Every finding on record at Citrus Post-Acute

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the care plans were revised and the interventions were followed for two of three sampled residents (Residents 1 and 2). * The facility failed to revise Resident 1's care plan to reflect the refusals and/or non-compliance of the bowel regimens when the resident was not having regular bowel movements. * The facility failed to implement Resident 2's care plan interventions for pain. These failures posed the risk of the residents not receiving appropriate, consistent, and individualized care.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person Centered revised 3/2022 showed the following:- the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment;-the residents are informed of his or her right to participate in his or her treatment, and provided advance notice of care planning conferences;-assessments of residents are ongoing and care plans are revised as information about the residents and resident's conditions change;-the resident has a right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies; and-care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relation between the resident's problem areas and their causes, and relevant clinical decision making. 1. Closed medical record review for Resident 1 was initiated on 5/13/26. Resident 1 was readmitted to the facility on [DATE], and transferred to the acute care facility on 1/26/26. Review of Resident 1's Care Plan Report dated 11/12/25, showed the following care plans:- risk for constipation related to decreased mobility, diminished appetite, medication side effect, poor fiber intake, and poor fluid intake. The care plan interventions included to assess for any signs and symptoms of constipation every shift, increase fiber and fluid intake, encourage physical activities as tolerated, monitor and report to physician as needed for signs and symptoms of complications related to constipation, offer prune juice if desired, and provide laxatives, suppositories and enemas only as needed; and- Resident 1 was on pain medication therapy (hydrocodone-acetaminophen, narcotic pain medication). The interventions included monitoring for constipation. Review of Resident 1's Order Summary Report dated 12/22/25, showed the following physicians orders:- hydrocodone-acetaminophen oral tablet 7.5-325 mg, one tablet by mouth every six hours as needed for severe pain (7-10, on the pain scale of 0 to 10 with 0 = no pain and 10 = worst);- Dulcolax (laxative) suppository 10 mg, insert one suppository rectally every 24 hours as needed for bowel management if the milk of magnesia (laxative) was ineffective;- Fleet Enema (laxative) rectal enema 7-19 grams/118 ml (Sodium Phosphates), insert one applicator rectally every 24 hours as needed for bowel management if the Dulcolax suppository was ineffective;- Milk of Magnesia oral suspension 400 mg/ml (Magnesium Hydroxide), give 30 ml by mouth every 24 hours as needed for bowel management; and- Polyethylene Glycol (laxative) 3350 Powder (Polyethylene Glycol 3350 (Bulk), give 17 grams by mouth as needed for constipation mix powder with four to eight ounces of water prior to administration. Review of Resident 1's Documentation Survey Report Bowel Movements dated from 1/17/26 to 1/24/26, showed the bowel movements per shift was coded as 1, indicating none. Review of Resident 1's Nurses Note dated 1/17/26, showed the resident refused any bowel regimen, stating she had a medium sized loose stool post dialysis on 1/16/25. Review of Resident 1's Nurses Notes dated 1/19/26, showed Resident 1 stated her last bowel movement was on 1/16/26, at around 1700 hours. A stool softener/laxative was offered but the resident declined. Review of Resident 1's Nurses Note dated 1/23/26, showed offered as needed stool softener/laxative, resident declined, attempts three times and explained risk and benefits, resident refused. On 5/19/26 at 1245 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. When asked what the process was if a resident was refusing care, the DON stated the process would be to notify the physician, document, and update the care plan for non-compliance. The DON verified Resident 1 had multiple episodes for refusals of bowel regimen, and the care plan was not revised to reflect the refusals. 2. Medical record review for Resident 2 was initiated on 5/13/26. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2' s Care Plan Report dated 4/20/26, showed a care plan problem addressing the resident's risk for pain. The interventions included to indicate the nonpharmacological interventions attempted prior to administering the pain medication. Review of Resident 2's Order Summary Report dated 4/21/26, showed to administer Hydromorphone HCL (hydrochloride) (opioid pain medication) 4 mg tablet by mouth every six hours as needed for moderate (4-6) to severe (7-10) pain scale. Alternatives used prior to administering as needed (1) reposition (2) distraction (3) breathing techniques (4) gentle massage (5) relaxation technique (6) music and (7) other. Review of Resident 2's MAR showed the pain medication was administered and the non-pharmacological interventions were documented as NA (not applicable) on the following dates:- dated 5/1/26 at 1415 hours; PRN E (effective)- dated 5/2/26 at 0350 hours, and 1212 hours; PRN E- dated 5/3/26 at 0506 hours; PRN E- dated 5/4/26 at 1130 hours; PRN E- dated 5/7/26 at 0602 hours, and 1441 hours; PRN E- dated 5/8/26 at 0444 hours, and 1242 hours; and PRN E and- dated 5/9/26 at 1413 hours PRN E. On 5/13/26 at 1539 hours, an interview was conducted with Resident 2. Resident 2 stated he was constipated until 5/12/26, when he finally decided to do an enema. Resident 2 stated the pain medications made him constipated. On 5/19/26 at 1057 hours, an interview and concurrent medical record review for Resident 2 was conducted with the ADON. When asked what NA meant, the ADON stated not applicable. When asked if nonpharmacological interventions were conducted when documented NA prior to the PRN was shown to be administered, the ADON stated she did not see any documentation for nonpharmacological interventions. On 5/19/26 at 1245 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. When asked what the process was when residents are on narcotic pain medication, the DON stated there was no specific process, however she was aware it could cause hard stool or constipation. The DON verified the non-pharmacological interventions for hydromorphone for Resident 2 were documented as NA and the medication were administered. The DON stated they should have documented which nonpharmacological interventions were attempted prior to the administration of the pain medication. On 5/19/26 at 1338 hours, an interview was conducted with the Administrator and the DON. The Administrator and the DON acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent constipation for one of three sampled residents (Resident 1). * The facility failed to follow the physician's order for the bowel management when Resident 1 did not have a bowel movement for four days from 1/12/26 to 1/15/26. This failure had the potential for not providing the necessary care and services and posed a risk for adverse complications.Findings: Review of the facility's P&P titled Bowel (Lower Gastrointestinal Tract) Disorders revised 9/2017 showed the staff and physician will identify risk factors related to bowel dysfunction; for example, severe anxiety disorder, recent antibiotic use, or taking mediations that are used to treat, or that may cause or contribute to, gastrointestinal (referring collectively to the stomach) erosion (wearing away), bleeding, diarrhea, dysmotility (condition where muscles of digestive tract do not function normally), etc. Review of the facility's P&P titled Care Plans, Comprehensive Person Centered revised 3/2022 showed the following:- the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment;-the residents are informed of his or her right to participate in his or her treatment, and provided advance notice of care planning conferences;-assessments of residents are ongoing and care plans are revised as information about the residents and resident's conditions change;-the resident has a right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies; and-care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relation between the resident's problem areas and their causes, and relevant clinical decision making. Closed medical record review for Resident 1 was initiated on 5/13/26. Resident 1 was readmitted to the facility on [DATE] and transferred to an acute care facility on 1/26/26. Review of Resident 1's Care Plan Report dated 11/12/25, showed the following care plans:- risk for constipation related to decreased mobility, diminished appetite, medication side effect, poor fiber intake, and poor fluid intake. The care plan interventions included to assess for any signs and symptoms of constipation every shift, increase fiber and fluid intake, encourage physical activities as tolerated, monitor and report to physician as needed for signs and symptoms of complications related to constipation, offer prune juice if desired, and provide laxatives, suppositories and enemas only as needed; and- Resident 1 was on pain medication therapy (hydrocodone-acetaminophen, narcotic pain medication). The interventions included monitoring for constipation. Review of Resident 1's Order Summary Report dated 12/22/25, showed the following physicians orders:- hydrocodone-acetaminophen oral tablet 7.5-325 mg, one tablet by mouth every six hours as needed for severe pain (7-10);- Dulcolax (laxative) suppository 10 mg, insert one suppository rectally every 24 hours as needed for bowel management if the milk of magnesia (laxative) was ineffective;- Fleet Enema (laxative) rectal enema 7-19 grams/118 ml (Sodium Phosphates), insert one applicator rectally every 24 hours as needed for bowel management if the Dulcolax suppository was ineffective;- Milk of Magnesia oral suspension 400 mg/ml (Magnesium Hydroxide), give 30 ml by mouth every 24 hours as needed for bowel management; and- Polyethylene Glycol (laxative) 3350 Powder (Polyethylene Glycol 3350 (Bulk), give 17 grams by mouth as needed for constipation mix powder with four to eight ounces of water prior to administration. Review of Resident 1's MAR for January 2026 showed Resident 1 was administered hydrocodone-acetaminophen from 1/12/26 to 1/15/26. Review of Resident 1's Documentation Survey Report Bowel Movements dated from 1/17/26-1/24/26, showed bowel movements per shift coded as 1, indicating none. Further review of Resident 1's medical record failed to show Resident 1 was offered or provided a bowel regimen for not having a bowel movement for four days (1/12/26 to 1/15/26). On 5/19/26 at 1245 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified there was no documentation showing Resident 1 was offered or provided a bowel management intervention for 1/12/26 to 1/15/26. On 5/19/26 at 1338 hours, an interview was conducted with the Administrator and the DON. The Administrator and the DON acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's medical information was complete and accurate for one of three sampled residents (Resident 1). * The facility failed to ensure the turning and repositioning for Resident 1 was accurate. This failure had the potential to Resident 1 to receive inadequate care as the clinical information was not accurate.Findings: Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Review of the facility's P&P titled Prevention of Pressure Injuries dated 4/2020 showed reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary team. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. Teach the residents who can change positions independently the importance of repositioning. Provide support devices and assistance as needed. Remind and encourage residents to change positions. Closed medical record review for Resident 1 was initiated on 5/13/26. Resident 1 was readmitted to the facility on [DATE], and transferred to the acute care facility on 1/26/26. Review of Resident 1's Skin assessment dated [DATE], showed Resident 1 was readmitted to the facility with 12 wounds. Review of Resident 1's Order Summary Report showed a physician's order dated 1/2/26, to initiate dialysis schedule for Monday, Wednesday, and Friday at 1330 hours. Review of Resident 1's document titled SNF Wound Care dated 1/5/26, showed a wound practitioner's note for an evaluation and treatment for Resident 1's wounds. The document showed to change positions often to keep pressure off the wound, and spread body weight evenly with cushions, mattresses, pillows, foam wedges, or other pressure-relieving devices. Review of Resident 1's document titled Documentation Survey Report Turning and Repositioning very two hours and PRN for January 2026 showed the following:-dated 1/2/26 at 1321 hours, 1, indicating yes;-dated 1/7/26 at 1400 hours, 1, indicating yes;-dated 1/9/26 at 1326 hours, 1, indicating yes;-dated 1/12/26 at 1318 hours, 1, indicating yes;-dated 1/14/26 at 1326 hours, 1, indicating yes;-dated 1/16/26 at 1433 hours, 1, indicating yes;-dated 1/21/26 at 1312 hours, 1, indicating yes; and-dated 1/23/26 at 1445 hours, 1, indicating yes. On 5/19/26 at 1057 hours an interview and concurrent medical record review for Resident 1 was conducted with the ADON. The ADON stated Resident 1 would get picked up for dialysis on Mondays, Wednesdays, and Fridays at 1300 hours, and returned at 2000 hours. When asked if Resident 1 was repositioned when the resident was out for dialysis, the ADON stated no. On 5/19/26 at 1245 hours, an interview and concurrent medical record review for Resident 1 conducted with the DON. The DON verified the above findings. On 5/19/26 at 1338 hours, an interview was conducted with the Administrator and the DON. The Administrator and DON acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was implemented to reflect the individual care needs for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1's risk for fall interventions for bilateral floor mats were implemented. This failure posed the risk of not providing appropriate, consistent, or individualized care to the resident.Findings: Review of the P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed the comprehensive, person-centered care plan describes the services that are to be furnished to attain the resident's highest practicable physical, mental, and psychological well-being. Medical record review for Resident 1 was initiated on 2/11/26. Resident was readmitted to the facility on [DATE]. Review of Resident 1's SBAR for falls dated 1/28/26, showed Resident 1 had an unwitnessed fall and was found lying face down on the side of the bed. Review of Resident 1's care plan for risk for falls dated 1/28/26, showed interventions including bilateral floor mats to minimize injury in case of falls. Review of Resident 1's Morse Fall assessment dated [DATE], showed a score of 65. Further review showed a score of 45 and above indicated a high fall risk. On 2/17/26 at 0849 hours, during an observation of Resident 1, Resident 1 was noted with a round hematoma (a localized collection of clotted or partially clotted blood outside blood vessels, often causing a painful, raised, and bruised lump) on her forehead, dark purple bruising on both cheeks, chin, and the front of her neck. There were no floor mats seen in the room or on the floor next to the resident's bed. On 2/17/26 at 1113 hours, during an interview with Resident 1, Resident 1 stated the bump on her forehead was from the fall she had at the facility. On 2/17/26 at 1242 hours, an observation of Resident 1 and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 1 did not have floor mats in place and stated there should be floor mats due to her being a fall risk. On 2/17/26 at 1539 hours, the Administrator and the DON acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcer for one of five sampled residents (Resident 5). * The facility failed to update the physician's order for Resident 5's low air-loss mattress setting to the resident's current weight. This failure had the potential for the resident to develop pressure ulcers or worsening of existing pressure ulcer(s).Findings: Review of the facility's P&P titled Support Surface Guidelines revised 9/2013 showed redistributing support surfaces are to promote comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Medical record review for Resident 5 was initiated on 2/13/26. Resident 5 was readmitted to the facility on [DATE]. Review of Resident 5's Order Summary Report dated 9/19/25, showed a physician's order to implement a low air-loss mattress for wound care and management. The setting was set for 99 lbs. every shift. Review of Resident 5's Weights and Vitals Summary dated 2/1/26, showed the resident weighed 115 lbs. Review of Resident 5's Skin assessment dated [DATE], showed Resident 5 had surgical wound on her left buttock. Further review showed the resident was on a low air-loss mattress that was functioning properly. On 2/13/26 at 0958 hours, during an observation in Resident 5's room, Resident 5's low air-loss mattress setting was set at 120 lbs. On 2/17/26 at 1440 hours, an observation and concurrent medical record review for Resident 5 was conducted with the ADON. The ADON verified Resident 5's low air-loss mattress was set at 120 lbs. The ADON verified the physician's order and low air-loss mattress setting were not updated to reflect Resident 5's current weight of 115 lbs. On 2/17/26 at 1539 hours, the Administrator and the DON acknowledged the above findings.

Based on interview, facility document review, and facility P&P review, the facility failed to thoroughly investigate the results of a background screening of a Medi-Cal excluded employee for one of two facility staff reviewed (RNA 1). * The facility failed to thoroughly investigate the exclusion status of a direct access employee that appeared on the new-hire background screening. This failure had the potential to compromise the safety of the residents in the facility.Findings: Review of the facility's P&P titled Background Screening Investigations revised [DATE] showed the following:- The facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents ( direct access employees).- For any individual applying for a position as a certified nursing assistant, the state nurse aide registry is contacted to determine if any findings of abuse, neglect, mistreatment of individuals, and/or theft of property have been entered into the applicant's file.- Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse, neglect, mistreatment of individuals, and/or misappropriation of property, the applicant is not employed or contracted. On [DATE] at 1314 hours, a review of the employment file for RNA 1 was conducted. The employment file showed a hire date of [DATE]. The CNA license number for RNA 1 was effective [DATE], and showed a status of ACTIVE, EMPLOYABLE. However, during the new hire background screening process in 2023, a second CNA license for the same name was found under license number, effective [DATE] and had expired on [DATE], with a status of REVOKED, NOT EMPLOYABLE. On [DATE] at 1342 hours, an interview and concurrent employment file review was conducted with the DSD. The DSD stated there was a new hiring process under the new facility management, and the background screening process was no longer managed by the DSD. The DSD verified the background screening of RNA 1 was completed before she began her employment with the facility. However, the DSD verified under the former background screening process, if an employee showed up as excluded during the background screening, she would attempt to clear the employee's name by adding additional information to the screening such as the Social Security Number and the date of birth or residential addresses, to verify if it was the same employee. The DSD verified this process was not followed during the background screening process of RNA 1 in 2023. On [DATE] at 1423 hours, an interview and concurrent employment file review was conducted with the DSD, Administrator, DON, and Recruitment Lead, who joined via telephone. The Administrator verified the new employees needed to pass the background screening before they could begin orientation at the facility. If the employee did not pass the background screening, the offer of employment would be rescinded. The Recruitment Lead verified under the new screening process, if an employee showed up on the excluded list, the employee would not be considered for employment. The Recruitment Lead stated they could not speak about what happened during the original hiring process of RNA 1 in 2023 but for this situation, since RNA 1 was already hired, the facility would conduct a repeat background screening under the new process to determine RNA 1's eligibility for employment. On [DATE] at 1034 hours, a follow up interview was conducted with the Administrator and Recruitment Lead, who joined via telephone. The Recruitment Lead verified a rigorous background screening process was conducted on RNA 1, which revealed RNA 1 was on the Medi-Cal exclusion list. On [DATE] at 1047 hours, an interview was conducted with the Administrator, DON, and RNA 1, who joined via telephone and an interpreter was used. RNA 1 verified in 2009 he worked under a previous CNA license number but used a fraudulent Social Security Number to obtain this CNA license. RNA 1 stated he then obtained a legal Social Security Number and used it when he applied for his current CNA license.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of three sampled residents (Resident 3) was revised to reflect the resident's current care needs and interventions. The facility failed to revise Resident 3's care plan to address the new interventions related to the management of weight loss. This failure posed the risk of not providing the resident with individualized and person-centered care.Findings: Review of the facility's P&P titled Care Plan, Comprehensive dated 12/2017 showed the care plans should be developed by the Interdisciplinary Team (IDT), which includes activities, dietary, nursing management, social services, and therapy and includes the input from the direct care staff, including the licensed nurses and nursing assistants. The plans are reviewed and revised by the IDT at least quarterly, following completion of the MDS assessment or following an assessment for a significant change of condition. Medical record review for Resident 3 was initiated on 7/17/25. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed the resident had a BIMS score of 5, indicating severe cognitive impairment. Review of Resident 3's monthly weight report showed the following:- on 1/2, 2/3, and 3/3/25, Resident 3's weight was 123 lbs;- on 4/30, 5/6, and 6/2/25, Resident 3's weight was 122 lbs;- on 7/3 and 7/7/25, Resident 3's weight was 115 lbs; and- on 7/14/25, Resident 3's weight was 119 lbs. Review of Resident 3's SBAR Communication Form dated 7/3/25, showed Resident 3 had a weight loss of seven pounds in one month from June to July 2025. Review of Resident 3's Order Review Report dated 7/17/25, showed the following physician's orders:- dated 7/3/25, to obtain the resident's weekly weight for four weeks; and- dated 7/3/25, to administer megestrol acetate (appetite stimulant) suspension 400 mg/10 ml by mouth two times a day for appetite stimulant. Review of Resident 3's plan of care dated 7/17/25, showed a care plan problem addressing the resident's seven pound weight loss in one month. However, the care plan failed to include the interventions of weekly weight for four weeks and the administration of the appetite stimulant medication as ordered by the physician. On 7/17/25 at 1345 hours, an interview and concurrent medical record review for Resident 3 was conducted with the LVN 3. LVN 3 verified the above findings and stated Resident 3's care plan should be revised to reflect the current interventions for the management of the resident's weight loss. On 7/17/25 at 1430 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of the medications. * The facility failed to ensure the temperature of Medication Storage room [ROOM NUMBER] was maintained within the acceptable range as per the facility's document. * The facility failed to ensure two open vials of tuberculin purified protein (used as a diagnostic test for inactive TB infection) were observed without an open date in the medication fridge in Medication Storage room [ROOM NUMBER]. * The facility failed to ensure the expired IV medications for Resident 37 were removed from the medication refrigerator in Medication Storage room [ROOM NUMBER]. * The facility failed to ensure timely restocking of the opened e-kit (container of medications to be readily available in the event of an emergency) in the medication refrigerator in Medication Storage room [ROOM NUMBER]. * The facility failed to ensure the medication refrigerator in Medication Storage room [ROOM NUMBER] had a thermometer. * The facility failed to ensure two soiled boxes of Microdot glucose gel 40% w/w (fasting acting gel used to raise blood sugar levels) were removed from Medication Storage room [ROOM NUMBER]. * The facility failed to ensure the expired, opened, and soiled supply packages were removed from Medication Cart 1. * The facility failed to ensure proper labeling of the opened box of artificial tears (lubricating eye drops used to relieve dry eyes and discomfort) in Medication Cart 3. * The facility failed to ensure no loose medication tablet and capsules in Medication Cart 3. * The facility failed to ensure the medication for Resident 86 in Medication Cart 2 had a visible expiration date. * The facility failed to ensure the complete and accurate labeling of two insulin pens stored in Medication Cart 2. * The facility failed to ensure the liquid medication bottles were clean, without sticky residue, in Medication Cart 2. * The facility failed to ensure the complete disposal of the four tablets and one capsule in the pharmaceutical waste bin. These failures had the potential for expired or deteriorated medications to be administered to the residents. Findings: Review of the facility's P&P titled Medication Storage in the Facility ID1: Storage of Medications revised ,d+[DATE] showed the medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy, or staff members lawfully authorized to administer medications. All medications dispensed by the pharmacy are stored in the box, bag, or container with the pharmacy label. Medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication, and reordered from the pharmacy, if a current order exists. Review of the facility's document titled Temperature Log for Refrigerator - Fahrenheit dated [DATE] showed the acceptable parameters for the temperature of Medication Storage room [ROOM NUMBER] was between 59 degrees F and 77 degrees F. 1. On [DATE] at 1510 hours, an inspection of Medication Storage room [ROOM NUMBER] and concurrent interview was conducted with RN 2. The following was observed: - the temperature of Medication Storage room [ROOM NUMBER] was 78 degrees F; - two vials of opened tuberculin purified protein in the medication fridge were not labeled with an open date; - three bags of the IV medication for Resident 37 were stored in the medication refrigerator with discard dates of ,d+[DATE], ,d+[DATE], and [DATE]; and - one opened refrigerated e-kit with an open date of [DATE]. RN 2 verified the above findings. On [DATE] at 0956 hours, a follow-up inspection of Medication Storage room [ROOM NUMBER] was conducted with RN 2. The temperature of the medication storage room was observed at 78 degrees F. The medication refrigerator was observed without a thermometer. RN 2 verified the findings and stated all the medication refrigerators should have a thermometer to ensure the medications were stored at the correct temperatures. On [DATE] at 0945 hours, an inspection of Medication Storage room [ROOM NUMBER] was conducted with the Unit Manager. Two boxes of Microdot Glucose Gel 40% w/w (rapidly absorbed glucose gel) were observed soiled with a clear, sticky residue. The Unit Manager verified the findings and stated all the medications were to be stored clean, dry, and free from a residue. 2. On [DATE] at 1030 hours, an inspection of Medication Cart 1 was conducted with the Unit Manager. The following was observed: - one box of 100 multifunction sterile red caps (used to cap syringes) with an expiration date of ,d+[DATE]; - one BD female Luer-Lok cap (used to cap syringes) with an expiration date of [DATE]; - one BD female Luer-Lok cap with an expiration date of [DATE]; - 25 BD female Luer-Lok caps with an expiration date of [DATE]; - one Prevantics antiseptic wipe (used to clean the skin and prevent infection prior to IV insertion) with an expiration date of ,d+[DATE]; - one package of povidine iodine (helps prevent infection in minor cuts, scrapes and burns) antiseptic swab sticks with expiration date of [DATE]; - one package of opened vitamin A&D ointment (moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations); and - one vented micro micro-spike adapter (used to transfer medication from glass vials) package with yellow staining. The Unit Manager verified the above findings. 3. On [DATE] at 1052 hours, an inspection of Medication Cart 3 was conducted with LVN 3. The following was observed: - one bottle of levocetirizine dihydrochloride (medication used to treat allergy symptoms) 5 mg tablets with no visible expiration date; - one box of opened artificial tears (eye drop) was observed labeled with Room B and no resident name; - one loose tablet in the bottom right drawer; and - two loose capsules in the third left drawer. LVN 3 verified the above findings. 4. On [DATE] at 1228 hours, an inspection of Medication Cart 2 was conducted with the Unit Manager. The following was observed: - one insulin Lantus (long-acting insulin, specifically insulin glargine, used to manage blood sugar levels in adults and children with type 1 or type 2 diabetes) 100 units per ml for Resident 94 labeled with an open date of [DATE], and expiration date of [DATE]; - one insulin Lispro (rapid-dacting insulin used to manage blood sugar in adults and children with type 1 or type 2 diabetes) 100 unit/ml pen for Resident 121 observed without an expiration date; - one bottle of potassium chloride (supplement) was observed with sticky orange residue; and - one bottle of lactulose 10 mg/15 ml solution with sticky white residue. The Unit Manager verified the above findings. The Unit Manager verified the expiration date of insulin should be within 28 days of the open date, and expiration dates were to be written on all the insulin pens. The Unit Manager stated the insulin pen for Resident 94 should have been labeled with an expiration date of [DATE]. 5. On [DATE] at 1047 hours, an inspection of the pharmaceutical waste bin located in the biohazard room was conducted with the DON and ADON. Four loose tablets and one loose capsule were observed on top of the locked pharmaceutical disposal bin. The ADON and DON verified the presence of the loose tablets and capsules. The ADON and DON were unable to identify the medications.

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure proper labeling and dating of food in the kitchen. * The facility failed to ensure the dented cans were sorted away from the intact cans. * The facility failed to ensure the food in the walk-in refrigerator was stored in a sanitary manner. * The facility failed to ensure the kitchen cooking equipment was air dried. * The facility failed to ensure the food preparation equipment was clean. * The facility failed to ensure the cutting board was free of corrosion. * The facility failed to ensure the maintenance tools were stored properly. * The facility failed to ensure there was a designated refrigerator to store the residents' food from the outside. * The facility failed to ensure the residents' food from the outside in the employees' lounge refrigerator was properly labeled and dated. * The facility failed to ensure the refrigerator which stored the residents' food from the outside contained a thermometer was monitored for the temperature and recorded in the temperature log. * The facility failed to ensure the food was not kept on the steam table two hours prior to tray line. * The facility failed to ensure the low temperature dishwasher had a wash and rinse temperature of 120 degrees F. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility's document titled Resident Count by Diet Order Report dated 5/7/25, showed 133 of 137 residents received food which was prepared in the facility's kitchen. 1. On 5/7/25 at 0809 hours, an initial tour of the kitchen was conducted with the DON. On the bread rack, one opened package of English muffins was observed with two opened dates, 5/4/25 and 5/6/25. The DON verified the findings and stated the food should be labeled with the open and expiration dates. 2. Review of the facility's P&P titled Food Safety in Receiving and Storage dated 2/2009 showed the food will be inspected when it is delivered to the facility and prior to storage for signs of contamination. Examples of signs of contamination include dents. Dented cans are kept in a designated location labeled dented cans until the vendor can pick them up. On 5/7/25 at 0809 hours, an initial tour of the kitchen was conducted with the DON. In the dry storage area, one dented can of diced red peppers was observed stored with the intact cans, not separated into the designated area for dented cans. The DON verified the findings. 3. Review of the facility's P&P titled Food Safety in Receiving and Storage dated 2/2009 showed the food that is repackaged will be placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container will be labeled with the name of the contents and dated with the date it was transferred to the new container. On 5/7/25 at 0809 hours, an initial tour of the kitchen was conducted with the DON. Inside the walk-in refrigerator, one opened package of sliced turkey breast was observed to be stored inside a colander and partially covered on the top with foil. The DON verified the findings and later asked a kitchen staff member to throw away the turkey breast. 4. According to the USDA Food Code 2022 Section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried. Review of the facility's P&P titled Manual Cleaning and Sanitizing dated 2/2017 showed to allow all the equipment, utensils, etcetera to drain and air-dry. On 5/7/25 at 0809 hours, an initial tour of the kitchen was conducted with the DON. The following was observed: - Three plastic containers which contained scoops, pitcher lids, and a smaller plastic container which were dripping wet. There was water observed at the bottom of each of the plastic containers and - A stack of plate domes were stacked and stored wet. The DON verified the above findings. 5. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, for materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be safe, durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. According to the USDA Food Code 2022 Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's P&P titled Manual Cleaning and Sanitizing dated 2/2017 showed the pot and pan equipment and cooking utensils are cleaned and sanitized appropriately after use. a. On 5/7/25 at 0809 hours, an initial tour of the kitchen was conducted with the DON. The following was observed: - The microwave in the kitchen was observed with brown scattered residue all over the top wall and sides; - Stacked clear cups with a white stain on the inside coating; - A knife stored on the clean knife block, with a green dried food residue on it; - The can opener was stored, there was a brown and orange dry residue observed on the blade; - One ladle and one tong with melted handles; and - Plate warmer was observed with dry brown scattered residue all over the bottom of the warmer. Two gloves were observed on the right side of the warmer. The DON verified the above findings and stated she would have the staff clean it. b. On 5/7/25 at 0900 hours, a concurrent observation and interview was conducted with the Activities Director in the facility's employee lounge. There were two refrigerators in the employee lounge. One refrigerator was observed to contain employee's food being stored with resident labeled food items. The refrigerator was observed with brown stains and dry brown residue on the bottom and the back of the refrigerator wall. The Activities Director stated the housekeeping was responsible to clean the refrigerator and verified the refrigerator was not clean. The Activities Director stated they heated up the resident's food in the employee lounge microwaves and there was no separate microwave for the residents. Both microwaves were observed with brown and yellow dried residue on the top and the walls of the microwave. The Activities Director verified the findings. 6. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 5/7/25 at 0834 hours, an initial tour of the kitchen was conducted with the DON. One green cutting board was heavily marred on both sides and melted on one side. The DON verified the findings and stated she would have the staff replace it. 7. According to the USDA Food Code 2022 Section 6-501.113, .Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be (B)Stored in an orderly manner that facilitates cleaning the area used for storing the maintenance tools. On 5/7/25 at 0845 hours, a concurrent observation and interview was conducted with the DSS. In the kitchen chemicals closet, four brooms were observed stored on the floor. The DSS verified the findings. The DSS was observed to hang all of the brooms off of the floor. 8. Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors revised 8/2023 showed the facility may refrigerate labeled/dated prepared items in a designated unit or pantry refrigerator. On 5/7/25 at 0900 hours, a concurrent observation and interview was conducted with the Activities Director in the facility's employees lounge. There were two refrigerators in the employees lounge and the Activities Director verified there was no designated refrigerator for the residents. One refrigerator was observed to contain employees' food being stored with resident labeled food items. The Activities Director verified the employee's food was stored together with the resident's food. The Activities Director stated they used one of the two microwaves in the employees lounge to heat up the residents' food. The Activities Director verified there was no separate microwave for the residents. On 5/7/25 at 0913 hours, a concurrent observation and interview was conducted with the DON and Administrator in the facility's employees lounge. The DON and Administrator observed and verified the resident's food from the outside was being stored in a refrigerator located in the employees lounge, not designated for the residents. On 5/7/25 at 0925 hours, an observation and concurrent interview was conducted with the DSD. The DSD verified there was no resident specific microwave and stated they should have one. 9. Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors revised 8/2023 showed prepared food items brought in by the resident's family or visitors must be labeled and dated. The facility may refrigerate labeled/dated prepared items in a designated unit or pantry refrigerator. On 5/7/25 at 0900 hours, a concurrent observation and interview was conducted with the Activities Director in the facility's employees lounge. One refrigerator was observed to contain employees' food being stored with resident labeled food items. The following was observed: - one plastic bag with undated food containers for Resident 44; - one unlabeled container filled with cut beets; - one pan covered with saran wrap containing an unlabeled partially eaten salad; - one undated box of half eaten pizza for Resident 97; - one unlabeled bag with cooked meat inside; - one unlabeled container of soup, unlabeled; - one unlabeled bag with a wet brown wrapped item; and - a bag filled with containers of undated food for Resident 98. The Activities Director verified the above findings. On 5/7/25 at 0925 hours, an observation and concurrent interview was conducted with the DSD. The DSD verified the residents' food from the outside was kept in one of the refrigerators in the employee lounge. The DSD stated the CNAs would place the residents' food in the refrigerator. The DSD stated she instructed the CNAs to write the last name, first initial of the resident, and date on the food item. 10. Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors revised 8/2023 showed refrigeration units will have internal thermometers to monitor safe storage temperatures. The staff will monitor unit refrigerators daily. The units will be assessed for temperature adjustment/repair needs. On 5/7/25 at 0900 hours, a concurrent observation and interview was conducted with the Activities Director in the facility's employees lounge. One refrigerator was observed to contain employees' food being stored with the resident labeled food items. There was no thermometer observed inside the refrigerator or freezer which contained the resident's food items. The Activities Director verified the findings. On 5/7/25 at 0910 hours, a concurrent observation and interview was conducted with the Maintenance Director in the facility's employee lounge. The Maintenance Director verified there was resident food items being stored inside one of the refrigerators in the lounge. The Maintenance Director verified there was no thermometer located inside the refrigerator used to store the residents' food and verified there was no temperature log to monitor the temperatures. 11. Review of the facility's P&P titled Safe Food Temperatures dated 2/2009 showed food is not put on the steam table more than 30 minutes prior to the start of the meal service. On 5/8/25 at 1057 hours, a concurrent observation and interview was conducted with [NAME] 2. [NAME] 2 stated she had already made the Vietnamese menu puree and showed three covered trays which were placed inside the steam table. [NAME] 2 stated she made the pureed foods at 0945 hours. [NAME] 2 stated the steam table was kept at over 170 degrees F. On 5/8/25 at 1200 hours, during the lunch trayline observation, the Vietnamese menu stir fry vegetable puree was being served by [NAME] 2. On 5/13/25 at 1053 hours, an interview was conducted with the DSS. The DSS stated the foods would be placed on the steam table 30 minutes before trayline. The DSS was informed of the findings and acknowledged the findings. 12. According to the USDA Food Code 2022 Section 4-501.15 Warewashing Machines, Manufacturers' Operating Instruction, to ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. According to the USDA Food Code 2022 Section 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. The wash solution temperature in mechanical warewashing equipment is critical to proper operation. The chemicals used may not adequately perform their function if the temperature is too low. Therefore, the manufacturer's instructions must be followed. The temperatures vary according to the specific equipment being used. Review of the facility P&P titled Dish Machine Usage dated 2/2009 showed to wash the dishes in dish machine according to equipment directions. Review of the Machine Operational Requirements label dated 1/2009 affixed onto the facility's dish machine showed the wash and rinse temperature should be a minimum of 120 degrees F. On 5/12/25 at 0900 hours, an observation was conducted of the facility's dish machine. Dietary Aide 2 was observed clearing dirty dishes, Dietary Aide 1 was observed washing and placing the dishes through the dish machine, and Dietary Aide 3 was observed to place the put away the clean dishes. Dietary Aide 1 was observed to place crates of trays, plates, plate covers through the dish machine and Dietary Aide 3 was observed to stack and put them away. On 5/12/25 at 0924 hours, a concurrent observation and interview was conducted with Dietary Aide 1. Dietary Aide 1 was asked how she ensured the dish machine was working properly. Dietary Aide 1 stated the temperature should be at 120 - 120 degrees F. Four wash cycles were observed. The temperature on the thermometer of the dish machine read the following during the observations: 102 degrees F, 100 degrees F, 102 degrees F, and 110 degrees F. Dietary Aide 1 then stopped placing dishes through the machine. On 5/12/25 at 0937 hours, a concurrent observation and interview was conducted with the Maintenance Assistant and Maintenance Director. The Maintenance Assistant stated the dish machine temperature should be at 120 degrees F. The Maintenance Assistant was observed to press a button on the dish machine to cycle hot water, ran a dish cycle, then showed the dish machine temperature increased to 120 degrees F. The Maintenance Director stated the staff had to constantly bring the hot water into the machine from the pipes before washing and then start washing the dishes once it reached 120 degrees F. The Maintenance Director stated whatever water was sitting in the pipes was not being heated by the water heater and stated the staff did not flush the dish machine prior to starting the wash. Afterwards, the DSS was informed of the findings. The DSS acknowledged the above findings and stated the staff had to flush the dish machine frequently. The DSS stated they would have to rewash the dishes because it was not the right temperature to be safe for sanitization.

Based on observation, interview, and facility P&P review, the facility failed to ensure the education on safe food handling of outside food was provided to the residents and visitors as per the facility's P&P. In addition, the facility failed to ensure food brought to the facility by the family member were stored, and safe food handling practices were followed for one nonsampled resident (Resident 538). These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from the outside sources. Findings: Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors revised 8/2023 showed it is the facility policy to honor a Resident's Right to have food brought in by family or other visitors, however, food must be handled and stored in a way to facilitate safety. Family members or other visitors may bring the resident food of their choosing. The staff will provide information on safe food storage and handling as deemed appropriate to resident and/or family. The resident and/or resident's representative are responsible for maintaining bedside food storage containers and contents in a safe/sanitary manner. 1. On 5/7/25 at 0913 hours, a concurrent observation and interview with the DON and Administrator was conducted in the facility's employee lounge. The DON and Administrator observed and verified the residents' food brought from the outside was being stored in a refrigerator located in the employees' lounge, not designated for the residents. The Administrator stated the facility did not have a resident refrigerator, the residents were not supposed to put the food in the refrigerator, and they were not supposed to keep any resident food. On 5/12/25 at 1455 hours, an interview was conducted with the Admissions Coordinator. The Admissions Coordinator stated the activities or the kitchen staff would provide the resident's family member safe food handling education. The Admissions Coordinator verified the facility's admission packet did not include information regarding safe food handling. On 5/12/25 at 1505 hours, an interview was conducted with the Activities Director. The Activities Director stated she did not provide education to the families regarding safe food handling. The Activities Director stated the DSD would educate the CNAs to talk to the residents' family members about safe food handling. On 5/12/25 at 1534 hours, an interview was conducted with LVN 7. LVN 7 stated for the residents whose family bring food from the outside, she would educate them if the resident was diabetic. LVN 7 stated she had not been educated or had educated the family about safe food handling practices. On 5/12/25 at 1542 hours, an interview was conducted with CNA 5. CNA 5 stated she would educate the resident's family to label the food and put it in the refrigerator. CNA 5 stated she did not know about safe food handling and did not remember if she had received the education. On 5/13/25 at 0807 hours, an interview was conducted with the Assistant Receptionist. The Assistant Receptionist stated she did not teach or give a hand out to the residents' family/visitors about safe food handling. On 5/12/25 at 0823 hours, an interview was conducted with LVN 8. LVN 8 stated when the resident's family brought food from the outside for the resident, she told them that the food depended on the resident's diet and restrictions and they could not leave the meals in the facility. LVN 8 stated she had not had any in-service education about safe food handling and assumed the family did safe food handling. On 5/13/25 at 0836 hours, an interview was conducted with the DSS. The DSS stated she did not provide the residents' families education about safe food handling and did not know who provided the education. On 5/13/25 at 0905 hours, an interview was conducted with the DSD. The DSD stated she did not provide the families education about safe food handling and the staff could provide the education if they are asked. On 5/13/25 at 0930 hours, an interview was conducted with the DON. The DON verified she did not provide education to the resident's family regarding safe food handling. 44175 2. On 5/7/25 at 0909 hours, an observation and concurrent interview was conducted with Resident 538. Resident 538 was lying in bed. There were unlabeled cooked sweet potatoes with sauce in a disposable paper cup, and peeled oranges in a closed plastic container stored on the bedside table (in room temperature) at the right side of Resident 538's bed. Resident 538 stated the food was brought in by her family the night before and she was planning to consume it later. Resident 538 stated the staff came into her room multiple times and was not sure if they noticed the food stored at her bedside. Resident 538 did not remember if the facility provided education on how to safely handle the food brought in from outside to her or her family member. Medical record review for Resident 538 was initiated on 5/7/25. Resident 538 was admitted to the facility on [DATE]. Review of Resident 538's MDS assessment dated [DATE], showed Resident 538 was cognitively intact. Review of Resident 538's medical record did not show if education on safe food handling for the foods brought in by the resident's family was provided to Resident 538. On 5/7/25 at 0916 hours, an observation and concurrent interview with the Unit Manager. The Unit Manager verified the above observation. The Unit Manager stated the food brought in by the family should be consumed immediately or thrown out and should not be stored at the bedside. On 5/9/25 at 0925 hours, an interview and concurrent medical record review for Resident 538 was conducted with the ADON. The ADON was informed of the above findings. The ADON stated the facility did not have the refrigerator to store food for the residents' food items brought in by the family. The ADON also verified there was no documented evidence if the education on safe food handling for the food items brought in by family was provided to Resident 538. On 5/9/25 at 1408 hours, the DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review and facility P&P review, the facility failed to maintain the infection prevention control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to implement the infection control monitoring and surveillance for April 2025. * The facility failed to perform legionella testing per the facility's Legionella Water Management Program frequency. * The facility failed ton ensure Resident 131's contact enteric precautions were followed. * Staff''s personal cell phone was stored in the treatment cart with the residents' treatment supplies. * Staff placed their face-shield on top of an upside-down dirty linen cart lid. * CNA 1 failed to don the gown when providing high-contact care to Resident 38 who was on EBP. * The facility failed to ensure residents' clean clothes were transported in a way that maintained infection control. * Two of four LVNs (LVNs 4 and 6) observed for medication administration did not follow proper hand hygiene procedure. * The tip of the eye medication dropper touch Resident 40's eyelashes during the medication administration. * The back side of the glucometer (medical device for determining the approximate concentration of glucose in the blood) for Medication Cart 2 was observed with red-brown smudges. These failures posed the risk for transmission of disease-causing microorganisms and infections. Findings: 1. On 5/13/25 at 0800 hours, a concurrent interview and review of the facility's IPCP was conducted with the IP. The IP stated the process was to review the residents' antibiotic orders as soon as possible to determine if their suspected infection met Loeb's Criteria (a set of minimum symptoms and signs used to guide the decision-making process for initiating antibiotic therapy in long-term care settings) or McGeer's Criteria (a set of specific definitions to identify true infections in long term nursing facilities). Infections are monitored for trends to determine if an outbreak occurs, or needed education on infection control practices. Review of the facility's antibiotic report for April 2025 showed 25 antibiotics were ordered for suspected infections. The IP stated she did not review the residents' suspected infections for April, to determine if they met criteria. The list showed Resident 123 started piperacillin sodium tazobactam (antibiotic) on 4/30/25. The IP reviewed Resident 123's records and verified the resident did not meet either Loeb's or McGeer's Criteria for infection. The IP verified since she did not review any residents with antibiotic orders for suspected infections in April previously, other residents with suspected infections might not have met criteria. 2. Review of the facility's Legionella Water Management Program showed Legionella testing will be performed quarterly. Legionella testing results were dated 2/14/24 and 3/25/25. On 5/9/25 at 1035 hours, an interview and facility document review was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated Legionella testing was conducted annually on 2/14/24 and 3/25/25. The Maintenance Supervisor reviewed the Legionella Water Management Program binder and verified the program showed testing would be done quarterly, and had not been. 3. Medical record review for Resident 131 was initiated on 5/7/25. Resident 131 was admitted to the facility on [DATE]. Review of Resident 131's Order Summary Report showed a physician's order dated 4/23/25, for contact enteric precaution for C. diff (Clostridium difficile-a contagious bacteria that can cause inflammation of the colon) toxin. On 5/7/25 at 0838 hours, an observation and concurrent interview was conducted with the Optometrist at Resident 131's bedside. The Optometrist was observed at the resident's bedside, in a mask, face shield, gown and gloves, in contact with the resident and other surfaces in the resident's room, including the edge of the bed and a bedside tray table. A sign was posted at the resident's doorway which showed for contact enteric precautions and instructed people to wash their hands with soap and water upon leaving the room. The Optometrist stated they were informed by the facility staff that the resident had isolation precautions for a UTI, not C. diff. The Optometrist was observed removing her isolation gown and gloves, and using ABHR for hand hygiene when leaving the room. The Optometrist then donned a new isolation gown and gloves, and entered another resident's room, went to their bedside, and examined the resident. The Optometrist's Assistant stated they were informed by the resident's nurse from the previous shift that Resident 131 was in isolation for a urinary tract infection, and not C. diff. On 5/7/25 at 0855 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated Resident 131 had contact enteric precautions for C. diff, and the staff and visitors should wash their hands with soap and water when leaving the room. 4. On 5/9/25 at 1054 hour, a wound care observation for Resident 8 was conducted with LVN 2. While LVN 2 gathered the supplies from the treatment cart, a cell phone was observed being stored in the top drawer with the treatment supplies. LVN 2 stated it was her personal cell phone and verified it should not be stored in the medication cart. The LVN stated there was also a wound care team cell phone, which the LVN was storing in her pocket. On 5/9/25 at 1115 hours, an interview was conducted with the DON. The DON stated the personal cell phones should not be stored in the treatment or medication carts for infection control. 5. On 5/9/25 at 0859 hours, a laundry area inspection was conducted with the Maintenance Supervisor and Janitor. Upon entering the dirty linen area, the Janitor was observed wearing a gown and face-shield, putting a clean liner in the dirty linen cart. The Janitor removed his face-shield, placed it on the upside-down dirty linen cart lid, and washed his hands. The Janitor then picked up the mask and placed it on a hook. The Janitor and Maintenance Supervisor verified the face-shield should not be placed on the contaminated surface of the dirty linen cart lid. 48882 6. Review of the facility's P&P titled Infection Prevention Manual for Long Term Care, revised 5/2024 showed it is the policy of the facility to implement enhanced barrier precautions when indicated for the prevention of transmission of multi drug- resistant organisms. The EBP refer to an infection control intervention designed to reduce the transmission of multidrug- resistant organisms that employ targeted gown and gloves use during high contact resident care activities. PPE for EBP is only necessary when performing high-contact care activities. High-contact Resident care activities may include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens. On 5/7/25 at 0803 hours, during the initial tour of the facility, an EBP sign was observed posted outside of Resident 38's room alerting the providers and staff to wear gloves and gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, and wound care. A E sticker was observed placed next to Resident 38's name. On 5/7/25 at 0908 hours, CNA 1 was observed turning Resident 38 on his left side to reposition the sheet under Resident 38. CNA 1 was then observed putting on a new gown for Resident 38. CNA 1 was not observed wearing a gown. On the ground, next to Resident 38's bed were two clear bags containing soiled linen inside. On 5/7/25 at 0918 hours, an interview was conducted with CNA 1. CNA 1 stated she was changing Resident 38's linen and sheets and was proving care to him. When asked about the facility's EBP protocol, CNA 1 stated for the residents who were on EBP, a sign would be placed outside of the resident's door and an E sticker would be placed next to the resident's name to notify staff when EBP should be followed. CNA 1 further stated for the residents on EBP, the staff should don a gown and gloves when providing care, changing, providing showers, and repositioning the resident. When asked if Resident 38 was on EBP, CNA 1 stated Resident 38 was on EBP due to the wound on his heel. CNA 1 verified she did not don a gown when providing care to Resident 38 and stated she should have worn a gown. Medical record review for Resident 38 was initiated on 5/7/25. Resident 38 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 38's H&P examination dated 10/22/24, showed Resident 38 had no capacity to make medical decisions. Review of Resident 38's Order Summary Report showed a physician's order dated 4/1/25, for EBP every shift for the left hallucial diabetic wound. On 5/12/25 at 1410 hours, an interview was conducted with the DON. The DON stated the facility staff were expected to wear a gown and gloves when entering the room, to provide direct care to the residents who were on the EBP. On 5/13/25 at 1207 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 47474 7. Review of the facility's P&P titled Laundry Manual - General Policy (undated) showed the clean linen shall be stored, handled, and transported in a way that precludes cross-contamination. On 5/9/25 at 1023 hours, during an observation, Laundry Assistant 1 transported an uncovered laundry cart containing the residents' clean clothes down the hallway near rooms [ROOM NUMBERS]. The laundry cart was stationed across from room [ROOM NUMBER] and exposed with residents' clean clothes touching the handrails. On 5/9/25 at 1026 hours, an observation and concurrent interview with Laundry Assistant 1 was conducted next to the laundry cart. Laundry Assistant 1 requested for CNA 7 be present during the interview to interpret. Laundry Assistant 1 verified the findings. Laundry Assistant 1 verified she had the laundry cart opened while transporting it down the hallway and verified the residents' clothes were touching the handrails. Laundry Assistant 1 further stated the laundry cart should have been closed to prevent contamination of the clean clothes. On 5/13/25 at 1208 hours, an interview was conducted with the Administrator and the DON. The Administrator and DON were informed and acknowledged the above findings. 51352 8. Review of the facility's P&P titled Review of the facility's P&P titled Preparation and General Guidelines IIA2: Medication Administration - General Guidelines revised 11/2021 showed the person administering the medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic preparations, and medications given via enteral tubes. On 5/7/25 at 0802 hours, the GT medication administration observation was conducted for Resident 102 with LVN 6. LVN 6 donned gloves and used Super Sani-Cloth sanitizing wipes to disinfect the BP cuff, tubing, and machine. LVN 6 doffed the gloves. LVN 6 did not perform hand hygiene after doffing the gloves. LVN 6 unlocked Medication Cart 2 and removed the glucometer, lancet (small, sharp, single-use device typically used to prick a finger to obtain a small blood sample for testing), and glucometer test trips and put the items on a tray. LVN 6 picked up the tray and entered Resident 102's room without performing hand hygiene. LVN 6 donned gloves and adjusted the prongs of Resident 102's nasal cannula (flexible tube to deliver oxygen into the nose). LVN 6 did not change her gloves or perform hand hygiene. LVN 6 wiped Resident 102's left ring finger with an alcohol swab for a few seconds. LVN 6 used the lancet on Resident 102's finger and obtained a blood sugar reading from Resident 102. LVN 6 doffed the gloves. LVN 6 left the room without performing hand hygiene. LVN 6 walked to the medication cart at Resident 102's doorway. LVN 6 entered Resident 102's room without performing hand hygiene, picked up Resident 102's remote from the floor, and placed the remote on Resident 102's bed. LVN 6 left the room without performing hand hygiene and walked to Medication Cart 2. LVN 6 donned clean gloves and used Super Sani-Cloth sanitizing wipes to disinfect the BP cuff, tubing, and machine. LVN 6 washed her hands in Resident 102's bathroom. LNV 6 prepared Resident 102's medications. LVN 6 used alcohol-based hand rub, donned a gown, and entered Resident 102's room with the medications. LVN 6 placed the medications on the bedside table and walked out of Resident 102's room without performing hand hygiene. LVN 6 walked to Medication Cart 2, took a pair of clean gloves, and entered Resident 102's room. LVN 6 did not perform hand hygiene before entering Resident 102's room. LVN 6 donned gloves and pulled the privacy curtain in preparation for the medication administration for Resident 102. LVN 6 left the room to walk to Medication Cart 2. LVN 6 did not perform hand hygiene when she left the room. LVN 6 doffed her gloves, picked up the stethoscope from Medication Cart 2 and entered Resident 102's room. LVN 6 did not perform hand hygiene prior to entering Resident 102' room. LVN 6 used Super Sani-Cloth sanitizing wipes to disinfect the stethoscope. LVN 6 donned gloves and began the medication administration for Resident 102. LVN 6 did not perform hand hygiene after using ungloved hands to sanitize the stethoscope or before she began the medication administration for Resident 102. On 5/7/25 at 1236 hours, a follow-up interview was conducted with LVN 6. LVN verified the staff should wash their hands or used alcohol-based hand rub prior to any medication administration. LVN 6 verified the staff should have washed her hands before donning gloves, after doffing gloves, and between tasks. 9. Review of the facility's P&P titled Specific Medication Administration Procedures IIB5: Eye Drop Administration revised 6/2021 showed the staff wash hands before and after the procedure. The tip of the dropper must not touch the eye or any other surface. On 5/7/25 0858 hours, a medication administration observation for Resident 40 was conducted with LVN 4. LVN 4 donned gloves and used Super Sani-Cloth sanitizing wipes to disinfect the BP cuff and stethoscope. LVN 6 doffed the gloves and did not perform hand hygiene. LVN 4 began medication preparation for administration to Resident 40. LVN 4 finished preparing the medications for Resident 40, performed hand hygiene with alcohol-based hand rub, and entered Resident 40's room. LVN 4 administered Resident 40's oral medications. LVN 4 then donned gloves to administer the GeriCare artificial tears to Resident 40. LVN 6 did not wash her hands prior to donning the gloves. LVN 4 administered one drop of GeriCare artificial tears to Resident 40's left eye. The tip of the dropper of the GeriCare medication touched the eyelashes on Resident 40's left eye. LVN 4 pressed a tissue to the inner corner of Resident 40's left eye. LVN 4 then administered one drop of the GeriCare medication to Resident 40's right eye. On 5/7/25 at 1303 hours, a follow-up interview was conducted with LVN 4. LVN 4 stated staff must wash their hands or use alcohol-based hand rub prior to the administration of ophthalmic (medications to treat conditions of the eye) medications. LVN 4 stated she did not see if the tip of the dropper for the GeriCare medication touched Resident 40's eyelashes during the medication administration. LVN 4 verified the dropper was no longer safe to use if the tip of the dropper touches the resident's eye or any other surface. 10. On 5/8/25 at 1228 hours, an inspection of Medication Cart 2 and a concurrent interview was conducted with the Unit Manager. The back side of glucometer was observed with red-brown smudges. The Unit Manager verified the presence of the red-brown smudges. When asked what the red-brown smudges on the back side of the glucometer were, the Unit Manager stated she did not know. On 5/13/25 at 1116 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview, medical record review, facility record review, and facility P&P review, the facility failed to implement their antibiotic stewardship program including timely monitoring of antibiotic use. * The IP did not review antibiotics for appropriateness for April 2025 which showed 25 antibiotics were ordered. * The IP failed to notify Residents 14 and 26's physicians to re-evaluate the appropriateness of the residents' antibiotics when it was determined their suspected infections did not meet criteria. These failures had the potential of not accurately identifying true infections and exposing the residents to unnecessary antibiotic use. Findings: According to the CDC, repeated and/or improper use of antibiotics was the primary cause of the proliferation of drug-resistant bacteria. Each time a person uses antibiotics, the sensitive bacteria are killed; however, resistant bacteria may result. These resistant bacteria may then grow and multiply. When the antibiotics fail to work, the consequences include longer lasting illnesses, extended hospital stays, and the need for more expensive and toxic medications. Some resistant infections can even cause death. On 5/13/25 at 0800 hours, a concurrent interview and review of the facility's IPCP, antibiotic stewardship, and Residents 14, 26, and 123's medical records was conducted with the IP. The IP stated the process was to review the residents' antibiotic orders as soon as possible to ensure the appropriateness of the antibiotics ordered. The IP stated she would review the residents' medical records, determine if the antibiotic ordered was appropriate and notify the physician to reevaluate. a. Review of facility's antibiotic report for April 2025 showed 25 antibiotics were ordered for suspected infections. The IP stated she did not review the residents' antibiotic orders for April 2025. The list showed Resident 123 was started on the piperacillin sodium tazobactam (antibiotic) medication on 4/30/25. The IP reviewed Resident 123's medical record and verified the resident did not meet the criteria for appropriate antibiotic usage. The IP verified since she did not review any residents' antibiotic orders for April previously and other residents could have received inappropriate antibiotics. The IP reviewed Resident 123's MARs for April and May 2025 and verified the antibiotics were administered to the resident for the full seven days of the ordered therapy. b. Review of the line listing report for March 2025 showed Resident 14 started doxycycline monohydrate (antibiotic) 100 mg medication on 3/5/25, for an infection that did not meet criteria. The IP verified there were no records to show the physician was notified that Resident 14's suspected infection did not meet the criteria and re-evaluated the antibiotics for appropriateness. The IP reviewed Resident 14's MAR for March 2025 and verified the doxycycline monohydrate 100 mg medication was administered to the resident for the full 10 days of the ordered therapy. c. Review of the line listing report for March 2025 showed Resident 26 started Levaquin 750 mg (antibiotic) on 3/18/25, for a suspected infection that did not meet criteria. The IP verified there were no records to show the physician was notified that Resident 26's suspected infection did not meet criteria and re-evaluated the antibiotics for appropriateness. The IP reviewed Resident 26's MAR for March 2025 and verified the Levaquin 750 mg medication was administered to the resident for the full seven days of the ordered therapy.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the physician's order for code status matched the resident's POLST DNR status for one of seven final sampled residents (Resident 102) reviewed for advanced directives. * Resident 102 had a DNR status selected on the POLST signed by Resident 102's responsible party; however, the facility failed to ensure there was a physician's order for Resident 102's code status. This failure had the potential for not honoring the Resident 102's responsible party wishes and providing unwanted life sustaining interventions. Findings: Review of the facility's P&P titled Promoting the Right of Self-Determination for Healthcare Decisions and Advanced Healthcare Directives dated ,d+[DATE] showed the staff should document in the medical chart, the existence of an advance directive, living will and/or standing physician order form (POLST). The staff should review the documents for completeness and confirm with the resident and/or legal healthcare decision maker that the documents are current and have not been revoked or superseded by subsequent documents. The staff should notify the resident's treating physician of current or changes to the advance directives or verbally expressed healthcare and treatment wishes, so that appropriate orders can be obtained and documented in the resident's plan of care. The physician must 'sign' all order to withhold treatment or withdraw life sustain treatment. The orders may not be carried out by the facility until the order has been 'signed', telephone orders for withholding treatment or to withdraw life sustaining treatment are not permitted. Medical record review for Resident 102 was initiated on [DATE]. Resident 102 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 102's H&P examination dated [DATE], showed Resident 102 had no capacity to understand and make decisions, and Resident 102's code status was DNR. Review of Resident 102's POLST dated [DATE], showed Resident 102's responsible party selected treatment as Do Not Attempt Resuscitation/DNR, and to allow a natural death. The form was signed by Resident 102's responsible party on [DATE], and signed by the physician on [DATE], 55 days after the form was signed by the resident's reponsible party. On [DATE] at 1541 hours, an interview and concurrent medical record review for Resident 102 was conducted with the SSD. The SSD stated every resident should have a physician's order with the code status. The SSD stated if the resident did not have a physician's order for the code status, the licensed nurse was responsible for contacting the physician. The SSD reviewed Resident 102's POLST form and stated Resident 102's responsible party had signed Resident 102's POLST on [DATE], and chose DNR. The SSD verified the above findings. Review of Resident 102's Order Summary Report showed a physician's order dated [DATE], for DNR, Comfort Measures. On [DATE] at 1437 hours, an interview was conducted with the DON. The DON stated the purpose of the POLST form was to provide directions to the nursing staff on how to respond in the event of emergency. If the POLST form was not signed or completed, the resident was considered a full code (prolonging life by all medically effective means); thus, in the event of an emergency, CPR would be attempted. Additionally, the DON stated all the residents should have a physician's order for the code status. If there was no physician's order for the code status, the resident would be considered a full code. The DON stated if the POLST form was signed by the resident's responsible party, the facility should follow-up to obtain the physician's signature as soon as possible. The DON stated the POLST must be signed by the physician to be effective. The DON stated if the physician would not be in the facility to sign the POLST form, the form could be faxed to the physician to sign as soon as possible. On [DATE] at 1207 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation and interview, the facility failed to maintain a homelike environment for one nonsampled resident (Resident 86). * Resident 86 resided in Room A. Resident 86 was observed sitting on his bed eating breakfast. A live pest (later identified as a water bug or roach) was observed on top of Resident 86's bed linen, next to Resident 86. This failure had the potential to negatively impact the resident's quality of life. Findings: Medical record review for Resident 86 was initiated on 5/7/25. Resident 86 was admitted to the facility on [DATE], and readmitted on [DATE]. On 5/12/25 at 0750 hours, an observation and concurrent interview was conducted with Resident 86 and CNA 10. Resident 86 was observed sitting on his bed eating breakfast. A live water bug/roach was observed on top of Resident 86's bed linen, next to Resident 86. CNA 10 verified the findings and then attempted to remove the bug/roach from Resident 86's bed, at which time the water bug/roach moved onto the floor. CNA 10 then stepped on the water bug/roach. Resident 86 was asked how the incident made him feel. Resident 86 stated he preferred no pests on his bed while eating. On 5/12/25 at 1500 hours, an interview and concurrent photographic review was conducted with the Pest Control Technician (from Pest Control Company 1). The Pest Control Technician arrived at the facility to conduct an inspection of Room A. The Pest Control Technician was shown a photograph of the pest that was observed on Resident 86's bed linen. The Pest Control Technician identified the pest as either a water bug or roach. The Pest Control Technician stated he placed pest monitors and applied pest gel throughout Room A.

Based on observation, interview, medical record review, facility record review, and facility P&P review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one of two sampled residents (final sampled resident, Resident 113) reviewed for abuse. * Resident 113 was hit in the face with a rehabilitation dowel by another resident (Resident 86). This failure resulted in Resident 113 suffering pain to the left side of his face and experiencing feelings of anger. Findings: Review of the facility's P&P titled Alleged or Suspected Abuse and Crime Reporting revised 10/2022 showed each resident has the right to be free from abuse. Physical abuse includes, but is not limited to, hitting, slapping, pinching and kicking. The facility will implement policies and procedures to prevent and prohibit all types of abuse. Medical record review for Resident 113 was initiated on 5/7/25. Resident 113 was admitted to the facility on [DATE]. Review of Resident 113's BIMS dated 5/5/25, showed Resident 113 was cognitively intact. On 5/7/25 at 0903 hours, an interview was conducted with Resident 113. Resident 113 was asked to describe the physical altercation between himself and his roommate (Resident 86). Resident 113 stated on 5/4/25 at approximately 2030 hours, he was lying in bed watching television. Resident 113 stated his roommate (Resident 86) started cursing at him and told him to turn off his television. Resident 113 stated he then lowered the volume of his television. Resident 113 stated Resident 86 then walked over to his bed and hit him in the face with a pole (later identified as a rehabilitation dowel). Resident 113 stated the dowel was solid and when it struck his face it hurt, causing pain to his face. Resident 113 stated before Resident 86 could hit him again, he grabbed the dowel, preventing Resident 86 from striking him again. Resident 113 stated the incident made him feel angry. Resident 113 stated he felt pain to his jaw and felt swelling to his face. Resident 113 stated he had difficulty chewing after the incident and informed the dietary staff and would prefer a soft diet. Review of Resident 113's Nursing Note dated 5/4/25, showed at 1945 hours, RN 3 responded to Resident 113's room. Residents 86 and 113 had a resident-to-resident altercation. Resident 113 was hit with a dowel by Resident 86 because Resident 113 refused to turn off his television when asked by Resident 86. Also, a water pitcher full of water was thrown on Resident 113's bed. Resident 113 was assessed and noted with redness to the left side of his face. Resident 113 complained of pain on the left side of his face and was given Tylenol for pain. A cold compress was also applied to Resident 113's face. Review of Resident 113's SBAR dated 5/4/25 at 2247 hours, showed at 1945 hours, Resident 113 had an altercation and physical abuse happen to him. Resident 113 was being monitored for emotional distress due to a resident-to-resident altercation. Review of Resident 86's Nursing Note dated 5/4/25 at 2012 hours, showed on 5/4/25 at approximately 1945 hours, the CNA responded to Residents 113 and Resident 86's room. The CNA saw both residents holding onto a dowel. Resident 113 was lying in his bed and Resident 86 was standing in front of him. As per Resident 113, Resident 86 came to his bed and hit him with the dowel on the left side of his face. When Resident 86 was asked why he tried to hit Resident 113, Resident 86 stated he got mad when he asked Resident 113 to turn off/lower the television volume and Resident 113 just ignored him. Review of Resident 86's care plan titled Potential Behavioral Disturbance related to diagnosis of schizoaffective disorder initiated 11/9/23, showed Resident 86 had behavior of physical aggressiveness/combativeness (per Resident 86's family). Interventions included to monitor Resident 86 for behavior of physical aggression/combativeness. On 5/7/25 at 1436 hours, an interview was conducted with CNA 11. CNA 11 stated on 5/4/25 in the evening, she heard screaming coming from Residents 113 and 86's room. CNA 11 stated when she entered the room, she saw Resident 113 lying on his bed and Resident 86 standing next to Resident 113's bed. CNA 11 stated the residents were struggling to gain control of a dowel. CNA 11 stated she was able to gain possession of the dowel and confiscated the dowel. CNA 11 stated Resident 113 told her that he was struck on the head with the dowel and then grabbed the dowel in an attempt to prevent Resident 86 from hitting him again. CNA 11 stated Resident 113 told her that he did not do anything wrong to cause Resident 86 to hit him. CNA 11 sated Resident 113 complained of pain to his face. CNA 11 stated Resident 86 told her that Resident 113 had his TV too loud. On 5/8/25 at 1033 hours, an interview was conducted with OT 1. OT 1 stated Resident 113 currently had no orders for PT or OT services. OT 1 stated Resident 113 had no orders for the use of a dowel. OT 1 stated no residents at the facility should be in possession of a dowel without staff present, to ensure the residents' safety. OT 1 stated she did not know how Resident 113 gained possession of the dowel. On 5/8/25 at 1603 hours, a concurrent interview, medical record review, and facility photograph review was conducted with the DON. The DON stated on the evening of 5/4/25, an incident occurred involving Residents 86 and 113. The DON stated Resident 113 told her the following information specific to the incident. Resident 113 was lying in bed watching television and Resident 86 asked him to turn off his TV. Resident 86 then walked over to Resident 113's bed and hit him on the let side of the face with a dowel. Resident 113 then grabbed the dowel, and both residents struggled to gain control of the dowel. CNA 11 had entered the room and was able to separate the residents and obtain possession of the dowel. The DON verified Resident 86's care plan titled Potential Behavioral Disturbance related to diagnosis of schizoaffective disorder initiated 11/9/23, showed Resident 86 had behavior of physical aggressiveness/combativeness (per Resident 86's family). The DON stated Resident 86 should not have possessed a dowel without a staff supervision, to ensure for resident safety. The DON provided a photograph of the confiscated dowel which was identified by a serial number on this side of the dowel. * The dowel was obtained from the rehabilitation department. The Maintenance Supervisor subsequently measured and weighed the dowel. On 5/8/25 at 1555 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor measured and weighed the dowel. The Maintenance Supervisor stated the dowel was constructed of a PVC pipe. The dowel measured 31.5 inches in length, 3 quarter inches in width, had a circumference of 1 1/4 inches, and weighed 1.4 pounds. On 5/8/25 at 1243 hours, an interview and concurrent facility record review was conducted with the Administrator. Review of the facility's Verification of Incident Investigation Administrative Summary dated 5/8/25, showed the facility conducted an investigation specific to the incident involving Residents 86 and 113. The Administrative Summary showed the facility had substantiated the incident because Resident 113 was actually struck. The Administrator stated he substantiated Resident 113 was struck with the dowel and Resident 113 had redness to his face consistent with where Resident 113 stated he was struck with the dowel.

Based on interview, medical record review,and facility P&P review the facility failed to ensure three of five final sampled residents (Residents 23, 59, and 112) reviewed for unnecessary medications were free from unnecessary medications. * The facility failed to ensure Resident 112 was monitored accurately for orthostatic hypotension as ordered by the physician for the use of risperidone (antipsychotic). In addition, the facility failed to implement nonpharmacological interventions prior to the use of the mirtazapine (antidepressant) medication and failed to ensure monitoring for the side effects of the mirtazapine medication. * The facility failed to ensure Resident 23's orthostatic blood pressures were accurately monitored for the use of the Seroquel (antipsychotic) medication. * The facility failed to ensure Resident 59's prescription for zolpidem tartrate (sedative-hypnotic) had documentation of the physician's clinical rationale when the PRN order was extended beyond 14 days. This failure had the potential to negatively impact the Resident 59's well-being from the continued use of the zolpidem tartrate medication. These failures had the potential for adverse effects from the psychotropic medications and the potential for not providing the correct data to the prescriber to adjust the dosage of psychotropic medication. Findings: Review of the facility's P&P titled Psychotropic Medication Management dated November 2017 showed clinically necessary PRN psychotropic drug orders are limited to 14 days. If the prescribing practitioner determines a need for continued PRN use beyond the original 14 days, it is accompanied by supporting documentation in the electronic health record (EHR) including the rationale for continued use and duration; and Review of the facility's P&P titled Use of Psychotropic Medication, revised 8/2024 showed the residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The Policy Explanation and Compliance Guidelines section of the P&P showed in part, the following: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants anti-anxiety, and hypnotics. 4. The indications for use of any psychotropic drug should be documented in the medical record. b. For psychotropic drugs that are initiated after the admission to the facility, documentation shall include the specific condition as diagnosed by the physician. ii. Non-pharmacological interventions that have been attempted and the target symptoms for monitoring shall be included in the documentation. 1. Medical record review for Resident 112 was initiated on 5/7/25. Resident 110 was initially admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 112's H&P examination dated 2/9/25, showed Resident 112 had a history of dementia and Schizophrenia. Further review of the H&P examination showed Resident 112 had no capacity to make medical decisions. a. Review of Resident 112's Order Summary Report dated 5/9/25, showed the following physician's orders: - dated 2/6/25, for risperidone oral tablet 0.25 mg one tablet by mouth in the morning for Schizophrenia manifested by paranoid delusional statements and physical aggression towards others, - dated 2/6/25, for risperidone oral tablet 0.25 mg two tablet by mouth at bedtime for Schizophrenia manifested by paranoid delusional statements and physical aggression towards others, - dated 2/7/25, to monitor for behavior for the use of risperidone medication for manifested by delusions/delusional statements and tally every shift, - dated 2/7/25, to monitor for antipsychotic medication side effects such as urinary retention, dry mouth, constipation, blurred vision, sedation, drowsiness, glaucoma (a group of eye disease that can cause vision loss and blindness), agranulocytosis (a life-threatening condition that involves having severely low levels of white blood cells), seizures, weight gain, diabetes, jaundice (as a yellow discoloration of the body tissue resulting from the accumulation of excess bilirubin), and Neuroleptic Malignant Syndrome (sudden onset of diffuse muscle rigidity, high fever, labile blood pressure, tremors, and notable cognitive dysfunction). - dated 2/7/25, to monitor for orthostatic BP lying down, sitting up, and standing up every week on Wednesday and notify MD if there is a systolic blood pressure drop of 20 mmHg or a diastolic blood pressure drop of 10 mmHg. Review of Resident 112's MARs for February through 5/11/25, showed the following: - Resident 112 was administered risperidone 0.25 mg one tablet by mouth at 0900 hours, from 2/7 to 2/28/25, 3/1 to 3/31/25, 4/1 to 4/30/25, and 5/1 to 5/11/25, and - Resident 112 was administered risperidone 0.25 mg two tablets by mouth at 2100 hours from 2/7 to 2/28/25, 3/1 to 3/31/25, 4/1 to 4/30/25, and 5/1 to 5/11/25, Further review of Resident 112's MARs for February through 5/11/25, showed the orthostatic BP (lying, sitting, and standing) were scheduled to be monitored every Wednesday. However, the BP readings for the three positions were the same as follows: - on 2/12/25, the BP readings were 125/76 mmHg for the lying, sitting, and standing position. - on 2/19/25, the BP readings were 127/69 mmHg for the lying, sitting, and standing positions. - on 2/26/25, the BP readings were 121/69 mmHg for the lying, sitting, and standing position. - on 3/5/25, the BP readings were 123/83 mmHg for the sitting and standing position. - on 3/12/25, the BP readings were 105/68 mmHg for the lying, sitting, and standing position. - on 3/19/25, the BP readings were 134/78 mmHg for the lying, sitting, and standing position. - on 3/26/25, the BP readings were 138/84 mmHg for the lying, sitting, and standing position. - on 4/30/25, the BP readings were 127/52 mmHg for the lying, sitting, and standing position. - on 5/7/24, the BP readings were 122/65 mm Hg for the sitting and standing position. On 5/13/25 at 1116 hours, an interview and concurrent medical record review was conducted with the DON for Resident 112. The DON verified the above findings. The DON stated the orthostatic BP readings should not be the same for the lying, sitting, and standing position if the proper procedure was followed. b. Review of Resident 112's Order Summary Report dated 5/9/25, showed an order dated 2/11/25, for mirtazapine oral tablet 15 mg one tablet by mouth at bedtime for depression as manifested by poor appetite (less than 50% of meal intake). Further review of Resident 112's Order Summary Report dated 5/9/25, failed to show a physician's order to monitor for the antidepressant medication side effects related to the use of the mirtapizine medication. Review of Resident 112's medical record failed to show the nonpharmacological interventions which were attempted prior to the use of the mirtapizine medication. Review of Resident 112's MARs for February through 5/11/25, showed Resident 112 was administered mirtazapine 15 mg one tablet at 2100 hours, from 2/11 to 2/28, 3/1 to 3/31/25, 4/1 to 4/30/25, and 5/1 to 5/11/25. Further review of Resident 112's MARs for February through 5/11/25, failed to show Resident 112 was monitored for the adverse effects related to the use of the mirtazapine medication. On 5/12/25 at 1116 hours, an interview and concurrent medical record review was conducted with the DON for Resident 112. The DON verified the above findings. On 5/13/25 at 1116 hours, an interview was conducted with the Administrator and the DON. The Administrator and DON were informed of and acknowledged the above findings. 48882 2. Medical record review for Resident 23 was initiated on 5/7/25. Resident 23 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 23's H&P examination dated 1/19/25, showed Resident 23 had no capacity to understand and make decisions. Review of Resident 23's Order Summary Report dated 5/9/25, showed the following physician's orders dated 4/4/25: - to monitor Resident 23's orthostatic BP sitting up every week on Wednesday, during the evening shift; and to notify the physician if there was a drop of 20 mmHg in the systolic BP, or a drop of 10 mmHg in the diastolic BP, - to monitor Resident 23's orthostatic BP lying down every week on Wednesday, during the evening shift; and to notify the physician if there was a drop of 20 mmHg in the systolic BP, or a drop of 10 mmHg in the diastolic BP, and - to administer Seroquel (antipsychotic) 25 mg by mouth two times a day for psychosis manifested by constant repetitive movements. Review of Resident 23's plan of care showed a care plan problem dated 4/8/25, addressing Resident 23's behavior problem of constant repetitive movements. The intervention included monitoring the orthostatic blood pressure as ordered. Review of Resident 23's MARs for April and May 2025 showed the following: - on 4/9/25, the BP readings were 126/52 mmHg for the sitting and lying position, - on 4/30/25, the BP readings were 125/62 mmHg for the sitting and lying position, and - on 5/17/25, the BP readings were 142/78 mmHg for the sitting and lying position. On 5/9/25 at 1057 hours, an interview and concurrent medical record review for Resident 23 was conducted with LVN 5. LVN 5 verified the above findings and stated the BP readings should not be the same for the different positions. On 5/12/25 at 1410 hours, an interview was conducted with the DON. The DON stated the residents on psychotropic medications should be monitored every shift for the side effects related to the use of the psychotropic medication, such as dizziness and orthostatic hypotension. The DON stated for the residents prescribed the antipsychotic medication, there should be a physician's order to monitor the resident for orthostatic hypotension. The DON further stated the monitoring for orthostatic hypotension was done by obtaining the resident's BP in different positions. The DON stated after the licensed nurse obtained the resident's BP readings in the different positions, the licensed nurse was expected to compare the BP readings and determine if there was a drop in the BP, which would indicate orthostatic hypotension. The DON stated the orthostatic BP readings should not be the same for the different positions. On 5/13/25 at 1207 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 52238 3. Medical record review for Resident 59 was initiated on 5/8/25. Resident 59 was initially admitted to the facility on [DATE]. Review of Resident 59's H&P examination dated 1/2/25, showed Resident 59 had capacity to understand and make decisions. Review of Resident 59's medical record showed the following physician's orders for zolpidem tartrate medication: - dated 4/12/25, to administer ambien oral tablet 5 mg (zolpidem tartrate) one tablet by mouth as needed for inability to sleep, give at bedtime; - dated 4/17/25, to administer ambien oral tablet 5 mg (zolpidem tartrate) one tablet by mouth as needed for inability to sleep until 4/26/25 at 2359 hours, give at bedtime (trial total 14 days from 4/12/25); - dated 4/26/25, to administer zolpidem tartrate tablet 10 mg one tablet by mouth as needed for inability to sleep for 14 days, give at bedtime; and - dated 5/11/25, to administer zolpidem tartrate tablet 10 mg one tablet by mouth as needed for inability to sleep for 14 days, give at bedtime. Further review of Resident 59's medical record did not show documentation of the clinical rationale from the prescribing physician when the use of zolpidem medication was extended and ordered on 4/12, 4/17, 4/26, and on 5/11 to 5/25/25. On 5/13/25 at 1242 hours, an interview and medical record review for Resident 59 was conducted with the DON. The DON verified Resident 59 had the physician's order for the zolpidem tartrate medication, and the initial order was on 4/12/25. The DON verified Resident 59 also had the physician's orders for zolpidem tartrate medication from 4/17 to 4/26/25, 4/26 to 5/10/25, and 5/11 to 5/25/25. The DON was not able to show documented evidence of the clinical rationale from the physician when the PRN order for the zolpidem tartrate was renewed after the initial order on 4/12/25.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the physician's recommendation was carried out as ordered for one nonsampled resident (Resident 94). This failure had the potential of Resident 94 not receiving care as ordered. Findings: Review of the facility's P&P titled Record Content - Laboratory and Radiology Reports dated 1/2004 showed the facility shall obtain laboratory, radiology, or other diagnostic service to meet the needs of the residents as prescribed by the physician. Contact the laboratory and/or radiology services in accordance with the physician's order. Log this in the lab and/or x-ray control log and complete the appropriate requisition form. The P&P further showed to sign and date the reports when reviewed. The license nurse or other will be responsible for faxing each report to the attending physician promptly after nurse's review. Moreover, the P&P showed to file the reports in the resident's health record when the nurse has signed off these reports. Contact the service and request an immediate copy of the laboratory or radiology reports that are not received within 48 hours. Medical record review for Resident 94 was initiated on 5/7/25. Resident 94 was admitted to the facility on [DATE], and readmitted back to the facility on [DATE]. Review of Resident 94's H&P examination dated 3/31/25, showed Resident 94 was alert and oriented. Review of Resident 94's Order Review Report from 4/1/2024 to 5/31/2024, showed an order dated 5/1/24, for an appointment for MRI of the brain and cervical spine without contrast scheduled on 5/23/24 at 1615 hours. Review of Resident 94's MRI of the Cervical Spine Without Contrast dated 5/23/24, showed the findings indicate in image number six, seven, and eight, there is suggestion for a mass involving the right side of the neck anterior to the sternocleidomastoid; however, this is a very limited observation because only in axial sections is present. The MRI results further showed the estimated size of the mass could be about 2.4 cm. This could be due to positioning; however, a mass cannot be ruled out. Review of Resident 94's Summary of the Visit report written in Spanish dated 12/20/24, showed the physician recommended to bring the result of the MRI on 5/23/24, to the next appointment at this neurology clinic scheduled on 4/11/25. Review of Resident 94's Neurology Clinic Progress Note dated 4/11/25, showed Resident 94 had the MRI performed, but the previous MRI on 5/23/24, was not available for review. The progress note further showed Resident 94 reported he continued to have weakness affecting the right hand and the bilateral legs. The recommendations of the appointment showed to follow up on the results of the MRI brain and C-spine (cervical spine - the first seven stacked vertebral bones of the spine), physical therapy as able, and return to center six months or sooner as needed. On 5/13/25 at 0935 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated when the residents went to in-office physician appointments, a copy of the resident's face sheet, physician orders, recent laboratory results, a blank telephone order sheet, and a blank progress note form would be given to them to provide to the provider for review and use of the telephone order sheet and progress note. RN 1 stated upon a resident's return from the physician appointment, the receiving nurse, charge nurse, or desk nurse would review and follow up on any orders given by the physician. RN 1 verified Resident 94's MRI results from 5/23/24, were uploaded on the resident's medical records on 5/1/25; however, RN 1 acknowledged the MRI was completed on 5/23/24. RN 1 stated the upload of the MRI results were late and documentation showed the request for a copy of the MRI results was dated 4/30/25. On 5/13/25 at 1051 hours, an interview and concurrent medical record review was conducted with the Case Manager. The Case Manager verified the above findings. The Case Manager stated when a resident returned from physician's appointment and the physician requested for imaging, he completed a form to provide the information where the results of the imaging should be sent directly to the ordering physician. When asked for a copy of the form, the Case Manager stated he did not keep the forms and had discarded it. The Case Manager further stated he did not follow up with the ordering physician's office if the MRI results were sent. On 5/13/25 at 1106 hours, an interview and concurrent medical record review was conducted with the Case Manager and RN 1 present to assist with the translation of Summary of the Visit report written in Spanish dated 12/20/24. RN 1 stated if the receiving license nurse could not read Spanish, the report should have been given to a license nurse who could translate the form. RN 1 translated the Summary of the Visit report and stated the report showed to bring the result of the MRI to the next neurology appointment scheduled on 4/11/25. RN 1 stated a copy of the MRI result from 5/23/24, should have been provided to the ordering physician. On 5/13/25 at 1208 hours, an interview was conducted with the Administrator and the DON. The DON stated she expected the license nurses to enter the orders received by the physician upon return from an appointment and to document. The DON further stated if an after summary visit report was in written in Spanish and the receiving nurse did not know how to read Spanish, the report should be given to a nurse who would be able to translate the report to ensure the physician's orders were carried out. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, and medical record review, the facility failed to provide the physician's order for a health shake with every meal for one of 30 final sampled residents (Resident 115). * Resident 115 had a physician's order to receive a four ounces of the health shake three times a day with meals. However, Resident 115 did not receive the health shake with meals. This failure had the potential to compromise Resident 115's nutritional status and posed the risk for negative health outcomes. Findings: Medical record review for Resident 115 was initiated on 5/8/25. Resident 115 was admitted to the facility on [DATE]. Review of Resident 115's H&P examination dated 10/31/24, showed Resident 115 had no capacity to understand and make decisions. Review of Resident 115's Order Summary Report showed a physician's order dated 11/14/24, to provide supplement health shake four oz three times a day with meals. On 5/8/25 at 1256 hours, an observation and concurrent interview was conducted with CNA 8. CNA 8 stated the food tray should have all the items listed on the meal ticket. CNA 8 verified the resident's printed meal ticket showed one health shake; however, there was no health shake observed on Resident 115's meal tray. On 5/9/25 at 0829 hours, an observation and concurrent interview was conducted with CNA 9. CNA 9 stated the food tray and meal ticket were checked in the kitchen to ensure the items match and the food items listed on the resident's meal ticket should be on the food tray. CNA 9 confirmed the meal shake was not on the tray during breakfast for Resident 115. On 5/9/25 at 1010 hours, an interview and concurrent medical record review for Resident 115 was conducted with the DON. The DON verified Resident 115 had a physician's order for a health shake three times a day and acknowledged the resident had not been receiving health shakes with meals.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure five of eight final sampled residents (Residents 52, 65, 70, 84, and 537) and two nonsampled residents (Residents 40 and 90) reviewed for respiratory care were provided with the appropriate respiratory care and services when: * The facility failed to ensure Resident 40's storage bag for the nebulizer was changed weekly and PRN as per the facility's P&P. * The facility failed to ensure Resident 52's storage bag for the nebulizer was changed weekly and PRN as per the facility's P&P. * The facility failed to ensure Resident 65's nebulizer mask and the storage bag was changed every seven days. * Resident 70's nasal cannula was improperly stored, as evidenced by hanging from a portable oxygen tank instead of stored in a clean bag. * The facility failed to ensure Resident 84's oxygen bag was changed weekly and PRN as per the facility's P&P. * The facility failed to ensure Resident 90's nebulizer mask and storage bag were changed every seven days. * The facility failed to ensure a physician's order was obtained for the use of oxygen for Resident 537. These failures had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: Review of the facility's P&P titled Oxygen Therapy and Devices dated 2013 showed oxygen is a drug which much be ordered by the physician. The section for Initiation of Oxygen showed to verify the physician order and to document in the resident's file. Review of the facility's P&P titled Oxygen Therapy and Devices dated 2/2013 showed the oxygen devices should be changed weekly and PRN, and placed in a labeled bag when not in use. 1. On 5/7/25 at 0844 hours, an observation and concurrent interview was conducted with Resident 537. Resident 537 was receiving oxygen at three LPM via the nasal cannula. The oxygen tubing was labeled with the date 5/1/25. Resident 537 stated she had been receiving oxygen since the night before. Medical record review for Resident 537 was initiated on 5/7/25. Resident 537 was admitted to the facility on [DATE]. Review of Resident 537's H&P examination dated 4/23/25, showed Resident 537 had the capacity to understand and make medical decisions. Review of Resident 537's Order Summary Report did not show a physician's order for the oxygen administration. Review of Resident 537's MAR for May 2025 did not show documentation of the oxygen administration. On 5/7/25 at 0854 hours, an observation, interview and concurrent medical record review for Resident 537 was conducted with LVN 6. Resident 537 was observed receiving an oxygen via nasal cannula. LVN 6 was observed checking the oxygen concentrator and stated Resident 537 had received an oxygen at three LPM. When asked to show the physician's order for the oxygen, LVN 6 verified there was no physician's order for the oxygen. When asked where the staff should document Resident 537's oxygen therapy, LVN 6 stated the licensed staff documented in the MAR. LVN 6 was unable to find documentation of the oxygen therapy in Resident 537's MAR. LVN 6 further stated she was not able to find documentation why the oxygen was being administered to Resident 537. On 5/9/25 at 1408 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 47474 2. Medical record review for Resident 52 was initiated on 5/7/25. Resident 52 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 52's annual MDS assessment dated [DATE], showed Resident 52 had a BIMS score of 11 which meant the resident's cognition was moderately impaired. Further review of Resident 52's Order Summary Report dated 5/9/25, showed an order dated 5/8/25, to change the nebulizer tubing weekly as needed when visibly soiled and night shift every Wednesday. On 5/7/25 at 0910 hours, during an initial tour of the facility, an observation and concurrent interview was conducted with the ADON in Resident 52's room. The storage bag for the nebulizer was observed with no label and dated 4/3. The ADON verified the storage bag for the nebulizer did not have a name and was dated 4/3. The ADON stated the respiratory storage bags were changed weekly on Wednesdays and done by the NOC shift (11 PM to 7 AM shift). The ADON further stated the storage bag for the nebulizer should be changed weekly and as needed to maintain for infection control. 3. Medical record review for Resident 84 was initiated on 5/7/25. Resident 84 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 84's H&P examination dated 10/18/24, showed Resident 84 had the capacity to understand and make decisions. Further review of Resident 84's Order Summary Report dated 5/9/25, showed the following physician orders: - dated 10/1/24, to change oxygen tubing weekly and when visibly soiled every night shift on Wednesdays. - dated 5/5/25, to administer oxygen at two LPM, may titrate to three LPM via nasal canula continuously to keep oxygen saturation level above 92% every shift. On 5/7/25 at 0816 hours, during an initial tour of the facility, Resident 84's oxygen bag was unlabeled and dated 4/3. On 5/7/25 at 0840 hours, an observation and concurrent interview was conducted with the Unit Manager in Resident 84's room. The Unit Manager verified the findings. The Unit Manager stated the respiratory bags were changed weekly on Wednesday or as needed and were dated and labeled. The Unit Manager further stated Resident 84's oxygen bag should have been changed to ensure infection control. On 5/13/25 at 1208 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings for Residents 52 and 84. 51352 4. Medical Record review for Resident 40 was initiated on 5/7/25. Resident 40 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 40's Order Summary Report dated 5/7/25, showed an order dated 4/6/24, for Ipratropium-Ablbuterol Inhalation Solution (inhaled medication used to treat common lung diseases that cause restricted airflow and breathing problems) 0.5-0.25 (3) mg/3 ml inhale orally every four hours as needed for shortness of breath and wheezing (a high-pitched, musical, lung sound produced by airflow through an abnormally narrow airways). On 5/7/25 at 0858 hours, during a medication administration observation and concurrent interview with LVN 4 for Resident 40, the storage bag for Resident 40's nebulizer mask was observed dated 4/3. LVN 4 verified the storage bag for Resident 40's nebulizer mask was dated 4/3. LVN 4 stated the respiratory storage bags were changed weekly on Wednesdays and Resident 40's nebulizer storage bag should have been changed. On 5/13/25 at 1116 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed of and acknowledged the above findings. 37726 5.a. Medical record review for Resident 70 was initiated on 5/7/25. Resident 70 was admitted to the facility on [DATE]. Review of Resident 70's Order Summary Report showed a physician's order dated 6/3/24, for oxygen to be administered at a rate of 2 LPM as needed for shortness of breath. Review of Resident 70's care plan titled Oxygen Therapy revised 3/13/25, showed to provide Resident 70 with portable oxygen apparatus. On 5/7/25 at 0746 hours, an observation and concurrent interview was conducted with Resident 70. Resident 70 stated he utilized the oxygen for shortness of breath and used a portable oxygen tank when he used his wheelchair. Resident 70's portable oxygen tank was observed at the entrance to Resident 70's room. A nasal cannula was observed hanging from the oxygen tank. The nasal cannula was not stored in a clean bag. On 5/7/25 at 0747 hours, an observation and concurrent interview was conducted with LVN 4. Resident 70's oxygen tank was observed at the entrance to Resident 70's room. A nasal cannula was observed hanging from the oxygen tank. The nasal cannula was not stored in a clean bag. LVN 4 verified the findings and stated Resident 70's nasal cannula should be stored in a clean bag for infection control. 47476 b. On 5/7/25 at 1104 hours, a concurrent observation and interview was conducted with Resident 70. A portable oxygen was observed at Resident 70's bedside with a nasal cannula inside an unlabeled respiratory bag. An oxygen concentrator was additionally observed, with the nasal cannula tubing attached to a humidifier dated 5/6/25, and hanging on top of Resident 70's front wheeled walker, not stored inside a respiratory bag. The nasal cannula tubing on the oxygen concentrator was not labeled and the respiratory bag placed on the machine was dated 4/17/25. Resident 70 stated he used oxygen at night and as needed and the portable oxygen tank as needed. On 5/7/25 at 1110 hours, a concurrent observation and interview was conducted with LVN 4. LVN 4 observed and verified the above findings. LVN 4 stated the respiratory bag labeled 4/17/25, should be changed when the humidifier and nasal cannula were changed and she would replace it. LVN 4 stated for the nasal cannula in the respiratory bag on Resident 70's portable oxygen tank, she did not label the respiratory bag and proceeded to label the bag and nasal cannula tubing. LVN 4 stated they needed to change the equipment for infection control. On 5/8/25 at 1559 hours, an interview was conducted with the DON. The DON stated the oxygen tubing should be changed weekly by the licensed nurses. The DON stated the nurse should label the set-up bag with the date and store the oxygen tubing in the bag when not in use. The DON stated they labeled and changed the equipment weekly for infection control. 48882 6. On 5/7/25 at 0835 hours, during the initial tour of the facility Resident 65's nebulizer mask was observed inside a plastic bag. The plastic bag was observed labeled 4/24/25. Medical record review for Resident 65 was initiated on 5/7/25. Resident 65 was admitted to the facility on [DATE]. Review of Resident 65's Order Summary Report dated 5/8/25, showed a physician's order dated 6/22/24, to administer ipratropium-albuterol solution 0.5-2.5 mg/3 ml via inhalation every four hours for wheezing/shortness of breath. Review of Resident 65's MAR for May 2025 showed Resident 65 was administered the ipratropium-albuterol solution 0.5-2.5 mg/3 ml via inhalation every four hours from 5/1 to 5/7/25 at 0000, 0400, 0800, 1200, 1600, and 2000 hours (except on 5/7/25 at 1600 hours). On 5/7/25 at 0839 hours, an interview was conducted with LVN 5. LVN 5 stated for the resident who received breathing treatments, the central supply staff was responsible for changing the nebulizer masks and tubing. LVN 5 stated the central supply staff changed the oxygen equipment once a week and labeled the date on the storage bag. LVN 5 stated prior to administering the breathing treatment to the resident, the licensed nurse was responsible for checking the date labeled on the bag and if the date was more than seven days, the licensed nurse should replace the breathing treatment equipment before administering the breathing treatment. On 5/7/25 at 0842 hours, a concurrent observation and interview was conducted with LVN 5. LVN 5 verified the plastic bag containing Resident 65's nebulizer mask was labeled 4/24/25 (more than seven days). 7. On 5/7/25 at 0818 hours, during the initial tour of the facility, Resident 90's nebulizer mask was observed inside a plastic bag. The plastic bag was observed labeled 4/24/25. Medical record review for Resident 90 was initiated on 5/7/25. Resident 90 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 90's Order Summary Report dated 5/8/25, showed a physician's order dated 2/21/25, to administer budesonide suspension (breathing treatment medication), 500 mcg by mouth via handheld nebulizer two times a day for wheezing/shortness of breath. Review of Resident 90's MAR for May 2025 showed Resident 65 was administered the budesonide suspension medication from 5/1 to 5/7/25 at 0900 and 1700 hours. On 5/7/25 at 0839 hours, a concurrent interview, observation, and medical record review for Resident 90 was conducted with LVN 5. LVN 5 stated for the residents who received breathing treatments, the central supply staff was responsible for changing the nebulizer masks and tubing. LVN 5 stated the central supply staff changed the oxygen equipment once a week and labeled the date on the storage bag. LVN 5 stated prior to administering the breathing treatment to the resident, the licensed nurse was responsible for checking the date labeled on the bag and if the date was more than seven days, the licensed nurse should replace the breathing treatment equipment, before administering the breathing treatment. LVN 5 reviewed Resident 90's medical record and stated Resident 90 received a breathing treatment two times a day for wheezing/shortness of breath. A concurrent observation and interview was conducted at Resident 90's bedside with LVN 5. LVN 5 verified the plastic bag containing Resident 90's nebulizer mask was labeled 4/24/25 (more than seven days). On 5/8/25 at 1538 hours, an interview was conducted with the DON. The DON stated for the oxygen tubing, nebulizer masks, or any oxygen equipment being used by the resident, the oxygen equipment should be changed weekly by the licensed nurses on the 2300 to 0700-hour shift; and the plastic bag used to store the oxygen equipment should be changed and labeled with the date weekly. The DON stated the purpose of changing the oxygen tubing weekly was for infection control purposes and to maintain clean oxygen equipment. The DON further stated prior to the administration of the breathing treatment, the licensed nurses were expected to check the date on the plastic bag. If the date was over seven days, the licensed nurse was expected to change the oxygen equipment, including the clear plastic bag, used for storage of the equipment and label the bag with the new date. On 5/13/25 at 1207 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on interview and medical record review, the facility failed to provide adequate and appropriate pain management for one of one final sampled resident (Resident 129) reviewed for pain management. * The facility failed to ensure the pain medication was administered as per the physicians' orders for Resident 129. This failure had the potential for Resident 129 not to receive the appropriate treatment for pain. Findings: Medical record review for Resident 129 was initiated on 5/7/25. Resident 129 was admitted to the facility on [DATE]. Review of Resident 129's Order Review Report showed a physician's order dated 5/5/25, showed to administer tramadol HCL (pain medication) 50 mg one tablet by mouth every six hours as needed for severe pain 7-10 (on a 0-10 pain scale, with 0 = no pain and 10 = worst pain). Review of Resident 129's MAR for May 2025 showed Resident 129 was administered the tramadol HCL 50 mg medication on 5/7/25 at 0933 hours, when the resident's pain level was six, not within the pain levels of 7-10 for tramadol HCL 50 mg as ordered. On 5/8/25 at 1128 hours, an interview and concurrent medical record review for Resident 129 was conducted with the ADON. The ADON verified above findings and stated the pain medication should have been administered as ordered by the physician. On 5/9/25 at 1408 hours, an interview with the DON was conducted. The DON was informed and acknowledged the above findings.