oxygen concentrator (a medical device that provides oxygen) was set at 4.5L/min. A review of Resident 120's Face Sheet, dated 8/5/26, indicated Resident 120 was admitted to the facility on [DATE].A review of Resident 120's Annual History and Physical (H&P), dated 3/31/26, indicated Resident 120 had diagnoses including chronic obstructive pulmonary disease ([COPD] - a progressive lung disease which blocks air flow making breathing difficult).A review of Resident 120's Order Summary Report, dated 8/5/26, indicated Resident 120 had physician's orders dated on 11/13/25, for, Continuous oxygen at 3L/min via nasal cannula/mask to keep oxygen saturation above 90% every shift for COPD. A review of Resident 120's MDS, dated 7/6/26, indicated a section titled, Section O O0110 – Special Treatments, Procedures, and Programs. Further review of the MDS assessment indicated oxygen therapy was not checked to indicate Resident 120 was receiving oxygen therapy. During a concurrent interview and record review on 8/5/26 at 2:27 PM with the MDSC, the MDSC stated Resident 120's MDS assessment did not indicate Resident 120 was on oxygen therapy and acknowledged the assessment was done incorrectly. The MDSC stated accurate coding of the MDS was important to ensure appropriate care and services were being provided to Resident 120. A review of the facility's policy and procedure (P&P) titled Resident Assessments, revised 1/2026, indicated, .It is the policy of this facility that resident's (sic) will be assessed and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified. An Accurate Comprehensive Assessment will be made of the resident's needs, strengths, goals, life history and preferences, using RAI (Resident Assessment Instrument) and will include at least the following:. Disease diagnosis and health conditions. A review of the facility's P&P titled, Quality of Care indicated a subject titled, Provision of Respiratory Therapy Services for Patients and Residents Who Are Not Receiving Invasive Mechanical Ventilation, revised 1/2026, indicated . MDS 3.0 Coding . Section O0100C Oxygen Therapy. Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Cross reference to F685.

Based on interview and record review, the facility failed to follow up with the Preadmission Screening and Resident Review ([PASARR] - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) to determine the resident's needs for specialized services and appropriate placement for two of eight sampled residents (Residents 7 and 9).This failure had the potential to result in inappropriate placement and unidentified specialized services necessary for Residents 7 and 9.Findings:1. A review of Resident 7's Face Sheet, (front page of the chart that contains a summary of basic information about the resident), dated 8/6/26, indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).A review of Resident 7's PASRR Level I (one) Screening, dated 5/1/26, indicated a Level I initial preadmission screening was completed. Further review indicated under Section III (three) -Serious Mental Illness (SMI), Resident 7's PASSR Level I screening was marked Yes, and Resident 7 was Level I - Positive SMI/Negative for ID (Intellectual Disability)/DD (Developmental Disability)/RC (Related Condition).A review of Resident 7's Notice of Attempted Evaluation, dated 5/4/26, indicated Facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the Level I screening, therefore California Department of Health Care Services (DHCS) was unable to complete a Level II (two) evaluation for SMI to determine if the individual could benefit from specialized services.2. A review of Resident 9's Face Sheet, dated 8/6/26, indicated Resident 9 was admitted to the facility on [DATE] with diagnoses including, Major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and mental disorder, not otherwise specified.A review of Resident 9's PASRR Level I Screening, dated 10/8/25, indicated a Level I initial preadmission screening was completed. Further review indicated under Section III -SMI Resident 9's PASSR Level I screening was marked Yes, and Resident 9 was Level I - Positive SMI/Negative for ID/DD/RC.A review of Resident 9's Notice of Attempted Evaluation, dated 10/10/25, indicated facility staff were unresponsive to two or more separate attempts of communication within 48 hours of the level I screening, therefore DHCS was unable to complete a level II evaluation for SMI to determine if the individual could benefit from specialized services.During a concurrent interview and record review with the admission Coordinator (AC) on 8/4/26 at 8:45 AM, the AC reviewed the following: - Resident 7's PASSR - Level I Screening, dated 5/1/26, and Resident 7's Notice of Attempted Evaluation, dated 5/4/26. - Resident 9's PASSR - Level I Screening, dated 10/8/25, and Resident 9's Notice of Attempted Evaluation, dated 10/10/25.The AC was asked to provide documented evidence the facility followed up on the attempted PASSR Level II Screening for Residents 7 and 9. The AC was unable to provide such evidence and stated it was missed and should have been completed.A review of the facility's policy and procedure (P&P) titled PASSAR, revised 01/2026, indicated, . A PASARR should be completed on every resident upon admission . Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with MI/MR (mental retardation).

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan (an individualized outline of specific care, interventions, and goals for a resident/patient) for three of 14 sampled residents (Residents 30, 88 and 4) when:1. There was no care plan for Resident 30 to address associated risks and alternatives for refusing Activities of Daily Living ([ADL] routine tasks/activities such as bathing, grooming, dressing and toileting a person performs daily to care for themselves). 2. There was no care plan for Resident 88 to address associated risks and alternatives for refusing ADL.3. There was no care plan for Resident 4 to address a Moisture-Associated Skin Damage ([MASD] skin damage caused from prolonged exposure to moisture).These deficient practices had the potential for care and services to remain unmet.Findings: 1. A review of Resident 30's Face Sheet, (front page of the chart that contains a summary of basic information about the resident) dated 8/6/26, indicated Resident 30 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia (a progressive state of decline in mental abilities) with behavioral disturbance, with onset (beginning or start) date of 6/3/26. During an observation on 8/3/26 at 8:33 AM inside Resident 30's room, Resident 30 was eating breakfast and was observed with long and dirty fingernails on both hands. A review of Resident 30's Minimum Data Set, ([MDS] a federally mandated standardized assessment tool) Section E- Behavior, dated 6/10/26, indicated Resident 30 rejected care for ADL, with frequency of 1 to 3 days during the assessment period. During a concurrent observation and interview on 8/4/26 at 5:02 PM with Certified Nurse Assistant (CNA) 3 at the dining area, Resident 30 was observed with long and dirty fingernails on both hands. CNA 3 stated Resident 30 had episodes of refusing care during showers where grooming was also offered. CNA 3 stated refusals are documented on the shower sheet and given to the Charge Nurse. A review of Resident 30's sampled Skin Assessment- Shower indicated:a. Resident 30 refused seven times for the month of June 2026.b. Resident 30 refused once for the month of July 2026.c. The last documented trimming of fingernails was on 6/9/26. During a concurrent interview and record review on 8/6/26 at 9:33 AM with the Director of Nursing (DON), Resident 30's Care Plan Report was reviewed. The DON stated there was no care plan developed for Resident 30's refusal of care, further stating a care plan should have been created. 2. A review of Resident 88's Face Sheet, dated 8/6/26, indicated Resident 88 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) with dyskinesia (uncontrollable, involuntary muscle movements) and generalized muscle weakness. During an observation on 8/3/26 at 8:54 AM inside Resident 88's room, Resident 88 was observed with long and dirty fingernails on both hands. During a concurrent observation and interview on 8/4/26 at 5:02 PM with CNA 3 at the dining area, Resident 88 was observed with long and dirty fingernails on both hands. CNA 3 stated Resident 88 had episodes of refusing care during showers where grooming was also offered. CNA 3 stated refusals are documented on the shower sheet and given to the Charge Nurse. A review of Resident 88's sampled Skin Assessment- Shower indicated Resident 88 refused seven times for the month of July 2026. During a concurrent interview and record review on 8/6/26 at 9:33 AM with the DON, Resident 88's Care Plan Report, initiated 8/5/26 was reviewed. Resident 88's Care Plan Report, had a Focus area indicating, (Resident 88) has episodes of refusal of showers and ADL care. The DON verified the care plan for the refusal of care was not initiated until 8/5/26, and there was no care plan prior to the initial observation on 8/3/26 during a recertification survey. The DON stated a care plan should have been developed for refusal of care when Resident 88 started refusing ADL care. During a concurrent interview and record review on 8/6/26 at 9:33 AM of the facility's policy and procedure (P&P) titled, Comprehensive Resident Centered Care Plan, revised April 2025, indicated, .It is the policy of this facility that the Interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 5. The resident has the right to refuse or discontinue treatment. In the event that a resident refuses certain services posing a risk to resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks, the IDT's effort to educate the resident and resident representative and any alternate means to address risk. The DON stated they did not follow their policy for developing care plan for refusal of care. 3. A review of Resident 4's Face Sheet, dated 8/6/26 indicated, Resident 4 was admitted to the facility on [DATE]. During a concurrent interview and record review on 8/6/26 at 8:22 AM, with LVN 3, Resident 4's Skin Check, dated 7/15/26 was reviewed and LVN 3 verified Resident 4 developed a new skin condition on the .generalized buttocks.specifically MASD.– incontinence associated dermatitis (IAD) while admitted at the facility. LVN 3 further reviewed Resident 4's medical record and verified the Skin Issue assessment form to assess and document the weekly progress of Resident 4's MASD was not completed after the MASD was identified on 7/15/26. LVN 3 verified the assessment should have been conducted every week, and acknowledged for the weeks of 7/20/26 and 7/27/26, there was no weekly Skin Issue assessment documented to monitor the condition of Resident 4's MASD. During a concurrent interview and record review on 8/6/26 at 11:29 AM, with RN 1, Resident 4's Skin Check, dated 7/15/26 was reviewed. RN 1 acknowledged Resident 4 was assessed for a new MASD on the generalized buttocks, and Resident 4 had a physician's order indicated in the 'Skin Issues Note,' to cleanse the wound area with normal saline, pat the area dry, and leave the wound open to air. During a review of Resident 4's plan of care, RN 1 verified there was no care plan developed to address Resident 4's MASD. RN 1 explained licensed nurses should have developed a plan of care specifically for Resident 4's MASD. Furthermore, RN 1 stated a plan of care would ensure the resident would receive appropriate wound care interventions, including wound treatments. Cross Reference F684, Finding 1

Based on interview and record review, the facility failed to ensure residents received the necessary care and services to maintain and improve the highest practicable well being for two of two sampled residents (Residents 4 and 25) when:1. Resident 4 was not consistently assessed for the resident's Moisture-Associated Skin Damage ([MASD] skin damage caused from prolonged exposure to moisture).2. Resident 25's ordered pain medication was not consistently documented as administered on the Treatment Administration Record ([TAR] - a daily documentation record used by a licensed nurse to document treatments given to a resident).These failures placed the residents at risk for receiving inappropriate care. Findings: 1. A review of Resident 4's Face Sheet (a document showing a summary of the resident's information) dated 8/6/26 indicated, the resident was admitted to the facility on [DATE]. A review of Resident 4's Braden Scale (an assessment tool in predicting the development of a pressure ulcer [localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence]) - for Predicting Pressure Ulcer Risk Evaluation dated 4/13/26 indicated, Resident 4's Braden Total Risk Score was a 12 which indicated Resident 4 was a high risk for developing a pressure ulcer. During a concurrent interview and record review on 8/6/26 at 8:22 AM with Licensed Vocational Nurse (LVN) 3, Resident 4's Skin Check, dated 7/15/26 was reviewed. LVN 3 stated the facility's process in assessing the Resident's skin was to conduct a skin check and document the findings on the Skin Check assessment form. The Skin Check assessment form would be utilized to assess if a new wound or skin condition was identified on a resident, or upon admission, and discharge of a resident. LVN 3 further explained when a wound or skin condition was identified, the Skin Issue assessment form would be utilized for the weekly assessment of a resident's wound. LVN 3 stated Resident 4's Skin Check, dated 7/15/26 indicated Resident 4 developed a new skin condition on the .generalized buttocks.specifically MASD.– incontinence associated dermatitis (IAD) while admitted at the facility. LVN 3 stated the Skin Check included an assessment, to document the condition of the wound and the periwound (skin surrounding the outer edge of the wound) of the MASD. Resident 4's Skin Check indicated the .surrounding tissue was intact. and the skin color was .bright red to dark red or purple. LVN 3 further reviewed Resident 4's medical record and verified the Skin Issue assessment form to assess and document the weekly progress of Resident 4's MASD was not completed after the MASD was identified on 7/15/26. LVN 3 verified the assessment should have been conducted every week, and acknowledged for the weeks of 7/20/26 and 7/27/26, there was no weekly Skin Issue assessment documented to monitor the condition of Resident 4's MASD. During a concurrent interview and record review on 8/6/26 at 12:10 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Wound Management, dated 1/2026 was reviewed. The P&P indicated, .1. a weekly skin assessment will be completed on all residents and documented in the nurses' notes.3. Each wound will be measured.size and depth, drainage, odor, color, and a short statement on progress.will be documented. The DON acknowledged the wound assessments for Resident 4 should be conducted by the nurses weekly and the completed weekly wound assessment would be documented in the Skin Issues assessment form, to capture a comprehensive assessment of the condition of the wound. Cross Reference F656, Finding 3 2. A review of Resident 25's Face Sheet, dated 8/5/26, indicated Resident 25 was originally admitted to the facility on [DATE]. A review of Resident 25's History and Physical (a formal medical document and evaluation process containing the physician's clinical assessment and plan for a resident), dated 7/31/26, indicated Resident 25 had diagnoses including chronic pain (pain that lasts longer than three months). A review of Resident 25's Order Summary Report, dated 8/5/26, indicated Resident 25 had a physician's order dated on 7/28/26, for Voltaren [a nonsteroidal anti-inflammatory drug used to treat joint pain and reduce inflammation] External Gel 1% (Diclofenac Sodium Topical) . Apply to foot topically four times a day for pain management. A review of Resident 25's Pain Management Review, dated 7/28/26, indicated Resident 25 experienced frequent pain the last five days.A review of Resident 25's TAR, dated July 2026, indicated Resident 25 had a physician's order dated 5/7/26 for Voltaren External Gel 1% (Diclofenac Sodium Topical) . Apply to bilateral feet topically four times a day for pain management. The TAR further indicated Resident 25's pain medication was not consistently documented as administered on 7/3/26, 7/8/26, 7/10/26, 7/11/26, and 7/18/26. A review of Resident 25's TAR, dated August 2026, indicated Resident 25 had a physician's order dated 7/28/26 for Voltaren External Gel 1% (Diclofenac Sodium Topical) . Apply to foot topically four times a day for pain management. The TAR further indicated Resident 25's pain medication was not consistently documented as administered on 8/1/24 and 8/2/26. During a concurrent interview and record review on 8/5/26 at 5:21 PM with the DON, the DON acknowledged the findings and stated licensed staff should have documented the medication on the TAR when it was administered. The DON further stated that without documentation, it would be difficult to determine whether the medication had been administered as ordered. A review of the facility's P&P titled, Resident Care, subject title, Recognition and Management of Pain, revised 1/2026 indicated . Medication(s) received, refused and response to medication will be documented on the Electronic Medication Administration Record.

Based on observation, interview and record review, the facility failed to revise the care plan (an individualized outline of specific care, interventions, and goals for a resident/patient) interventions addressing the wound care clinic appointments for two of two sampled residents (Residents 7 and 10).Findings:1. During a facility tour, a concurrent observation and interview on 8/3/26 at 11:20 AM with Resident 10, in the Resident 10's bedroom, the resident wore a light blue boot on both feet. Resident 10 stated the wound on Resident 10's foot was taking longer to heal.A review of Resident 10's Face Sheet, (front page of the chart that contains a summary of basic information about the resident), dated 8/6/26 indicated, Resident 10 was admitted to the facility on [DATE].A review of Resident 10's Order Summary Report, dated 8/6/26 indicated, a physician's order, dated 5/9/26, for Resident 10 to .arrange a follow-up appointment for wound management.A review of Resident 10's Care Plan Report, dated 5/8/26 indicated, a Focus area addressing Resident 10 had a pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) r/t (related to) right heel pressure Stage 3.During a concurrent interview and record review on 8/6/26 at 11:53 AM with Licensed Vocational Nurse (LVN) 3, Resident 10's Care Plan Report, dated 5/8/26, and Resident 10's Order Summary Report, dated 8/6/26, were reviewed. LVN 3 acknowledged Resident 10 had a pressure ulcer to the right heel and was being treated outpatient by a wound care physician.During a further review of Resident 10's Care Plan Report, dated 5/8/26, the Care Plan Report did not indicate the follow-up appointments for wound management in the Resident 10's care plan as an intervention. LVN 3 stated the follow-up appointment should be included in the care plan interventions to address Resident 10's pressure ulcer problem. LVN 3 further stated Resident 10 would usually go for wound management clinic every week.A review of Resident 10's After Visit Summary (discharge instructions after a visit with a physician), dated 8/4/26, the summary indicated, the resident was followed up for a Stage 3 pressure ulcer on the resident's right heel at a wound care clinic. 2. During a facility tour, a concurrent observation and interview on 8/3/26 at 8:52 AM with Resident 7, in Resident 7's bedroom, the resident was laying in bed. Resident 7 stated there was a wound on the resident's lower back.A review of Resident 7's Face Sheet, dated 8/5/26 indicated, Resident 7 was admitted to the facility on [DATE].A review of the Resident 7's Order Summary Report, dated 8/6/26 indicated, a physician's order, dated 6/17/26, to Refer to wound care center r/t Stage 4 pressure ulcer sacrococcygeal (lower back and tailbone) and Stage 3 right heel pressure ulcer.A review of Resident 7's After Visit Summary, dated 7/27/26, the summary indicated, the resident was followed up at a wound care clinic, including, for a Stage 3 pressure injury on the resident's right heel and a Stage 3 pressure injury on the resident's sacral region.A review of Resident 7's Care Plan Report indicated;- On 5/12/26, a Focus area indicating Resident 7 had a Stage 3 pressure injury on the right heel,- On 5/26/26, a Focus area indicating Resident 7 had a Stage 3 pressure injury on the resident's sacroccygeal area.During a concurrent interview and record review on 8/6/26 at 11:45 AM with LVN 3, Resident 7's Care Plan Reports, dated 5/12/26 and 5/26/26, and Resident 7's Order Summary Report, dated 8/6/26, were reviewed. LVN 3 acknowledged Resident 7 had pressure ulcers to the right heel, sacroccygeal area, and was being treated outpatient by a wound care physician.During a further review of Resident 7's Care Plan Report, the Care Plan Report did not indicate, the Resident 7's referral and visits to the wound care center was included in the care plan interventions. LVN 3 acknowledged this finding. LVN 3 stated the physician's order to refer Resident 7 to a wound care center should be included in the care plan interventions to address Resident 7's pressure injury care plan problems. LVN 3 further stated Resident 7 would usually go to the wound care center every week.A review of the facility's policy and procedure (P&P), titled Comprehensive Person-Centered Care Planning, reviewed and revised on 5/2025, the P&P indicated the resident's comprehensive plan of care will be reviewed and/or revised by the IDT (Interdisciplinary Team) after each assessment, including both the comprehensive and quarterly review assessments.

Based on observation, interview, and record review, the facility failed to ensure the maintenance of hearing abilities for one of one sampled resident (Resident 66) when staff failed to timely address Resident 66's missing hearing aids.This failure had the potential to impair Resident 66's ability to communicate effectively.Findings: During an initial tour, a concurrent observation and interview on 8/3/26 at 9:39 AM with Resident 66 in Resident 66's bedroom, Resident 66 laid in bed, gestured with his right hand to move closer to the resident, and stated he was unable to hear well. Resident 66 needed the questions repeated during the interview. There were no hearing aid devices observed in Resident 66's ears.A review of Resident 66's Face Sheet (front page of the chart that contains a summary of basic information about the resident), dated 8/5/26 indicated, Resident 66 was admitted to the facility on [DATE].A review Resident 66's Minimum Data Set ([MDS] - a federally mandated standardized assessment tool), dated 2/4/26, indicated a section titled, Section B - Hearing, Speech and Vision. Further review of the MDS assessment indicated Resident 66 had moderate difficulty with hearing ability, and Resident 66 had a hearing aid device in place during the assessment.During an interview on 8/4/26 at 4:09 PM with the Certified Nursing Assistant (CNA) 1, CNA 1 stated CNA 1 was familiar with the care of Resident 66 and stated Resident 66 was hard of hearing. CNA 1 further stated CNA 1 had to speak loudly and repeat statements or words for Resident 66 to understand. CNA 1 acknowledged Resident 66 had been using a hearing aid device; however, the hearing aid had been missing since May of 2026. CNA 1 stated CNA 1 reported the missing hearing aid to Resident 66's charge nurse and was informed the charge nurse would look into the missing hearing aid and speak with other nurses. CNA 1 stated, without the hearing aid the, CNA 1 had to move closer to Resident 66 when speaking to Resident 66 to ensure Resident 66 understood. CNA 1 acknowledged Resident 66's hearing aid had been missing for approximately two months.During an interview on 8/5/26 at 8:09 AM with the MDS Coordinator (MDSC) 1, MDSC 1 acknowledged Resident 66's hearing aid device was usually stored in the drawers of the resident's nightstand.During a concurrent interview and record review on 8/5/26 at 11:51 AM with Social Services Director (SSD), Resident 66's Theft and Loss - Referral Slip, was reviewed. SSD stated Resident 66's hearing aid was found missing on 5/25/26, but the Theft and Loss - Referral Slip was only completed on 8/4/26, two months after Resident 66's hearing aids were reported missing. The SSD further stated the Theft and Loss - Referral Slip should have been completed when the hearing aids were first reported missing to initiate timely replacement of the hearing device.During a telephone interview on 8/5/26 at 12:06 PM with Family Member A, Family Member A stated Resident 66 has been using a hearing aid device for over 10 years. Family Member A stated the hearing aid was brought to Resident 66 at the facility but could not recall the exact date.During an interview on 8/5/26 at 12:45 PM with the Assistant Administrator (AA) and the SSD, the AA stated a CNA reported Resident 66's missing hearing aids to the SSD on 8/4/26. AA further stated the CNA had initially reported Resident 66's missing hearing aids to the charge nurse in May 2026; however, the charge nurse did not report the missing hearing aids to SSD.A review of the facility's policy and procedure (P&P), titled Theft and Loss, revised 12/2025, indicated . 1. Loss or theft of resident or visitor property worth more than $25.00 will be documented on Resident Theft and Loss Report. Each report will be submitted to the Administrator for investigation, police reporting or other appropriate action.Cross Reference F641, Finding 2

Based on observation, interview and record review, the facility failed to ensure the environment was free from potential accident hazards for 2 of 32 sampled residents when:1. The facility failed to implement the facility's policy and procedure (P&P) and Resident 75's care plan interventions to address proper storage of Resident 75's smoking materials.2. A space heater (a portable or small appliance used to heat a single room or a localized indoor area) was found inside Resident 9's room. This had the potential to cause an electrical hazard if used inside the facility. Findings: 1. During a facility tour, a concurrent observation and interview on 8/3/26 at 9:10 AM, inside Resident 75's bedroom, the resident was in bed, and a red and white box was observed on Resident 75's bedside table. Resident 75 acknowledged the red and white box was an empty cigarette box. Resident 75 stated he smoked at the facility and proceeded to remove a lighter from his shirt pocket. Resident 75 further stated he was able to keep own lighter and cigarette. A review of Resident 75's Face Sheet, (front page of the chart that contains a summary of basic information about the resident) dated 8/5/26, indicated the resident was admitted to the facility on [DATE]. A review of Resident 75's History and Physical, (H&P), dated 12/15/25, indicated Resident 75 had a past medical history of active tobacco use. A review of Resident 75's Smoking Evaluation, dated 2/9/26, indicated Resident 75 smoked 6 times per day and was capable of smoking in the patio. A review of Resident 75's Care Plan Report, revised 1/31/26, indicated Resident 75 had a care plan (an individualized outline of specific care, interventions, and goals for a resident/patient) Focus:.potential for injury r/t (related to) smoking.Interventions included.monitor to assess compliance with facility smoking policy. During a concurrent interview and record review on 8/5/26, at 2:40 PM with Licensed Vocational Nurse (LVN) 1, Resident 75's Smoking Evaluation, dated 2/9/26 was reviewed with LVN 1. LVN 1 stated Resident 75 was assessed as a smoker, and smoked at the facility's designated smoking patio. LVN 1 continued to review Resident 75's Care Plan Report, dated 1/31/26, and verified the care plan indicated an intervention to ensure the facility's smoking policy was followed by Resident 75. LVN 1 stated smoking materials such as lighters and cigarettes, were kept by the nursing staff and staff would light the cigarette for the residents who smoked. During a concurrent observation and interview on 8/5/26 at 3:00 PM with Resident 75 and LVN 1, in the smoking patio, Resident 75 was smoking a cigarette. Resident 75 stated the cigarette was lit using his personal lighter. Subsequently, Resident 75 showed a brown-colored lighter used to light the cigarette. LVN 1 verified Resident 75 had a lighter in his possession and stated LVN 1 did not provide and was unaware who provided the lighter to Resident 75. LVN 1 explained nurses should ensure residents who smoked at the facility should not keep their own smoking materials. LVN 1 further explained, if the resident who smoked, did not return the smoking materials, the materials should be confiscated by the staff after smoking. During a concurrent interview and record review on 8/5/26 at 3:13 PM with the Director of Nursing (DON), Resident 75's Care Plan Report, revised 1/31/26 and the facility's P&P titled Smoking Policy, reviewed 5/2026 were verified by the DON. The DON acknowledged, according to the facility's P&P and Resident 75's care plan, the resident was not allowed to keep the resident's smoking materials. The DON stated smoking paraphernalia especially lighters should be kept by licensed nurses. A review of the facility's (P&P) titled, Smoking Policy dated 5/2026, indicated, .8. If it is determined that a resident is independent and a safe smoker, lighting /smoking materials will still be retained by nursing staff, Activities or Social Services Staff; and they may come and request for them at the time they desire to go out to smoke. This was promoting oversight by staff. 2. A review of Resident 9's Face Sheet (front page of the chart that contains a summary of basic information about the resident), dated 8/6/26, indicated Resident 9 was admitted to the facility on [DATE]. During a concurrent observation and interview on 8/3/26 at 10:00 AM inside Resident 9's room, an unplugged space heater was found located at the far end corner of the room. During a concurrent observation and interview on 8/3/26 at 3:39 PM inside Resident 9's room, with Certified Nurse Assistant (CNA) 4, CNA 4 stated Resident 9 brought personal belongings from admission. During a concurrent observation and interview on 8/3/26 at 4:00 PM inside Resident 9's room, with LVN 6, LVN 6 verified Resident 9 had a space heater at the far end corner of Resident 9's room and stated space heaters were not allowed in the facility. During an interview on 8/3/26 at 4:54 PM with the Administrator, the Administrator stated resident belongings that were brought into the facility were evaluated for safety and appropriate use. The Administrator further stated that devices that produced heat including space heaters were prohibited due to safety concerns. During a review of the facility's P&P titled, Accident Prevention and Intervention, revised 1/2026 indicated, . It is the policy of this facility that the resident environment remains as free of accident hazards as is possible and that each residents receives adequate supervision and assistance devices to prevent accidents. Procedures. A list of accident preventive measures follows. Accident Prevention and Safety. 26. Report the use of electric blankets, coffee pots, heating pads or irons and other electrical items.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 120) received oxygen therapy in accordance with the physician's orders when:1. Resident 120 was observed receiving oxygen at 4.5 liters per minute (L/min - measurement for the speed of flow) despite a physician's order for continuous oxygen at 3L/min.2. Resident 120's oxygen saturation levels (O2 sat - a measurement of how much oxygen the blood is carrying as a percentage) were not documented on the Respiratory Administration Record (RAR - a daily documentation record used by a licensed nurse to document oxygen therapy) for the required shifts. These failures had the potential for Resident 120 to experience complications related to oxygen therapy. Findings:1. During a concurrent observation and interview on 8/3/26 at 11:57 AM with Resident 120 inside of Resident 120's room, Resident 120 was sitting upright in bed with a nasal cannula (a light and flexible plastic device used to give oxygen into a person's nose) in place. Resident 120 stated he was receiving continuous oxygen to help him breathe. Resident 120's oxygen concentrator (a medical device that provides oxygen) was set at 4.5L/min.A review of Resident 120's Face Sheet, (front page of the chart that contains a summary of basic information about the resident) dated 8/5/26, indicated Resident 120 was admitted to the facility on [DATE].A review of Resident 120's Annual History and Physical (H&P), dated 3/31/26, indicated Resident 120 had diagnoses including chronic obstructive pulmonary disease ([COPD] - a progressive lung disease which blocks air flow making breathing difficult).A review of Resident 120's Order Summary Report, dated 8/5/26, indicated Resident 120 had physician's orders dated on 11/13/25, for, Continuous oxygen at 3L/min via nasal cannula/mask to keep oxygen saturation above 90% every shift for COPD.A review of Resident 120's Care Plan Report, revised 7/21/26 indicated Resident 120 had a care plan (an individualized outline of specific care, interventions, and goals for a resident/patient) 'Focus' area titled 'At risk for episodes of alteration in breathing.' indicated an intervention for 'Continuous oxygen at 3L/min via nasal cannula.'A review of Resident 120's Long Term Care Evaluation, dated 8/2/26 indicated Resident 120 was to receive oxygen via nasal cannula at 3L/min.During a concurrent observation and interview on 8/5/26 at 7:49 AM with the Director of Nursing in Training (DIT) 1 inside Resident 120's room, Resident 120's oxygen concentrator was set at 4.5L/min. The DIT 1 verified the findings and stated Resident 120's oxygen concentrator should have been set at 3L/min. The DIT 1 stated it is important to follow the physician's orders for Resident 120 to prevent complications.2. A review of Resident 120's Order Summary Report, indicated Resident 120 had physician's orders dated on 3/29/25, for, Pulse oximetry every shift to monitor O2 sats.A review of Resident 120's Respiratory Administration Record, dated July 2026 and August 2026, indicated Resident 120 had a physician's order dated 11/13/25, for continuous oxygen at 3L/min via nasal cannula/mask to keep oxygen saturation above 90%. The RAR further indicated Resident 120's O2 sats were not consistently documented on certain shifts on the following dates: 7/1/26 - 7/2/26, 7/4/26 - 7/9/26, 7/17/26 - 7/20/26, 7/24/26 - 7/25/26, 7/27/26, 7/29/26, 7/31/26, and 8/1/26 - 8/3/26. During a concurrent interview and record review on 8/5/26 at 10:21 AM with the DIT 1, the DIT 1 acknowledged the missing RAR documentation for July and August 2026. The DIT 1 stated licensed staff were expected to document Resident 120's O2 sats every shift to ensure Resident 120 was receiving the proper amount of oxygen.A review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, revised 1/2026, indicated It is the policy of this facility to administer oxygen as prescribed by the physician, in a safe manner.A review of the facility's P&P titled, Quality of Care, subject title, Provision of Respiratory Therapy Services for Patients and Residents Who Are Not Receiving Invasive Mechanical Ventilation, revised 1/2026 indicated under Monitoring and documentation. 3. documentation shall include, as appropriate: vital signs, including the respiratory rate and oxygen saturation.

Based on observation and interview, the facility failed to prepare puree food in the proper form and consistency. This deficient practice had the potential to affect 11 residents (Residents 19, 23, 24, 49, 66, 73, 76, 79, 86, 88, 113) who required puree consistency by providing food that did not meet required texture specifications, increasing the risk of choking, poor intake, and compromised nutrition. Findings:During a concurrent test tray observation and interview on 8/5/2026 at 12:32 PM with the Registered Dietitian (RD) and Kitchen Manager (KM), the puree cake was thin and runny. The RD acknowledged it was runny and performed the spoon tilt and fork drip test. The RD confirmed it did not pass the spoon tilt and fork drip test. During a review of the Diet Order Report on 8/5/26, the report indicated 11 residents (Residents 19, 23, 24, 49, 66, 73, 76, 79, 86, 88, 113) received a puree diet. During a review of the facility's puree recipe titled, Recipe: Puree (IDDSI LEVEL 4) Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and other Bread Products with date 2024 indicated, 4. The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt tests).

Based on interview and record review, the facility failed to ensure the physician's treatment order for one of six sampled residents (Resident 24) was complete and contained an indication and location for staff to accurately implement the prescribed treatment.This failure had the potential to result in inconsistent or incorrect implementation of the prescribed treatment and place the residents at risk for adverse health outcome.Findings:A review of Resident 24's Face Sheet, (front page of the chart that contains a summary of basic information about the resident) dated 8/5/26, indicated Resident 24 was admitted to the facility on [DATE].During an initial tour observation on 8/3/26, at 9:19 AM in Resident 24's room, Resident 24 was observed with support bandages wrapped around both lower extremities (human limbs like arms, legs, hands, and feet).During a review on 8/4/24, at 10:12 AM of Resident 24's record titled, Order Listing Report, (a document showing current physician orders for a resident) dated 2/23/26, indicated a physician treatment order for Tubi grips (a brand of stretchy fabric tube or wrap) ON in AM, OFF at bedtime every shift. The physician's treatment order did not specify the location and indication for the treatment.During a concurrent interview and record review on 8/5/26 at 9:18 AM, with Registered Nurse (RN) 2, RN 2 reviewed Resident 24's physician's orders. RN 2 stated Resident 24's bilateral (both) lower extremities were edematous (swollen, puffy, or filled with an excessive accumulation of fluid in the body's tissues) and Resident 24 had a physician's order dated 2/23/26, for Tubi grip treatment. RN 2 confirmed Resident 24's physician's order was incomplete because the physician's order did not specify the affected area and the indication for treatment.During an interview with the Director of Nursing in Training (DNT) 1 on 8/6/26, at 3:11 PM, DNT 1 stated the physician's orders for medications and treatments should be complete and include the indication, treatment, location, application instructions, and duration. DNT 1 further stated licensed nursing staff should clarify incomplete physician's orders and verify their completeness before transcription to ensure the treatment is carried out correctly and safely.A review of the facility's policy and procedure (P&P) titled, Physician's Orders, revised 01/2026, indicated, .6. Orders for medications must include.A. Name and strength of the drug.B. Quantity or specific duration of therapy.C. Dosage and frequency of administration.D. Route of administration if other than oral and.E. Reason or problem for which given.

Based on record review, interview, and facility Policy and Procedure (P/P) the facility failed to ensure care plan interventions were updated following score increase, multiple subsequent falls for one and three resident (Resident 1). This facility failure resulted with resident having repeated preventable falls. During a concurrent interview on 4/12/26 at 11:30 a.m., the Minimum Data Set (MDS) coordinator confirmed that Resident 1 experienced three previous falls (on 10/17/25, 11/27/25, and 12/11/25) prior to a fourth fall on 3/31/26. This most recent incident resulted in a left periprosthetic femoral fracture (a break in the thigh bone adjacent to a hip prosthesis).A review of Resident 1's comprehensive care plan for falls initially dated 8/20/25, revised 8/30/25, revealed there was no documentation to show an updated interventions following Resident 1's multiple subsequent falls on 10/17/25, 11/27/25, and 12/11/25. While the fall on 3/31/26 was addressed, the interventions remained identical to the original 8/20/25 plan, indicating a lack of revision in response to changing needs.A review of Resident 1's fall evaluation record titled Fall Risk Evaluation Form indicated, initial admission fall risk score (8/20/25) was 10, categorizing the resident as High Risk. A follow-up assessment on 2/25/26 showed an increased score of 17, indicating continued High Risk status. Per the Fall Risk Evaluation Form utilized indicated that a score of 10 or greater, the resident should be considered at HIGH RISK for potential falls and preventive protocols must be initiated instantly and documented.During a concurrent record review of Resident 1's fall intervention with MDS on 4/12/26 at 11:30 a.m., it revealed that despite an increased Fall Risk Assessment score of 17 and four subsequent falls, the comprehensive care plan was not updated or revised since 8/20/25.During a concurrent interview and record review on 4/12/26 at 11:30 a.m. with MDS 1, Resident 1's fall care plans were reviewed. MDS 1 was questioned regarding the lack of revisions to the initial comprehensive long-term care plan for falls since August 20, 2025, despite Resident 1's Fall Risk Assessment score increasing to 17 and experiencing multiple (4 ) falls in the facility, the interventions and tasks outlined in the care plan remained unchanged. Upon reviewing the care plan, MDS 1 was unable to provide an explanation. MDS acknowledged the care plan should have been updated following the score increase, each fall, and during quarterly reviews.During an interview with Administrator (ADM) and Assistant Director of Nursing (ADON), on 4/13/26 at 4:21 a.m., both concurred and acknowledged the policies and procedures were not followed when there no documentation to show Resident 1's care plan interventions were updated following score increase, multiple subsequent falls on 10/17/25, 11/27/25, 12/11/25, and during quarterly reviews.During a review of the facility's policy and procedure (P&P) titled, Care Planning, dated /revised 01/26, the P&P indicated, . Revision or updating of the care plan will occur with quarterly, annually, upon significant changes of condition.A review of the facility's P&P, titled, Resident Assessment and Associated Processes, with a revised date of 1/2026, indicated the following, Comprehensive Assessment: includes the completion of the MDS (Minimum Data Set) as well as the CAA (Care Area Assessment) process, followed by development and/or review of the comprehensive care plan. Comprehensive MDS assessments include Admission, Annual, Significant Change in Status Assessment and Significant Correction to Prior Comprehensive Assessment.3. a. Significant Change: iii. Requires IDT review and/or revision of the care plan.4. Each resident will be assessed every 3 months (at least every 92 days) between comprehensive assessments using a standardized quarterly review process.5. Assessment information will be used to develop, review, and revise the resident's comprehensive care plan.

Based on observation, interview, and record review, the facility failed to: 1. Ensure a sanitary environment and safe food handling practices within the food service operation for 113 of 119 residents residing at the facility on 10/28/19, as evidenced by live and non-moving cockroaches being present in the kitchen during daylight and while the kitchen was being operated. 2. Ensure a sanitary environment and safe food handling practices within the food service operation for 115 of 121 residents residing at the facility on 11/1 and 11/2/19, as evidenced by the infestation of live cockroaches in the kitchen and the dry food storage area. The unsanitary conditions in the kitchen related to a cockroach infestation resulted in two immediate jeopardy (IJ - situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situations and placed 115 highly susceptible residents at risk for acquiring foodborne illnesses. According to the FDA (Food and Drug Administration) Food Code (YEAR), A Highly susceptible population means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; . or older adults; and (2) Obtaining food at a facility that provides services such as .health care . 1. On 10/28/19, at 3:28 p.m., the survey team notified the Director of Nursing (DON), Dietary Director (DD), Registered Dietitian (RD), Maintenance Director, and Assistant Director of Nursing (ADON) of the IJ situation due to the cockroach infestation in the kitchen. On 10/28/19, at 5:20 p.m., the IJ was removed in the presence of the DON and the Operations Manager/Administrator in training (OM) after a temporary acceptable plan of correction (P[NAME]), which addressed the immediacy of the situation, was provided by the DON. The P[NAME] included the following: A deep clean of the kitchen will take place on 10/28/19 by facility staff including flushing of the sewer lines by maintenance. Food will be prepared in conference room using the emergency food supply, the alternative food menu as established in the facility EOP (Emergency Operations Plan), and disposable serve ware for meals for dinner on 10/28/19 and if necessary, breakfast on 10/29/19. After inspection for any cockroaches in the kitchen after sanitation by the kitchen manager, registered dietitian, and maintenance on 10/29/19, kitchen will be reassessed for use of food service. Open dry goods will be removed and discarded on 10/29/19. Pest control services will be out in the morning of 10/29/19 for treatment to mitigate the safety concern. If pest control service requires overnight treatment on 10/29/19 of the kitchen, then (name of the facility) will continue alternate menu food service until after deep clean post treatment can be completed. Any notable crack in the floor of the kitchen that is not part of ongoing OSHPD (Office of Statewide Health Planning and Development - organization that ensures healthcare buildings are safe) projects will sealed on 10/28/19 by maintenance. The open floor due to ongoing OSHPD project will be resealed using silicone and plastic and wood overlay to reduce the pest exposure coming from the open floor repair by maintenance after the deep clean on 10/28/19. Any emergency food product utilized will be replenished as soon as possible. Findings: On 10/28/19 the Department received a complaint indicating there were cockroaches inside the facility. According to the Food and Drug Administration (a federal agency of the United States Department of Health and Human Services which is responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nation's food supply, cosmetics, and products that emit [MEDICAL CONDITION]), Insects and rodents are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. The presence of insects and rodents is minimized by protecting outer openings to the food establishment. (FDA Annex 3 - Public Health Reasons/Administrative Guidelines, 6-202.15 Outer Openings, Protected.) According to the Centers for Disease Control and Prevention (a federal agency that conducts and supports health promotion, prevention and preparedness activities in the United States, with the goal of improving overall public health), Guidelines for Environmental Infection Control in Health-Care Facilities, Cockroaches .are among the typical arthropod and vertebrate pest populations found in health-care facilities. Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector ., .outbreaks of infection attributed to microorganisms carried by insects may occur because of infestation coupled with breaks in standard infection-control practices . (https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf, page 95 of 240). The facility policy and procedure titled Food Procurement, Store/Prepare/Serve/Sanitary Conditions, dated 3/1/18, indicated in part, The department is to be free from vermin, insects and debris. During an observation of the kitchen area on 10/28/19, at 1:49 p.m., one live cockroach was sitting on the wall to the left of the food steamer, one live cockroach was sitting on the wall to the right of the food steamer, and three live cockroaches were sitting on the wall behind the food steamer. At 1:53 p.m., two live cockroaches were observed to be sitting to the left of the kitchen oven. During an observation and a concurrent interview with the Registered Dietitian (RD), on 10/28/19, at 1:55 p.m., the RD acknowledged the live cockroaches were sitting to the left, to the right, and behind the food steamer, as well as behind the kitchen oven, and stated Oh yeah, I see them. When asked, the RD stated No, it is not okay to have roaches in the kitchen. During an observation on 10/28/19, at 1:59 p.m., when the cover from the drain underneath the steam table was lifted, one live cockroach jumped out of the drain, landed on its back, and continued to move around. During a concurrent interview, the RD acknowledged there was a live cockroach in the drain underneath the steam table. During an observation on 10/28/19, at 2:05 p.m., one non-moving cockroach was observed on the floor underneath the three sinks area. During a concurrent interview with the RD and a Dietary Director (DD), both acknowledged there was a cockroach underneath the three sinks area. During an interview with the Assistant Dietary Aid (ADA), on 10/28/19, at 2:02 p.m., the ADA stated Now and then I see a live roach. Last time maybe a month ago. If I see one, I get it with a napkin, kill it, throw it away, and that is it. During an interview with the DD, on 10/28/19, at 2:03 p.m., the DD stated I was aware of the cockroach situation, but I thought it was controlled. They are cleaning as much as they can. During an interview with the RD, on 10/28/19, at 2:15 p.m., the RD stated We are very concerned there are live roaches in the kitchen. Very concerned. I am in the kitchen every day, but I do not look around for roaches when I come to the kitchen. I thought the problem with roaches was under control. During an interview with the RD on 10/28/19, at 2:25 p.m., the RD acknowledged the significance of the situation and confirmed the kitchen environment is unsanitary. The RD also confirmed food prepared and stored in the kitchen with live cockroaches is not safe and stated It is not okay to serve dinner today with live roaches present in the kitchen. On 10/28/19, at 3:28 p.m., the survey team notified the RD, DD, Director of Nursing (DON), Maintenance Director, and Assistant Director of Nursing (ADON) of the IJ situation due to the cockroach infestation in the kitchen. 2. On 11/2/19, at 12:22 a.m., the Department determined a second IJ existed. The facility staff were unable to get a hold of anyone from the administration. At 12:40 a.m., the Director of Staff Development (DSD) was contacted by phone and notified of the current IJ situation due to the cockroach infestation in the kitchen and the dry food storage area. The DSD was asked to get a hold of someone from the administration to make them aware there was an IJ situation at the facility. On 11/2/19, at 6:28 a.m., the IJ was removed in the presence of the Administrator, and the OM, after a temporary acceptable plan of correction (P[NAME]), which addressed the immediacy of the situation, was provided by the Administrator. The P[NAME] included the following: The facility immediately closed the kitchen and no food preparation will be done inside the kitchen .The facility will serve food from outside sources until the mobile kitchen is in place .All food items inside the dry storage room and resident refrigerators has been discarded .Pest control company service was requested immediately on 11/2/19. An onsite visit will be scheduled with the pest control company to assess the existing program .Dietary will be in-serviced to report any presence of roach sighting .The facility will initiate pest sighting log to monitor signs of infestations. Any findings will be reported to the facility administrator. Findings: During an observation of the kitchen area on 11/1/19, at 11:50 p.m., made together with a night shift Licensed Nurse (LN 3), hundreds of live cockroaches were observed to be running in different directions on the kitchen floor, as soon as LN 3 opened the kitchen door and the light from the hallway shined into the kitchen. Once the surveyor and LN 3 went inside the kitchen, the remaining multiple live cockroaches were observed to be running throughout the kitchen floor. During a concurrent interview, LN 3 acknowledged the cockroaches were running throughout the kitchen floor and stated Oh wow! During an observation of the dry food storage area, on 11/1/19, at 11:53 p.m., made together with LN 3, one live cockroach was observed to be crawling on the floor. There were two open bags of bread and a box with uncovered plastic utensils on the shelves in the dry food storage area. During a concurrent interview, LN 3 acknowledged there was a live cockroach in the dry food storage area. During an interview with the DSD, on 11/2/19, at 1:38 a.m., once the DSD arrived to the facility, the DSD was notified once again about the IJ situation due to live cockroaches present in the kitchen and in the dry food storage area. The DSD indicated she has been trying and was still unable to get a hold of anyone from the administration. During an observation of the kitchen area, made together with the DSD, on 11/2/19, at 1:41 a.m., multiple live cockroaches were still running around the kitchen floor. During a concurrent interview, the DSD acknowledged live cockroaches were present and confirmed the kitchen and the dry food storage area cannot be used. The DSD confirmed the facility needs to come up with an immediate plan and make arrangements for breakfast on 11/2/19 to feed the residents with some alternative food. The DSD indicated she was unaware of the facility having an alternative plan to provide breakfast to residents on 11/2/19. During an interview with LN 1 and LN 2, on 11/2/19, at 2:40 a.m., both indicated they are unaware of any alternative plan to provide breakfast to residents on 11/2/19. LN 1 and LN 2 indicated the kitchen was operational and the kitchen staff will arrive around 5 a.m., to start preparing breakfast for the residents. During an interview with the Clinical Resource RN (CRRN1), on 11/2/19, at 2:45 a.m., the CRRN1 indicated she was aware of the cockroach infestation and the facility had not set up a system for all shifts to monitor for cockroach activity. During an interview with the OM, on 11/2/19, at 3:25 a.m., the OM indicated the facility was aware of the cockroach problems and they had already had a pest control company out to treat the facility. He also indicated the kitchen was in use since Friday 10/31/19 and that the facility had not been monitoring the facility at night for cockroach activity. The OM agreed they did not have a plan in place for the upcoming breakfast meal. In an interview with a dietary aide (DA1), on 11/2/19, at 5:45 a.m., the DA1 stated she had worked at the facility for almost 8 years. She stated she had, Seen cockroaches frequently in the kitchen and the dishroom, throughout the years she had worked there. In an interview with the cook (C1), on 11/2/19 at 5:57 a.m., the C1 indicated she had worked for the facility for twelve to thirteen years. She stated she has seen cockroaches in the kitchen for a long time. She stated she, Sees them in the dishroom regularly. The C1 indicated she was going to prepare breakfast in the kitchen for the residents on the morning of 11/2/19 until after she arrived at work and was informed of the problem with the roach infestation. In an interview with the Dietary Director (DD), on 11/2/19, at 6:10 a.m., the DD indicated she had seen cockroaches occasionally. She indicated she had only been working there for about a year. The DD also indicated she was in a hurry since they could not use the kitchen to prepare breakfast for the residents. She was observed giving a large amount of cash to the DA1 to purchase breakfast for the residents from a local restaurant. She instructed the DA1 to, Buy a new blender and to, Order 120 meals for the residents.

Based on interview and record review, the facility failed to ensure one of 24 sampled residents, Resident 24 who was assessed upon admission to the facility as a high risk for elopement (leaving the facility unnoticed), and recent history of elopement, received adequate supervision and effective and/or functioning alarming system to alert the facility staff of an unsafe exit from the facility. As a result of this failure, Resident 24 eloped on 01/21/17 and sustained right 5th and 6th rib fractures, shattered right humeral head (shoulder) fracture, and mild dependent atelectasis (collapsed lung). Findings: Clinical record review on 3/2/17 indicated Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. which causes problems with memory and cognitive functioning). Review of the facility's Comprehensive Nursing Observation Upon Admission assessment dated [DATE] indicated Resident 24 was alert, with periods of confusion and forgetfulness. The resident had a behavior of wandering, and attempted to elope from the facility on the day of admission. The resident had reduced strength to legs, and gait was unsteady. Review of the facility's Elopement Risk Evaluation assessment on 1/16/17 indicated Resident 24 was at risk for elopement because the resident had: a. history of elopement, b. attempted to leave a residence or other place unescorted that placed him in danger, c. poor decision-making skills, and ability to walk independently, d. verbalized intent to leave facility, e. wandered and sought to find family, f. wandered aimlessly, and g. exhibited exit-seeking behavior. Review of the facility's care plan interventions indicated the facility will implement a Wandergaurd bracelet (an alarming device that alerts the facility staff when the resident attempts to exit the facility). Review of the facility's nurses notes (Clinical Notes Report) dated 1/21/17 indicated at approximately 10:30 a.m. resident (Resident 24) seen in doorway of his room standing and observing hallway .at approximately 12:15 during medication administration resident was not in room .last seen by a CNA (certified nursing assistant) at 11:45 a.m. Review of the facility's nurses' notes indicated on 1/21/17 at 8:16 p.m., a Registered Nurse documented, at 12:15 resident was noticed by charge nurse to be missing from his room .last visualization of resident by staff was approximately 11:45 in his room. As of 2:15 p.m., resident had not returned to the facility. Phone call placed to local dispatch, and followed up with emergency contact .as of the time of this report (8:15 p.m.) resident has not yet returned . Review of the facility's Interdisciplinary Team (IDT) conference/care plan review, dated 1/23/17 at 3:15 p.m., indicated an acute care hospital contacted the facility on 1/22/17 that Resident 24 was admitted on [DATE] at 12:19 a.m. (0019). Review of the acute care hospital's ED Provider Notes dated 1/22/17 at 12:19 (0019) a.m., indicated Resident 24 was brought in by ambulance to the emergency room (approximately 12 hours after elopement from the facility). Resident 24 was found staggering on the street approximately 5 miles from the facility. Resident 24 was transported to the emergency room with multiple abrasions and bruising to all extremities and upper chest, with a bracelet on, and covered with stool. Resident 24 was diagnosed with [REDACTED]. Review of the acute care hospital's Discharge Summaries dated 2/16/17 indicated Traumatic comminuted (R) humeral head fracture s/p (past) repair now displaced. The patient underwent ORIF (open reduction and internal fixation on 1/22/17. X-ray showed complete failure of previous right shoulder repair (humeral head component markedly abnormally rotated inferiorly). Patient will likely requires hemearthroplasty given the extent of his new fracture. During a concurrent interview and a review of the facility's Wandergaurd Tract Form on 3/3/17 at 10:55 a.m., the facility's Lead CNA (CNA 1) and the Administrator provided a list of residents who were wearing Wandergaurd Bracelets. Resident 24 was part of the list. The CNA indicated Resident 24's Wandergaurd was checked on 1/21/17 at the beginning of the morning shift. The Wandergaurd Tract Form did not indicate what time the device was checked on 1/21/17. The facility was unable to provide documentation to indicate the Wandergaurd was checked again on that day, or an intervention to prevent elopement was provided when Resident 24 was seen in doorway of his room standing and observing hallway. During an interview and a concurrent record review on 3/6/17 at 1:25 p.m., the facility's Administrator stated, maybe between the time the Wandergaurd bracelet was checked to have been activated/functional and the time the resident left, the Wandergaurd had become deactivated. This is the only way that I can think of how it happened.