Every finding on record at Cornerstone at the Ranch

Based on observations, interviews, and record reviews, the facility failed to ensure controlled substance medications were accurately reconciled in the Controlled Substance Record for 11 residents (#2, #7, #8, #10, #14, #28, #31, #44, #46, #48, and #60) whose medications were stored on MedCartA. This deficient practice was evidenced when S9LPN failed to sign out controlled medications in the Controlled Substance Record, at the time the medications were administered. Findings: Review of the facility's policy titled Controlled Substances with a last review date of 01/15/2026, read in part, Policy Statement- The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation an Implementation- 7. The charge nurse who administers the prescribed narcotic will immediately document it on the medication administration record and the controlled drug administration record. On 08/05/2026 at 1:40 p.m., a medicine cart review of MedCartA and an interview was conducted with S9LPN. A random narcotics count was observed to be inaccurate. S9LPN stated that she had not signed out any of the narcotics that she had administered for her shift on the Controlled Substance Record. She stated the narcotic count was not accurate for those medications she had administered on her shift. S9LPN stated that per facility policy, she should have signed out those narcotics on the Controlled Substance Record at the time the medications were administered to ensure controlled medication counts would be accurate. On 08/05/2026 at 1:50 p.m., an interview was conducted with S3DON. She confirmed that S9LPN should have signed out on the Controlled Substance Record any controlled medications she had administered at the time of administration, to ensure that the controlled medication reconciliation would be accurate. On 08/05/2026 at 1:55 p.m., an interview and complete narcotic count was performed on MedCartA with S10CDRC. Residents #2, #7, #8, #10, #14, #28, #31, #44, #46, #48, and #60 had inaccurate narcotic counts. S10CDRC confirmed the inaccurate narcotic count. She stated that S9LPN should have signed out on the Controlled Substance Record any controlled medications she had administered at the time of administration, to ensure that the controlled medication reconciliation would be accurate. The results of the full narcotic count with S10CDRC for MedCartA resulted in the following: Resident #2 Review of Resident #2's physician orders revealed an order dated 04/29/2026 for Hydrocodone-Acetaminophen oral tablet 10-325mg (milligrams), give 1 tablet by mouth every 8 hours as needed for pain related to pain, unspecified. Review or Resident #2's August 2026 MAR (Medication Administration Record) revealed that Hydrocodone-Acetaminophen oral tablet 10-325mg, 1 tablet was administered on 08/05/2026 at 10:20 a.m. Review of Resident #2's Controlled Substance Record revealed a count of 33 tablets with the last dose documented on 08/04/26 at 10:28 p.m. The actual count of tablets observed was 32. Resident #7 Review of Resident #7's physician orders revealed an order dated 05/12/2026 for Oxycodone with Acetaminophen tab 5-325mg give 1 tablet orally every 6 hours as needed for pain related to phantom limb syndrome with pain. Review or Resident #7's August 2026 MAR revealed Oxycodone with Acetaminophen tab 5-325mg 1 tablet was administered on 08/05/2026 at 1:40 p.m. Review of Resident #7's Controlled Substance Record revealed an Oxycodone with Acetaminophen count of 53 tablets for this medication with the last dose documented on 08/05/2026 at 6:04 a.m. The actual count of Oxycodone with Acetaminophen tablets observed was 52. Resident #8 Review of Resident #8's physician orders revealed an order dated 06/29/2026 for KlonoPIN oral tablet 0.5mg (Clonazepam) give 1 tablet by mouth two times a day related to generalized anxiety disorder. Review or Resident #8's August 2026 MAR revealed that KlonoPIN oral tablet 0.5mg (Clonazepam) 1 tablet was administered on 08/05/2026 at 10:00 a.m. Review of Resident #8's Controlled Substance Record revealed a count of 27 tablets for this medication with the last dose documented on 08/04/2026 at 10:00 p.m. The actual count of tablets observed was 26. Resident #10 Review of Resident #10's physician orders revealed an order dated 07/15/2026 for Tramadol HCL (hydrochloride) oral tablet 50mg, give 2 tablet by mouth every 6 hours related to pain, unspecified. Review or Resident #10's August 2026 MAR revealed that Tramadol HCL oral tablet 50mg, 2 tablets were administered on 08/05/2026 at 10:00 a.m. Review of Resident #10's Controlled Substance Record revealed a count of 6 tablets with the last dose documented on 08/05/2026 at 4:00 a.m. The actual count of tablets observed was 4. Resident #14 Review of Resident #14's physician orders revealed an order dated 04/16/2026 for Norco oral tablet 10-325 mg, give 1 tablet by mouth every 6 hours related to pain, unspecified; wedge compression fracture of T11-T12 vertebra, subsequent encounter for fracture with routine healing. Review or Resident #14's August 2026 MAR revealed that Norco oral tablet 10-325 mg, 1 tablet was administered on 08/05/2026 at 10:00 a.m. Review of Resident #14's Controlled Substance Record revealed a count of 49 tablets for this medication with the last dose documented on 08/05/2026 at 4:00 a.m. The actual count of tablets observed was 48. Resident #28 Review of Resident #28's physician orders revealed an order dated 03/23/2026 for Lorazepam oral tablet 1mg, give 1 tablet by mouth in the afternoon related to generalized anxiety disorder and an order dated 09/16/2025 for Clonazepam oral tablet 1 mg, give 1 tablet by mouth two time a day related to epilepsy, unspecified, not intractable, without status epilepticus. Further review revealed an order dated 04/04/2025 for Methadone HCL oral tablet 5mg, give 1 tablet by mouth three times a day related to pain, unspecified. Review or Resident #28's August 2026 MAR revealed that Lorazepam oral tablet 1mg, 1 tablet was administered on 08/05/2026 at 11:00 a.m., Clonazepam oral tablet 1 mg, 1 tablet was administered at 8:00 am on 08/05/2026, and Methadone HCL oral tablet 5mg, 1 tablet was administered on 08/05/2026 at 8:00 a.m. Review of Resident #28's Controlled Substance Record revealed a Lorazepam count of 17 tablets for this medication with the last dose documented on 08/04/2026 at 5:00 p.m. The actual count of Lorazepam tablets observed was 16. Further review of Resident #28's Controlled Substance Record revealed a Clonazepam count of 27 tablets for this medication with the last dose documented on 08/04/26 at 8:00 p.m. The actual count of Clonazepam tablets observed was 26. Continuing review of Resident #28's Controlled Substance Record revealed a Methadone count of 41 tablets for this medication with the last dose documented on 08/04/2026 at 8:00 p.m. The actual count of Methadone tablets observed was 40. Resident #31 Review of Resident #31's physician orders revealed an order dated 07/23/2025 for Lyrica oral capsule 150 mg (Pregabalin) give 1 capsule by mouth three times a day related to pain, unspecified; restless legs syndrome. Review or Resident #31's August 2026 MAR revealed Lyrica oral capsule 150 mg (Pregabalin) 1 capsule was administered on 08/05/2026 at 8:00 a.m. and 12:00 p.m. Review of Resident #31's Controlled Substance Record revealed a Lyrica (Pregabalin) count of 2 capsules for this medication with the last doses documented on 08/04/26 at 8:00 p.m. The actual count of Lyrica (Pregabaline) capsules observed was 0. Resident #44 Review of Resident #44's physician orders revealed an order dated 04/16/2026 for Oxycodone with Acetaminophen tab (tablet) 10-325 mg, give 1 tablet orally every 6 hours related to type 2 diabetes mellitus with diabetic polyneuropathy; other polyosteoarthritis; pain, unspecified. Review or Resident #44's August 2026 MAR revealed Oxycodone with Acetaminophen tab (tablet) 10-325 mg, 1 tablet was administered on 08/05/2026 at 10:00 a.m. Review of Resident #44's Controlled Substance Record revealed a Oxycodone with Acetaminophen count of 28 tablets for this medication with the last dose documented on 08/05/2026 at 4:00 a.m. The actual count of Oxycodone with Acetaminophen tablets observed was 27. Resident #46 Review of Resident #46's physician orders revealed an order dated 03/04/2026 for Vimpat oral tablet 50mg (Lacosamide) give 50 mg via PEG (Percutaneous Endoscopic Gastrostomy)-tube two times a day related to other seizures. Review or Resident #46's August 2026 MAR revealed Vimpat oral tablet 50mg (Lacosamide) 50 mg was administered on 08/05/2026 at 8:00 a.m. Review of Resident #46's Controlled Substance Record revealed a Vimpat (Lacosamide) count of 59 tablets for this medication with the last dose documented on 08/04/2026 at 8:00 p.m. The actual count of Vimpat (Lacosamide) tablets observed was 58. Resident #48 Review of Resident #48's physician orders revealed an order dated 04/25/2026 for Alprazolam oral tablet 0.5mg give 1 tablet by mouth two times a day related to anxiety disorder, unspecified and an order dated 10/01/2025 for Oxycodone HCL oral tablet 10 mg, give 1 tablet by mouth every 4 hours for pain related to multiple sclerosis, unspecified; polyneuropathy, unspecified. Review or Resident #48's August 2026 MAR revealed Alprazolam oral tablet 0.5mg, 1 tablet was administered on 08/05/2026 at 8:00 a.m. and Oxycodone HCL oral tablet 10 mg, 1 tablet was administered on 08/05/2026 at 8:00 a.m. and 12:00 p.m. Review of Resident #48's Controlled Substance Record revealed an Alprazolam count of 20 tablets for this medication with the last dose documented on 08/04/2026 at 8:00 p.m. The actual count of Alprazolam tablets observed was 19. Further review of Resident #48's Controlled Substance Record revealed an Oxycodone count of 17 tablets for this medication with the last dose documented on 08/05/2026 at 4:00 a.m. The actual count of Oxycodone tablets observed was 15. Resident #60 Review of Resident #60's physician orders revealed an order dated 06/11/2025 for Oxycodone HCL oral tablet 10mg, give 1 tablet by mouth every 4 hours as need for pain related to chronic pain syndrome. Review or Resident #60's August 2026 MAR revealed Oxycodone HCL oral tablet 10mg, 1 tablet was administered on 08/05/2026 at 8:29 a.m. and another at 1:26 p.m. Review of Resident #60's Controlled Substance Record revealed an Oxycodone count of 42 tablets for this medication with the last dose documented on 08/04/2026 at 9:56 p.m. The actual count of Oxycodone tablets observed was 40. On 08/05/2026 at 4:00 p.m., S3DON confirmed that S9LPN was the charge nurse as mentioned in the above policy. She stated that S9LPN began her shift on 08/05/2026 at 6 a.m. and was responsible for administering and immediately reconciling all the narcotics that she gave.

Based on record review, observations and interviews, the facility failed to ensure dietary staff prepared, distributed and served food in accordance with professional standards for food service safety as evidenced by: Staff touching cooked food with bare hands; and3 dietary staff (S6AC, S7C and S8D) in kitchen with uncovered facial hair. This deficient practice had the potential to affect the 79 residents who ate from the kitchen.Findings:Review of a document titled General Food Preparation and Handling with no review date, read in part: Policy: Food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances.Procedure: g. bare hands should never touch ready to eat food directly.h. food will be prepared and served with clean tongs, scoops, forks, spoons, or other suitable implements to avoid manual contact of prepared foods. 5. Equipment - f. tongs or other serving utensils will be used to serve items to avoid bare hand contact with food. Review of a document titled Food Preparation and Service with a review date of 01/16/2026, read in part: Policy Statement - Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices.Food distribution and service: 6. bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Gloves are worn when touching the actual food items. Review of a document titled [NAME] Covering Policy with a review date of 01/16/2026, read in part: Purpose: to establish a standard for covering facial hair in the dietary department to promote food safety, infection prevention, and compliance with facility policies.Policy: employees with beards, goatees, or other facial hair who work in food preparation, food service, dishwashing, or any area where exposed food, clean equipment, or utensils are handled shall cover facial hair while on duty. The facility permits the use of a disposable surgical mask or other beard covering as a beard covering when the mask encloses the beard and facial hair.Procedure: 2 position the surgical mask or other beard covering so that facial hair is covered. On 08/03/2026 at 10:50 a.m., an observation was made of S5Cook preparing puree bread. She poured the puree bread into a serving pan to be placed on the serving line, and was then observed wiping the rim of the pan with her bare finger, and added the residual she took from the rim of the pan back into the serving pan. An immediate interview was conducted with S5Cook who confirmed she should not have touched the puree bread without gloves. On 08/03/2026 at 11:00 a.m., an observation of the male dietary staff revealed S6AC and S8D wearing surgical masks that did not fully cover their facial hair. On 08/04/2026 at 7:20 a.m., a follow up observation was conducted in the kitchen. S6AC was assisting S5Cook in preparing the lunch meal, and S8D was observed washing dishes. S6AC and S8D were observed wearing surgical mask that did not cover all of their facial hair. On 08/04/2026 at 11:30 a.m., another observation in the kitchen revealed S7Cook serving the lunch meal from the food line, and S6AC and S8AD were observed placing lunch plates on trays for resident distribution. All three kitchen staff workers were observed wearing surgical mask that did not fully cover their facial hair. On 08/04/2026 at 12:39 p.m., an interview was conducted with S4DM who stated the male dietary staff should be wearing beard restraints. She confirmed the surgical mask did not cover all of the hair on S6AC, S7Cook or S8D faces. On 08/04/2026 at 12:40 p.m., an observation and an interview was conducted with S2Admin who stated surgical masks was used as a beard restraint. S2Admin refused to confirm the exposed salt and pepper facial hair on S8D on immediate observation. S2Adm was then asked if it was safe and sanitary for S5Cook to use her bare index finger to remove excess puree bread from the rim of the serving pan. S2Admin stated he didn't' know anything about that. On 08/04/2026 at 4:15 p.m., an interview was conducted with S3DON who was asked if dietary staff should wear gloves when handling cooked food. S3DON stated from an infection control stand point, staff should have worn gloves to remove the excess puree bread from the rim of the servicing pan.

Based on record review and interviews, the facility failed to ensure the residents' plan of care were developed and/or implemented for 2 (Resident #36, Resident #43) out of a total sample of 39 residents, by failing to:1.Develop a comprehensive patient centered care plan for Resident #36 who was dependent for ADLs (Activities of Daily Living); and2.Follow physician's order for medication administration of Vitamin B1 for Resident #43. Findings: Resident #36 Review of Resident #36's electronic medical record revealed she was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, cerebral infarction, unspecified, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and dependence on wheelchair. Review of Resident #36's admission MDS (Minimum Data Set) with an ARD of 07/16/2026, revealed in Section GG Functional Abilities that she was impaired on one side upper and lower extremities. Further review revealed in part: she was dependent for toileting hygiene, shower/bathe self, putting on/taking off footwear, chair/bed-to-chair transfer, and tub/shower transfer. Review of Resident #36's current care plan revealed no evidence of a focus area nor interventions to address the resident's dependence on assistance for ADLs. On 08/04/2026 at 4:06 p.m., an interview and review of the comprehensive care plan for Resident #36 was conducted with S12MDS and S13MDS. Both confirmed that Resident #36 required assistance with ADLs according to her admission MDS. They also confirmed the patient centered care plan did not address Resident #36's dependence on assistance for ADLs and stated it should have. On 08/05/2026 at 10:25 a.m., an interview and review of the care plan and admission MDS for Resident #36 was conducted with S3DON. She confirmed that Resident #36 was dependent for most ADLs and the facility had not developed a comprehensive patient centered care plan that addressed her ADLs. Resident #43 Review of Resident #43's electronic medical record revealed he was admitted to the facility on [DATE] with a diagnoses which included, but was not limited to alcohol abuse, uncomplicated. Review of Resident #43's August 2026 MAR (Medication Administration Record) revealed the following order dated 07/10/2026 which read Vitamin B1 oral tablet 100 mg (milligrams) Thiamine HCL (hydrochloride) give 1 tablet by mouth one time a day related to alcohol abuse, uncomplicated. On 08/04/2026 at 8:11 a.m. an interview and observation of S11LPN administering medications to Resident #43 was conducted. S11LPN was observed administering a 50mg tablet of Vitamin B1 to Resident #43 during morning medication pass. After medication were administered to Resident #43, the resident's physician orders were reviewed with S11LPN. She confirmed that 100mg of Vitamin B1 should have been administered to the resident instead of 50mg. On 08/05/2026 at 9:32 a.m., a record review and interview was conducted with S3DON. She confirmed that on the 08/04/2026 morning medication pass, Resident #43 should have received 100mg of B1 per the physician orders instead of 50mg .

Based on record review, observations and interview, the facility failed to ensure a resident's treatment plan for pressure ulcers was followed by failing to apply a resident's heel protectors as ordered for 1(Resident #3) out of 2 residents investigated for pressure ulcers.Findings: Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE], with diagnoses that included, but were not limited to paroxysmal atrial fibrillation, cerebral infarction, other lack of coordination, cognitive communication deficit, muscle weakness, and pressure ulcer of left heel, unstageable.Review of the resident's quarterly MDS (Minimum Data Set) dated 05/12/2026, revealed his BIMS (Brief Interview of Mental Status) score was 5, indicating severe cognitive impairment.Resident #3 required substantial/maximal assistance with mobility. Further review revealed under Section M-Skin Conditions, the resident was coded to have one or more unhealed pressure ulcers/injuries, unstageable. Review of Resident #3's current care plan revealed a focus area for pressure ulcer. Interventions included in part.Administer treatment as ordered. A Follow-up LTC (Long Term Care) wound progress note for Resident #3 dated 07/27/2026, read in part, HPI (History of Present Illness). Left heel wound unstageable with adherent slough to site and santyl is continuing to soften slough for easier removal. Debrided atbedside, patient tolerated well. Recommend continuing treatment to santyl topically for enzymatic debridement of eschar to site and promote healing, offload with protector boot.Recommendations: Recommendations consisting of.Prevent contact of heels with bed or other surface. , Implement pressure relieving measures, offloading, and repositioning, as tolerated. Review of Resident #3's current physician orders revealed an order that read, heel lift boots to bilateral feet while in bed. Monitor q shift.On 08/05/2026 at 2:15 p.m., an observation was made of Resident #3 in his bed with his family at his bedside. The resident's family member removed the resident's blanket from over the resident's feet, revealing no heel protectors on his feet. On 08/05/2026 at 2:45 p.m., an observation and an interview was conducted with S11LPN. She confirmed that she was Resident #3's nurse. S11LPN removed the resident's blanket from over the resident's feet in order to make an observation of his feet. She confirmed that the resident did not have heel protectors on his feet and stated that he should have been wearing them while in bed.

Based on observation, record review and interview, the facility failed to ensure the resident was receiving continuous oxygen at the ordered flow rate for 1 (#74) out of 39 sampled residents. Findings:Resident #74. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, acute and chronic respiratory failure with hypoxia and acute on diastolic (congestive) heart failure. A review of Resident #74's admission MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 07/09/2026 revealed she had a BIMS (Brief Interview for Mental Status) score of 10, indicating the resident's cognition was moderately impaired. Review of the Resident #74 Order Summary Report revealed an active physician's orders dated 07/03/2026 for Oxygen at 3L (Liters)/NC (Nasal Cannula) continuous to relieve SOB (Shortness of Breath)/Hypoxia. May remove for ADLs (Activities of Daily Living) and at resident's discretion, every shift related to acute and chronic respiratory failure with hypoxia. On 08/03/2026 at 9:42 a.m., an observation was made of Resident #74 in bed. Her oxygen concentrator was set at 2L with the resident receiving oxygen per nasal cannula. On 08/03/2026 at 12:04 p.m., an observation was made of Resident #74 in bed. Her oxygen concentrator was set at 2L with the resident receiving oxygen per nasal cannula. On 08/04/2026 at 8:10 a.m., an observation was made of Resident #74 in bed. Her oxygen concentrator was set at 2L with the resident receiving oxygen per nasal cannula. On 08/04/2026 at 8:37 a.m., an interview, record review, and observation of Resident #74's oxygen concentrator was conducted with S11LPN. The resident was observed in bed receiving oxygen through a nasal cannula. S11LPN confirmed that the O2 concentrator was set to 2L. She further confirmed that according the resident's physician orders, the oxygen concentrator should have been set at 3L. S11LPN stated this is probably not at the resident's discretion as mentioned in the physician orders. On 08/04/2026 at 4:05 p.m., and interview was conducted with Resident #74. She stated she has not requested a change in her oxygen flow nor changed the flow herself. On 08/05/2026 at 8:27 a.m., an interview was conducted with S12LPN, nurse assigned to Resident #74. She stated that Resident #74 does not request adjustments for her oxygen. On 08/05/2026 at 9:36 a.m., an interview and record review was conducted with S3DON. She confirmed that Resident #74 should have been receiving 3L of oxygen continuously on 08/03/2026 and 08/04/2026.

Based on observations, interviews, and a review of manufacturer's instructions, the facility failed to ensure kitchen staff followed recipes for pureed diets. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs, and weight loss for the 7 residents who received pureed meals from the kitchen. Findings: Review of the manufacturer's package instructions for puree bread read in part: For serving of 8 add 3 cups cold water and 1 cup of mix. Optional ingredient 3 teaspoons of butter or margarine. On 08/03/2026 at 10:45 a.m., S5Cook was observed preparing puree bread with a pot of boiling water on the stove. She poured a white powdery substance from a white bag into the water and continuously stirred the mixture with a whisk. Closer observation revealed the bag contained instant puree bread. S5Cook was asked how much water was in the pot and she stated she did not know. S5Cook stated she added enough water to make enough bread for seven puree diets. S5Cook confirmed she did not measure the water nor the puree bread mixture, and stated she had been doing it for so long, she did not need to measure. On 08/03/2026 at 10:47 a.m., a review of the manufacturer's instructions and an interview was conducted with S5Cook and S4DM. S4DM read the manufacturer's directions that were written on the puree bread package and asked S5Cook if she had followed the directions on the package. S5Cook stated she had been preparing the puree bread without measuring for a long time. S4DM told S5Cook that she was supposed to follow the manufacturer's instructions for preparing the puree bread.

Based on observations, interviews, policy review, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection. This was evidenced by the staff failing to use appropriate Personal Protective Equipment (PPE) while changing linens for 1 (Resident #45) resident who was on Enhanced Barrier Precautions (EBP). Findings:A review of the facility's police with a last revised date of 01/22/2026, titled Enhanced Barrier Precaution read in part: Multidrug-resistant organism (MDRO) transmission is common long term care (LTC) facilities. Many residents in nursing homes are at increased risk becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistance organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care. [NAME] Gloves and activities that provide opportunities for transfer of MDROs to staff hands and clothing. Donning PPE for residents on EBP based on activity provided/Assistance while in resident room: Resident activity/assistance - changing linens - [NAME] Gloves and Gown - Yes.Review of Resident #45's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, diverticulitis of large intestine with perforation and abscess without bleeding, constipation, unspecified, perforation of the intestine, (nontraumatic), and colostomy status.Review of Resident's #45's current physician's orders revealed an order written 08/06/2024 that read in part: Enhanced Barrier Precautions During High Contact Resident Care Activities Every Shift. Every shift related to Colostomy Status.Review of Resident #45's care plan revealed a focus that read in part: the resident is on enhanced barrier precautions related to colostomy. Date initiated: 11/18/2025. Interventions included in part: Direct care staff to follow EBP, Direct care staff to utilize gowns and gloves for all personal care. Date initiated 11/18/2025. On 08/03/2026 at 10:12 a.m., an observation was made of a sign on Resident #45's room door that read in part: Enhanced Barrier Precautions, Providers and Staff Must Also wear gloves and a gown for the following high-contact resident care activities: changing linens. Resident #45 was observed in her room. S14CNA was observed changing Resident #45's linens and was not wearing a gown. S14CNA stated that she was responsible for providing care for Resident #45. She stated that she had not noticed the sign for EBP on Resident #45's door. S14CNA confirmed that Resident #45 was on EBP and she should have put on a gown while changing her linens. On 08/05/2026 at 8:59 a.m., an interview, record review and observation was conducted with S15IP. She confirmed that Resident #45 was on EBP as ordered and care planned. S15IP also confirmed that Resident #45 had an EBP sign posted on her room door. S15IP confirmed that S14CNA should have worn a gown while changing Resident #45's linens.On 08/05/2026 at 10:25 a.m., a record review and interview was conducted with S3DON. She confirmed that Resident #45 was currently on EBP as per her physician's orders. S3DON confirmed that S14CNA should have worn a gown while changing Resident #45's linens.

Based on observation, interview, and record review, the facility failed to ensure that a resident received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from worsening. The facility failed to: 1. conduct weekly body audits;2. report new skin findings to the nurse practitioner/physician in addition to the treatment nurse; and3. administer standing wound care orders for newly identified stage I pressure ulcer for 1 (#44) of 3 (#2, #11, and #44) residents reviewed for pressure ulcers. This deficient practice resulted in actual harm for Resident #44 on 07/29/2025 when S11LPN assessed his sacral area and discovered a Stage II pressure ulcer that measured 1 cm (centimeter) x 0.5 cm to coccyx (area near base of spine). On 07/05/2025, S6LPN discovered redness to Resident #44's his sacral (area at base of spine) area and did not report it to the treatment nurse nor implement treatment as specified in the facility's wound care standing orders. S6LPN also noted redness to the same area on 07/12/2025 and again did not report to the treatment nurse nor implement the wound care standing orders. Review of Resident #44's July 2025 TAR (treatment administration record) failed to reveal that wound treatment per the facility's protocol had been provided since the identification of the redness. There was no evidence in the resident's record that a weekly body audit had been conducted after 07/12/2025. On 07/29/2025 at 9:54 a.m., Resident #44 reported to S11LPN that he had pain to his bottom. At this time, a skin observation of the resident's bottom was conducted by S11LPN in the presence of surveyor that revealed a stage II pressure ulcer to the resident's sacral area. S11LPN was unware of the resident's pressure prior to the observation.A review of Resident #44's clinical record revealed that he was admitted to the facility on [DATE] with diagnoses that included, but not limited to, type 2 diabetes mellitus, multiple sclerosis, and mild protein-calorie malnutrition. The resident also had a Stage II pressure ulcer to his sacrum upon admission that was resolved on 05/06/2025. Review of Resident #44's Minimum Data Set (MDS) dated [DATE] revealed his cognition was 15, indicating he was cognitively intact. The resident was independent with bed mobility and was occasionally incontinent of urine. Further review revealed he was at risk for developing pressure ulcers and had an unhealed pressure Stage II pressure ulcer upon admission. A review of Resident #44's Care Plan dated 04/25/2025 read, in part: Resident has potential for pressure ulcer/pressure injury development. Interventions read in part: Observe/document/report to physician as needed changes in skin status. On 07/05/2025, the resident had potential for impairment to skin integrity, skin tears, bruises related to age related changes to skin integrity. Interventions: middle of sacral area cleanse dry with normal saline, pat dry, apply zinc oxide or facility skin barrier and leave open to air daily. It further read in part: Resident has bladder incontinence at times. Interventions: brief use. Provide resident with briefs and incontinence aids as needed. Protective barrier cream as needed. Review of Resident #44's progress notes documented per S6LPN (Licensed Practical Nurses) dated 07/05/2025 read in part: Body Audit sacral redness in center surrounding skin is pink and margins intact. Further review of the progress notes revealed a body audit per S6LPN on 07/12/2025 read in part. sacral redness in center of surrounding skin is pink and margins intact. Resident #44's progress notes failed to reveal any additional body audits conducted after 07/12/2025. On 07/29/2025 10:15 a.m., an interview was conducted with S2DON (Director of Nursing) who stated that body audits on residents are to be done weekly. She reported that the facility had a wound care standing order protocol that required the nurses to notify the physician, treatment nurse, and initiate wound care when an area of concern was identified. Review of the facility document entitled Wound Care Standing Orders which read in part:2. Pressure Wounds: Notify physician/nurse practitioner, Responsible Party, and Treatment Nurse upon discovery. Stage I persistent reddened area that does not blanch - cleanse with normal saline, pat dry, apply zinc oxide or facility skin barrier.and leave open to air daily. Stage II - if serum filled blister - cleanse gently with normal saline and wound cleanser, gently apply skin barrier.or skin prep and leave open to air until healed. For abrasion or shallow crater: cleanse gently with normal saline or wound cleanser, apply skin barrier.mixed with collagen, cover with dry clean dressing daily and as needed until healed. On 07/30/2025 at 11:25 a.m., a phone interview was conducted with S6LPN. She stated she identified the red area on his sacral area on 07/05/2025 and 07/12/2025 but failed to notify the treatment nurse since the standing order treatment required the use of normal saline. She stated that the protocol was to identify the area; notify the nurse practitioner; initiate the treatment; and document the information into the communication log for shift to shift awareness. She confirmed that she had not notified the treatment nurse of the resident's redness.Review of the facility document entitled Weekly Pressure Wound Quality Insurance (QI) Log dated 07/09/2025 through 07/16/2025 failed to list Resident #44 for wound care treatment. The facility did not provide a log for the week of 07/23/2025. Review of physician order detail for TAR (treatment administration record) dated 07/05/2025 read in part.middle of sacral area cleanse dry with normal saline. Pat dry. Apply zinc oxide or facility skin barrier.and leave open to air daily. Review of another physician order detail for TAR dated 07/24/2025 read in part.sacrum cleanse with pat dry apply zinc oxide; leave open to air one time daily. Review of Resident #44's July 2025 TAR read in part.middle of sacral area cleanse dry with normal saline, pat dry, apply zinc oxide or facility skin barrier.and leave open to air daily with a start date of 07/05/2025. There was no discontinue date listed. Further review revealed that no staff initialed that the treatment was administered from 07/05/2025 to 07/30/2025. There was another treatment order entry dated 07/24/2025 for sacrum - cleanse with pat dry apply zinc oxide leave open to air one time a day with a start and discontinue date of 07/24/205 of which there was no staff initials that the treatment had been provided. On 07/28/2025 at 9:40 a.m., an interview was conducted with Resident #44 who stated he had a sore on his back side that was painful and wanted it to be healed. He reported that the aides were putting cream on during peri-care but the treatment nurse had not assessed the area. On 07/28/2025 at 10:00 a.m., an interview was conducted with S10LPN who stated that she was working as the treatment nurse for the day. When asked if she had Resident #44 on the wound care treatment list, she stated Resident #44 did not have a wound and was not on the wound care list. On 07/29/2025 at 9:54 a.m., an observation of Resident #44 and interview was conducted with S11LPN in the resident's room. She stated that she was filling in for the wound care nurse. S11LPN stated Resident #44 was not on the wound care list and that she had no knowledge of him having a wound. Resident #44 stated to S11LPN that he had been having pain on his bottom. S11LPN proceeded to conduct an assessment of the resident's bottom. During the observation, she saw an open, pink area on his sacrum and classified it as a Stage II ulcer. She stated that the wound care nurse and physician should have been notified of the wound. A review of a progress note dated 07/29/2025 at 10:51 a.m. per S11LPN revealed Resident #44 was discovered with a Stage II pressure ulcer that measured 1 cm (Centimeter) x 0.5 cm to coccyx (tailbone) area. On 07/29/2025 at 11:03 a.m., a follow up interview was conducted with S2DON. She confirmed Resident #44 had not been placed on the wound care list and failed to follow protocol of notifying the treatment nurse of any wound care orders.

Based on record reviews and interview, the facility failed ensure that a resident's drug regimen was free from unnecessary drugs by failing to ensure gradual dose reduction forms were reviewed by the physician for 2 (Resident #11 and Resident #46) out of 6 residents (#4, #7, #11, #36, #46, and #81) reviewed for unnecessary medications.Resident #11Resident #11 was admitted to the facility on [DATE]. His diagnoses include in part, but not limited to dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression;, restlessness and agitation.Review of Resident #11's annual MDS (Minimum Data Set) date 07/09/2025 revealed under Section N--Medications, the resident was taking an antipsychotic, antianxiety and antidepressant medications. Further review of the MDS revealed N0450, letter D, was marked with the number 1, indicating that a GDR had been documented by a physician as clinically contraindicated. Review of the facility's GDR binder revealed the following GDR forms dated 06/09/2025 for Resident #11 were not addressed by the physician: Psychotropic Diagnosis Request and Behavior for the use of Haldol (antipsychotic medication), Psychoactive Gradual Dose Reduction for the use of Haldol, Klonopin (antianxiety medication), Remeron and Zoloft (antidepressant medications) and, Antipsychotic Diagnosis Verification for use of Haldol. Resident #46Review of Resident #46's medical record revealed she was admitted to the facility on [DATE]. Her diagnosis included in part, but not limited to, depression, unspecified psychosis not due to a substance or known physiological condition, anxiety and senile degeneration of brain, not elsewhere classified. Further review revealed the resident was on hospice services.Review of Resident #46's quarterly MDS dated [DATE] revealed under Section N--Medications, the resident was taking an antipsychotic, antianxiety, and antidepressant medications. Further review of the MDS revealed N0450, letter D, was marked with the number 0, indicating that a GDR had not been documented by the physician as clinically contraindicated.Review of the facility's GDR binder revealed the following GDR form dated 06/09/2025 for Resident #46 was not addressed by the physician: Psychoactive Gradual Dose Reduction for the use of Quetiapine Fumarate (Seroquel) and Citalopram Hydrobromide (Celexa) (antidepressant medications) and Lorazepam (antianxiety medication). On 07/30/2025 at 5:00 P.M., S1ADM (Administrator). S1ADM stated that she was unable to provide documented evidence that Resident #11 and Resident #46's GDR(s) for June were addressed by the physician. She confirmed the GDRs should have been reviewed by now.

Based on record reviews, observations and, interviews the facility failed to ensure the resident's care plan and physician's orders were followed for 5 (#8, #12, #36, #72, and #74) of 46 sampled residents. This was evidenced when staff failed to:1. document the severity of edema for Residents #8 and #72,2. document fluid intake with every meal for Resident #8,3. follow physician orders by not applying swath and sling to Resident #12's left arm,4. complete vital signs every shift for Resident #36,5. update Resident #74's care plan and physician's orders with the resident's code status and admission to hospice services Resident #12 Review of Resident #12's electronic clinical record revealed an admit date of 09/29/2020 with diagnoses that included Alzheimer’s Disease, Bilateral primary Osteoarthritis of knee, Osteoarthritis, and Mild protein calorie malnutrition. Review of Resident #12’s physician orders dated July 2025 revealed the following orders: Wear swath and sling to left arm when not icing or elevating it. Review of the resident's care plan dated 06/09/2025 read in part, wear swath and sling to left arm when not icing or elevating it as tolerated. Review of Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment. On 07/28/2025 at 8:50 a.m., an observation was conducted in the resident’s room. Further observation did not reveal the resident was wearing swath and sling on her left arm. No icing or elevation of the left arm were observed. On 07/28/2025 at 11:50 a.m., an observation was conducted of Resident #12 during the lunch meal. Further observation revealed that Resident #12 left arm swath and sling had not been applied. On 07/29/2025 at 9:38 a.m., another observation was conducted inside Resident #12’s room. S13HCNA (Hospice Certified Nursing Assistant) had completed her bath, and was asked about the application of the swath and sling. S13HCNA stated she did not know anything about that. She stated that she had given the resident her bath for some time now, and had never seen nor applied a swath and sling to her left arm. On 07/29/2025 at 3:30 p.m., an interview was conducted with S14RN (Registered Nurse) who stated that the resident had a physician’s order for the swath and sling, and did not have an end date. The staff were supposed to be applying the swath and sling as per physician orders and per her care plan. Resident #72 Review of Resident #72’s electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, displaced fracture of base of neck of right femur, and aftercare following joint replacement surgery. Review of Resident 72’s July 2025 physician’s orders revealed an order dated 07/27/2025 for Monitor for edema q (every) shift. Chart severity. Chart 0=No edema noted, 1=+1 Edema, 2=+2 Edema, 3=+3 Edema, 4=+4 edema noted. Review of Resident #72’s July 2025 MAR (Medication Administration Record) revealed the following: Monitor for Edema Q-Shift. Chart severity. Chart 0=No edema noted, 1=+1 Edema, 2=+2 Edema, 3=+3 Edema, 4=+4 edema noted. There was no documentation that the charting of severity was done for the resident on the dates of 07/27/2025, 07/28/2025, 07/29/2025 and 07/30/2025. On 07/30/2025 at 5:20 p.m., an interview and record review was conducted with S3ADON (Assistant Director of Nursing). She reviewed Resident #72’s MAR and confirmed the resident’s severity of edema were not charted as ordered in July 2025. Resident #74 Review of Resident #74’s electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, normal pressure hydrocephalus. Review of Resident #74’s hospice binder revealed that he was admitted to hospice services on 10/26/2024. Review of Resident #74's record revealed a Louisiana Physician Orders For Scope of Treatment (LaPOST) checked for: A. Do Not Attempt Resuscitation (DNR) B. Medical interventions: Person has pulse or is breathing-Selective Treatment C. Artificially Administered Fluids and Nutrition-No artificial nutrition by tube. D. Summary Discussed with-Personal Health Care Representative (PHCR), signed by physician on 10/26/2024 and signed by PHCR on 10/26/2024. Review of Resident #74’s July 2025 physician’s orders revealed no order for a DNR code status. Further review of Resident #74’s July 2025 physician’s order revealed no order for an admission to hospice services. Review of Resident #74’s care plan revealed no care plan had been developed for a code status. Further review of Resident #74’s care plan revealed no care plan had been developed for an admission to hospice services. On 07/29/2025 at 2:06 p.m., an interview and record review was conducted with S2DON (Director of Nursing). S2DON confirmed that Resident #74’s July 2025 physician’s orders did not reveal an order for his code status or his admission to hospice services. S2DON confirmed that a physician’s order should have been documented for Resident #74’s code status and admission to hospice services and was not. S2DON also confirmed that Resident #74’s care plan did not include a care plan for his code status or his admission to hospice services. S2DON confirmed that a care plan should have been developed for Resident #74’s code status and admission to hospice and was not. Resident #36 Resident #36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, hypertension, and dementia. Review of Resident #36’s electronic health record (EHR) revealed a physician’s order written on 06/17/2025, which read “Vitals Q shift every shift.” Further review of Resident #36’s EHR revealed in the vital signs documents for 07/2025 that vital signs were done only on the following dates: Blood pressure: 06/13/2025, 07/02/2025, 07/03/2025, 07/07/2025, and 07/22/2025; Temperature: 06/13/2025, 07/02/2025, 07/03/2025; Pulse: 06/13/2025, 07/02/2025, 07/03/2025, 07/07/2025, 07/22/2025; Respiration: 06/13/2025, 07/02/2025, 07/03/2025; and Oxygen Saturation: 06/13/2025, 07/02/2025, and 07/03/2025. Review of Resident #36’s medication and treatment administration records for 07/2025 revealed no vital signs recorded. On 07/30/2025 at 9:35 a.m. an interview and review of Resident #36’s EHR was conducted with S2DON (Director of Nursing) and S3ADON (Assistant Director of Nursing). They both confirmed the above vital signs were the only ones recorded for 07/2025. They also confirmed Resident #36 had an order for vital signs to be completed every shift and they should have been completed and recorded every shift and were not. Findings: Resident #8 Review of Resident #8’s EHR (Electronic Health Record) revealed she was admitted to the facility on [DATE] and had diagnoses including, but not limited to, end stage renal disease, essential hypertension, and chronic obstructive pulmonary disease, unspecified protein calorie malnutrition. Review of Resident #8’s July 2025 physician’s orders revealed the following orders with start date of 4/25/2025: Monitor for Edema Q-Shift (every shift) Chart Severity. Chart 0= No edema noted; 1= +1 Edema; 2= 2+ Edema, 3= 3+ Edema, 4= 4+ Edema noted. Monitor fluid intake q (every) meal; 4=100%; 3=75%; 2=50%; 1=25%; 0=0% Review of Resident #8’s plan of care revealed the following in part: Potential for weight loss r/t (related to) Unspecified Protein-Calorie Malnutrition/Vitamin Deficiency - Interventions: Res (Resident) with 6% (6lb) wt (weight) loss in less than 30 days….Will continue to monitor intake and weigh weekly. I am at risk for complications related to dialysis for the diagnosis of: End Stage Renal Disease- Resident has right wall tunnel cath (catheter) - Interventions: Monitor fluid intake q (every) meal. Review of Resident #8’s EHR failed to reveal any evidence that the resident’s edema severity was documented every shift or that the resident’s fluid intake was monitored at every meal. On 07/29/2025 at 9:12 a.m., an interview was conducted with S6LPN (Licensed Practical Nurse). Resident #8’s physician’s orders were reviewed with S6LPN. S6LPN was asked if she had charted the severity of the resident’s edema as the physician order had stated. S6LPN was unable to provide evidence that the severity of the edema, if any, had been charted every shift. S6LPN was also asked if she monitored the resident's fluid intake and documented the percentage of fluid intake with each meal as stated in the physician’s orders. She stated that even though there was a physician’s order to monitor the resident’s fluid intake, the CNAs (Certified Nursing Assistants) were responsible for monitoring and documenting the resident’s fluid intake, and she had not documented the percentage of fluid intake with each meal. On 07/29/2025 at 9:40 a.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated that because there had been a physician's order for monitoring the resident's fluid intake with each meal, it would have been the nurse's responsibility to monitor and document it. S2DON failed to provide evidence that Resident #8’s fluid intake had been documented with every meal. S2DON also confirmed there was no documented evidence that the nurses charted the severity of the resident’s edema each shift.

Based on record review and interview, the facility failed to maintain an effective QAPI (Quality Assurance and Performance Improvement) program by failing to adequately monitor QAPI projects that were opened to determine if corrections or revisions were necessary. This had the potential to affect the 73 residents that resided at the facility. Findings: On 07/30/2025 at 5:30 p.m., review of the facility's QAPI program and current performance improvement projects and interview was conducted with S2DON (Director of Nursing). S2DON stated the facility had multiple nursing QA (Quality Assurance) projects that were opened prior to the survey. A review of the open QA projects was conducted with S2DON and revealed the following: -A QA project for GDRs (Gradual Dose Reductions) to be monitored and implemented was opened on 05/22/2025. Action steps were to meet with pharmacy consultant monthly and prn (as needed). There was no monitoring or audits conducted for the QA project. S2DON stated that she had not been monitoring or conducting audits for the GDRs QA project. -A second QA project for weekly body audits was reviewed with S2DON. The project was opened on 05/28/2025 and documented as ongoing on 05/30/2025. Action steps included placing a schedule for required daily body audits at each nurses' station, in-servicing staff, and monitoring. DON or designee was to complete 2 random observations throughout the facility at minimum 3 times per week for 4 weeks and will continue as deemed necessary. A nursing in-service conducted on 05/28/2025 revealed the following: We are required to do weekly skin inspections and general notes on our residents. This is the schedule. Also, please remind CNAs (Certified Nursing Assistants) to report all skin issues- redness, bruises, abrasions, etc). Monitoring began on 06/02/2025, with the last recorded monitoring conducted on 07/10/2025. S2DON stated that her treatment nurse had been out for the last two weeks, and the monitoring for this QA project had not been done from 07/10/2025 to 7/30/25. -A third QA project was reviewed with S2DON for expired medications that was opened on 05/30/2025. The QA monitoring for the medication room read: The DON/designee will complete a minimum of 5 random observations throughout the facility weekly for 4 weeks and will continue as deemed necessary. Monitoring began on 06/02/2025, and three observations were completed. Three observations were completed on 06/10/2025, and 06/18/2025. There was no other monitoring conducted from 6/18/2025 to 7/30/2025. At this time, S2DON confirmed that she was aware of deficient practice being cited on the current survey regarding GDRs, weekly body audits, and expired medications. She confirmed that adequate monitoring of opened QA projects had not been conducted prior to the survey.

Based on record review, and interview, the facility failed to ensure each resident's clinical record accurately reflected their advanced directives for 1 (#74) out of 1 (#74) residents reviewed for advanced directive. This deficient practice had the potential to affect the entire census of 73 residents. Findings:Review of Resident #74's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, normal pressure hydrocephalus. Review of Resident #74's admission record revealed DNR (Do Not Resuscitate) status. Review of Resident #74's record revealed a Louisiana Physician Orders For Scope of Treatment (LaPOST) checked for:A. Do Not Attempt Resuscitation (DNR)B. Medical interventions: Person has pulse or is breathing-Selective Treatment C. Artificially Administered Fluids and Nutrition-No artificial nutrition by tube. D. Summary Discussed with-Personal Health Care Representative (PHCR), signed by physician on 10/26/2024 and signed by PHCR on 10/26/2024. A review of Resident #74's facility's document titled, Care Profile Report, Special Instructions revealed: Full Code. On 07/29/2024 at 2:06 p.m., a record review and interview was conducted with S2DON (Director of Nursing). S2DON confirmed the facility's document, Care Profile Report, Special Instructions read the resident is a full code. S2DON confirmed Resident #74's admission record read the resident is a DNR. S2DON confirmed Resident #74's record revealed the LaPOST form that indicated the resident had a DNR status and was signed on 10/26/2024. She stated the facility's document, Cornerstone at the Ranch Care Profile Report should have been updated to reflect the code status to DNR status and was not.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (#76) of 46 sampled residents.Review of Resident #76's electronic health record (EHR) revealed an admission date of 04/15/2025 and a discharge date of 05/06/2025.Review of Resident #76's Discharge Return Not Anticipated MDS dated [DATE] revealed in Section A2105 a discharge status of short-term general hospital. Review of the facility's emergency transfer logs from March 2025 to July 2025 revealed Resident #76 was not listed as going to the hospital.Review of Resident #76's progress notes dated 05/06/2025, revealed an entry by S15LPN (Licensed Practical Nurse), resident left ama (against medical advice). Checked on post dc (discharge) by administrator and resident found in good condition in safe home.On 07/30/2025 at 11:56 a.m., an interview was conducted with S16SSD (Social Services Director). She stated that Resident #76 left the facility AMA to go home and was not sent to the hospital.On 07/30/2025 at 12:15 p.m., an interview was conducted with S1ADM (Administrator) and S2DON (Director of nursing). S1ADM stated Resident #76 left the facility AMA to go home. S2DON confirmed Resident #76 left AMA for her own home and stated that the MDS was incorrectly coded.

Based on observations, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with current accepted professional principles by failing to discard expired medication in 2 medication rooms (Room A and Med Room B/C) of 2 (Med Room A and Med Room B/C) medication rooms sampled for medication storage. Findings:On [DATE], a review of the facility's policy titled, Storage of Medication dated [DATE], revealed in part. Policy Heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation:.4 .Discontinued, outdated, or deteriorated drugs or biologicals are destroyed.On [DATE] at 12:09 p.m., an observation was conducted of Med Room A with S3ADON (Assistant Director of Nursing) which revealed the following: 1. Sodium Chloride Tablets 1 gm (gram) bottle with an expiration date of 04/20252. (6) Acetaminophen Supp (suppository) 650 mg (milligram) with an expiration date of [DATE]. (8) Bisacodly Supp (suppository) 10 mg with an expiration date of [DATE]At that time, S3ADON confirmed the above medications were expired and should have been discarded and not in the medication room.On [DATE] 12:19 p.m., an observation was conducted of Med Room B/C with S3ADON which revealed the following: 1. Ferrous Sulfate Elixir bottle with an expiration date of 06/20252. Vitamin D-3 125 mcg (microgram) 5000 IU (international units) bottle with an expiration date of 06/2025 At that time, S3ADON confirmed the above medications were expired and should have been discarded and not in the medication room.

Based on observations and interviews, the facility failed to dispose of garbage and refuse properly in the dietary garbage disposal area.On 07/30/2025, a review of the facility's undated policy and procedure titled Policy and Procedure for: Disposing of Garbage & Refuse Properly, read in part 1. Proper Garbage Containers.b. Waste must be properly contained and covered in dumpsters or compactors.2. Sanitary Garbage Storage: a. Garbage storage areas must be maintained in a sanitary condition.Conduct regular checks of garbage containers, transport routes, and storage areas to ensure compliance.On 07/28/2025 at 9:20 a.m., an observation was made of the dietary garbage disposal area with S4DM (Dietary Manager). Used gloves and other trash items were observed on the right immediately after stepping outside the building and entering the walkway leading to the garbage dumpster. There were two gloves on the ground close to a large yellow bucket. The garbage dumpster was open, and there were three used gloves on the ground in front of the dumpster. Further observation revealed a white garbage bag containing refuse outside and to the left of the dumpster. S4DM stated that the garbage dumpster was supposed to be kept closed and the surrounding areas clean at all times.On 07/29/2025 at 10:38 a.m., an interview was conducted with S1ADM (Administrator). She stated that the dumpster was used by the kitchen staff only. She stated that it was not supposed to be left like that and that the kitchen staff was responsible for maintaining the cleanliness of the area.

Based on observations, interviews, and record reviews, the facility failed to store food in accordance with professional standards for food service and ensure sanitary conditions were maintained in the kitchen, as evidenced by: 1. the flooring was not clean; 2. rodent droppings in a storage area; 3. opened and unlabeled food items in the refrigerator designated for resident supplements; and 4. a thick layer of debris and food residue on the deep fryer. This deficient practice had the potential to affect the 79 residents who resided in the facility. Findings: On 06/16/2025 at 12:15 p.m., a review of the facility's undated policy titled, Policy and Procedure for: Food Procurement, Store/Prepare/Serve-Sanitary, revealed in part: 2. All food items in refrigerators and freezers must be labeled and dated .15. Observe for any evidence of pests in the food storage, preparation, or service areas and report to the dietary supervisor. Review of the state department Sanitarian's notice of violations revealed a routine/renewal visit was conducted on 06/05/2025 at 10:30 a.m. with non-critical items of: Floors are not clean, signed by S2DM (Dietary Manager) Review of the state department Sanitarian's notice of violations revealed a complaint visit was conducted on 06/12/2025 at 12:25 p.m. with a critical item violation described as: Rodents are present in the establishment. Non-critical item violations were described as: Non-food contact surfaces not being cleaned at a frequency necessary to preclude the accumulation of soil residues, and a repeat violation of floors not being clean. Under the comments section, read in part: Inspection: Rodent droppings were found in the kitchen storage areas. S1AssistAdmin (Assistant Administrator) signed the notice. On 06/12/2025 at 8:01 a.m. an initial tour of the kitchen was conducted. There was a separate area of the kitchen that was not in use to prep and serve food; it was used as storage. There was a commercial stationary steam table, not working, with an open section between the cold and hot well systems. The open section did not have tile on the floor, observed two single-use empty round condiment containers, a black glue rodent and insect trap, and multiple dark colored, dried droppings scattered on the floor. On 06/12/2025 at 8:03 a.m., an upright freezer/refrigerator located in the open storage area was observed. S2DM explained the freezer/refrigerator was designated for residents' supplements during meal services. Upon opening the refrigerator, an observation was made of the third shelf. The third shelf consisted of a pull-out drawer for storage. Inside the drawer, there were three storage plastic bags of lettuce; two of the bags were unlabeled and unopened. One of the plastic storage bags of lettuce was opened and not dated.S2DM confirmed the bags were not dated or labeled. S2DM immediately removed and disposed the three plastic storage bags of lettuce. On 06/12/2025 at 12:33 p.m., a follow up observation was conducted in the kitchen. A deep fryer was observed with a thick layer of debris and food residual on both sides of the fryer. The flooring underneath the fryer was observed with a dark thick layer of residue. On 06/12/2025 at 1:01 p.m., S3KS (Kitchen Staff) was observed sweeping the floor surrounding the upright freezer/refrigerator. S3KS explained the Sanitarian who was present instructed S3KS to sweep the floor due to observations of rodent droppings. S3KS explained that the items in the upright freezer/refrigerator were utilized by facility staff to grab supplements needed when serving residents their meals. On 06/12/2025 at 5:00 p.m., an observation and interview was conducted with S2DM who confirmed the sides of the fryer and the flooring underneath the fryer were not cleaned and should have been.

Based on observations and interviews, the facility failed to provide a safe, sanitary, and comfortable environment as evidenced by failing to ensure that an electrical outlet was sealed and secured properly into the wall in the kitchen. This deficient practice had the potential to affect the 79 residents who resided in the facility. Findings: On 06/12/2025, a review of the facility's policy titled, Quality of Life-Homelike Environment, with a last revision date of April 11, 2025, revealed in part . 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment . On 06/12/2025 at 8:09 a.m., an observation of the kitchen was conducted. An electrical outlet near the food preparation area was not sealed and secured properly into the wall. The box of the outlet was protruding out of the wall, and a square hole was observed where the outlet was supposed to be secured to the wall. On 06/12/2025 at 5:08 p.m., an observation and interview was conducted with S1AssistantADM (Assistant Administrator) who confirmed the electrical outlet was not sealed and secured properly into the wall and should have been.

Based on record review and interviews, the facility failed to notify a resident's physician when a resident had a significant change in condition for 1 (#3) out of 3 (#1, #2, #3) residents sampled. Findings: A review of the facility's policy titled, Change in a Resident's Condition or Status with a last reviewed date of 01/15/2024, read in part, Our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status . Review of Resident #3's record revealed she was admitted to the facility on [DATE] with a diagnoses that included in part, Dementia, Human Immunodeficiency Virus, Chronic Kidney Disease, Abnormal Weight Loss, and Moderate Protein- Calorie Malnutrition. Resident #3 had a discharge date of [DATE]. Review of Resident #3's SNF (Skilled Nursing Facility) Nurses' Notes from 10/04/2024 to 10/10/2024 read in part, Gastrointestinal: 6. Does the resident have problems with consistency of bowel movement? B. Diarrhea. On 11/04/2024 at 3:21 p.m., an interview was conducted with S2CNA (Certified Nursing Assistant). S2CNA stated that she cared for Resident #3 during her stay at the facility. She stated that she had frequent loose stools every day, requiring her to change the resident 18-19 times per shift. On 11/06/2024 at 12:30 p.m., an interview was conducted with S3NP (Nurse Practitioner). S3NP stated that he had not been notified of Resident #3's episodes of diarrhea during her stay at the facility and should have been. On 11/06/2024 at 01:46 p.m., a phone interview was conducted with S1LPN (Licensed Practical Nurse). She stated that she had cared for Resident #3. She stated that she was aware of the resident's diarrhea episodes. S1LPN stated that she had not notified the physician of Resident #3's diarrhea. On 11/06/2024 at 01:58 p.m., an interview was conducted with S2CNA. She stated that she had reported twice to the nurse responsible for Resident #3's care of the resident's diarrhea episodes. On 11/06/2024 at 04:13 p.m., an interview and record review was conducted with S4CRN (Corporate Registered Nurse). She stated that she was a DON (Director of Nursing) with the corporation and would be answering questions for the facility's DON in her absence. A review of Resident #3's medical record was conducted with S4RN. She confirmed there was documentation of Resident #3's episodes of diarrhea during her stay at the facility. She also confirmed that there was no documentation that Resident #3's physician or NP was notified and should have been.

Based on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standard and practices for 1(#3) of 3(#1,#2, and #3) sampled residents as evidenced by failure to ensure documentation of bowel charting was accurate. The deficient practice had the potential to effect a total census of 71. Findings: A review of the facility's policy titled, Charting and Documentation with a last reviewed status of 01/15/2024, read in part, . All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective, complete, and accurate. Review of Resident #3's record revealed she was admitted to the facility on [DATE] with a diagnoses that included in part, Dementia, Human Immunodeficiency Virus, Chronic Kidney Disease, Abnormal Weight Loss, and Moderate Protein- Calorie Malnutrition. Resident #3 had a discharge date of [DATE]. Review of Resident #3's Bowel and Bladder Charting for October 2024, revealed an area on the grid for documentation of Size (S=small, M=Medium, L=Large) and Consistency (S=Soft, H=Hard, W=Watery). Shift #1's documentation read in part: Size: a. 10/04/2024- 10/13/2024: 10 entries with the letter Y Consistency: a. 10/04/2024- 10/09/2024: 6 entries with the letter Y b. 10/10/2024- 10/11/2024: 2 entries with the letter L On 10/06/2024 at 2:45 p.m., an interview and record review of Resident #3's Bowel and Bladder Charting for October 2024 was conducted with S5ADON (Assistant Director of Nursing). S5ADON confirmed that Size was documented with Y and should have been documented with the letters S, M, or L. S. S5ADON also confirmed Consistency was documented with Y and L and should have been documented with the letters S, H, or W. S5ADON confirmed the CNA's (Certified Nursing Assistants) did not document accurately, and the key provided was not used correctly and should have been. On 10/06/2024 at 4:13 p.m., an interview and record review was conducted with S6ADM (Administrator). S6ADM confirmed that documentation by CNA's was not documented correctly by CNAs for Shift #1's Size and Consistency areas of the Bowel and Bladder Charting, for October 2024, and should have been.

Based on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standard and practices for 2 (#2, #3) of 3 (#1-#3) sampled residents by failing to ensure: 1. An accurate assessment of edema, and mood/behaviors was documented for Resident #2; and 2. An accurate assessment of edema was documented for Resident #3. Findings: 1. Review of the Resident #2's Electronic Medical Record revealed she was admitted to the facility on [DATE] and had diagnoses including Diabetes Mellitus Type II, Cellulitis Right Lower Extremity, Schizoaffective Disorder, Bipolar Disorder, Anxiety Disorder and Congestive Heart Failure. Review of Resident #2's September 2024 physician orders revealed an order to monitor edema every shift, and monitor mood and behaviors every shift starting on 07/22/2024. Review of a facility document titled, ___ Med Progress Note, dated 08/13/2024 read in part peripheral 2 plus edema to lower extremity. Resident had increased bilateral edema and felt tight. Further review revealed a note dated 08/21/2024 which read in part .peripheral edema 2 plus to lower extremity, and chronic bilateral edema. Review of Resident #2's August 2024 Medication Administration Record (MAR) revealed S5LPN documented on 08/12/2024 and 08/21/2024 Resident #2 did not have edema. Further review revealed S4LPN documented on 08/21/2024 Resident #2 did not have edema. Review of the resident's Electronic Medical Record revealed Nursing Progress Notes dated 09/01/2024 at 1:49 p.m., and documented by S3LPN (Licensed Practical Nurse) read in part Resident #2 yelling in hallway refusing to let aid assist her to her room to receive incontinence care. Further review of S3LPN documentation revealed at 1:53 p.m., Resident #2 was yelling and cursing in dining area for breakfast because no one bought her a (soda). Resident #2 tried to throw her clothing protector at another resident. Further review of Resident #2's MAR revealed on 09/01/2024, S3LPN documented no behaviors were observed. S4LPN and S5LPN were not available for interview. On 09/24/2024 at 3:15 p.m., an interview, and observation was conducted with S3LPN who confirmed that Resident #2 had an order to monitor the edema to her lower extremities. She stated the times she had cared for Resident #2, her bilateral lower extremities were always edematous. She stated the resident always had edema to her lower extremities. S3LPN also confirmed that the documentation on 09/01/2024 regarding the resident's mood/behavior was not accurate. She stated the resident was experiencing behaviors of profanity and attempting to throw her clothing protector at another resident. She added that due to the resident's behaviors, the resident had to be sent out for a psychological evaluation that day. 44269 2. Review of Resident #3's Electronic Medical Record revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Chronic Diastolic (Congestive) Heart Failure, Chronic Kidney Disease and Type 2 Diabetes Mellitus. Review of Resident #3's September 2024 physician orders revealed an order with a start date of 07/17/2024 for Furosemide (diuretic) 20 mg (milligram) tablet one po (by mouth) QD (every day)-monitor edema prior to administering the diuretic. Review of Resident #3's September 2024 MAR revealed the resident was administered Furesomide 20 mg tablet, a diuretic, (fluid medication) every day and nursing was to monitor the resident's edema prior to administering the diuretic. The resident's edema was documented as present per S3LPN on 09/04, 09/13, 09/18, 09/19, 09/23 and 09/24. Review of Resident #3's Daily Skilled Nursing Assessments for September 2024 revealed the resident was assessed as having no edema present on 09/04, 09/13, 09/18, 09/19, 09/23 and 09/24. On 09/24/2024 at 12:10 p.m., an interview was conducted with S3LPN. S3LPN confirmed the resident received a diuretic daily and that the day shift nurse was to monitor and document whether or not edema was present before giving the diuretic. She confirmed the resident was skilled and that the day shift documented a skilled nursing assessment daily which included assessing the presence of edema on the resident. S3LPN confirmed the resident's September 2024 MAR and daily skilled nursing assessments for the dates of 09/04, 09/13, 09/18, 09/19, 09/23 and 09/24 were not accurately documented to reflect the resident had edema present. On 09/24/2024 at 1:15 p.m., an observation was made of Resident #3 sitting in her wheelchair with +2 edema noted. On 09/24/2024 at 4:00 p.m., an interview was conducted with S2DON. S2DON confirmed the resident was skilled and required daily nursing assessments. S2DON verified that the monitoring of edema on the resident's MAR and daily nursing assessments should match and had not.