Every finding on record at Cottonwood Healthcare Center

Based on observation, interview, and record review, the facility failed to provide a notice of transfer to 51 long-term care residents and/or their representatives at least 30 days before transfer, when 51 residents were transferred to other facilities within 10 days of transfer notification. This failure decreased the facility's potential to provide safe and effective transition of care while maintaining the residents' highest practicable physical, mental and psychosocial wellbeing.Findings: A review of the admission records for 51 long-term care residents indicated the following:- Resident 1 was readmitted to the facility in March 2025 and transferred to another facility on 7/17/26;- Resident 2 was readmitted to the facility in July 2025 and transferred to another facility on 7/16/26;- Resident 3 was readmitted to the facility in June 2025 and transferred to another facility on 7/16/26;- Resident 4 was readmitted to the facility in May 2026 and transferred to another facility on 7/24/26;- Resident 5 was readmitted to the facility in November 2023 and transferred to another facility on 7/22/26;- Resident 6 was readmitted to the facility in September 2021 and transferred to another facility on 7/22/26;- Resident 7 was readmitted to the facility in September 2025 and transferred to another facility on 7/21/26;- Resident 8 was admitted to the facility in September 2023 and transferred to another facility on 7/19/26;- Resident 9 was readmitted to the facility in March 2024 and transferred to another facility on 7/17/26;- Resident 10 was readmitted to the facility in February 2026 and transferred to another facility on 7/18/26;- Resident 11 was readmitted to the facility in January 2024 and transferred to another facility on 7/20/26;- Resident 12 was admitted to the facility in June 2024 and transferred to another facility on 7/16/26;- Resident 13 was readmitted to the facility in May 2024 and transferred to another facility on 7/20/26;- Resident 14 was readmitted to the facility in May 2024 and transferred to another facility on 7/18/26;- Resident 15 was admitted to the facility in September 2021 and transferred to another facility on 7/19/26;- Resident 16 was admitted to the facility in July 2018 and transferred to another facility on 7/20/26;- Resident 17 was admitted to the facility in April 2024 and transferred to another facility on 7/17/26;- Resident 18 was readmitted to the facility in November 2023 and transferred to another facility on 7/20/26;- Resident 19 was admitted to the facility in September 2024 and transferred to another facility on 7/18/26;- Resident 20 was admitted to the facility in October 2024 and transferred to another facility on 7/21/26;- Resident 21 was readmitted to the facility in January 2023 and transferred to another facility on 7/19/26;- Resident 22 was readmitted to the facility in February 2026 and transferred to another facility on 7/20/26;- Resident 23 was readmitted to the facility in January 2022 and transferred to another facility on 7/21/26;- Resident 24 was readmitted to the facility in October 2025 and transferred to another facility on 7/19/26;- Resident 25 was admitted to the facility in May 2023 and transferred to another facility on 7/20/26;- Resident 26 was admitted to the facility in November 2024 and transferred to another facility on 7/17/26;- Resident 27 was admitted to the facility in November 2023 and transferred to another facility on 7/23/26;- Resident 28 was admitted to the facility in August 2022 and transferred to another facility on 7/23/26;- Resident 29 was admitted to the facility in October 2024 and transferred to another facility on 7/24/26;- Resident 30 was admitted to the facility in October 2022 and transferred to another facility on 7/19/26;- Resident 31 was admitted to the facility in September 2021 and transferred to another facility on 7/21/26;- Resident 32 was readmitted to the facility in July 2025 and transferred to another facility on 7/24/26;- Resident 33 was readmitted to the facility in March 2025 and transferred to another facility on 7/21/26;- Resident 34 was admitted to the facility in March 2026 and transferred to another facility on 7/17/26;- Resident 35 was admitted to the facility in April 2026 and transferred to another facility on 7/23/26;- Resident 36 was readmitted to the facility in May 2026 and transferred to another facility on 7/17/26;- Resident 37 was readmitted to the facility in October 2024 and transferred to another facility on 7/21/26;- Resident 38 was readmitted to the facility in March 2026 and transferred to another facility on 7/17/26;- Resident 39 was readmitted to the facility in April 2021 and transferred to another facility on 7/21/26;- Resident 40 was readmitted to the facility in November 2024 and transferred to another facility on 7/16/26;- Resident 41 was admitted to the facility in June 2011 and transferred to another facility on 7/20/26;- Resident 42 was admitted to the facility in April 2025 and transferred to another facility on 7/20/26;- Resident 43 was admitted to the facility in June 2024 and transferred to another facility on 7/20/26;- Resident 44 was admitted to the facility in June 2018 and transferred to another facility on 7/24/26;- Resident 45 was admitted to the facility in June 2023 and transferred to another facility on 7/21/26;- Resident 46 was admitted to the facility in December 2019 and transferred to another facility on 7/21/26;- Resident 47 was readmitted to the facility in February 2025 and transferred to another facility on 7/23/26;- Resident 48 was readmitted to the facility in January 2026 and transferred to another facility on 7/23/26;- Resident 49 was admitted to the facility in September 2023 and transferred to another facility on 7/23/26;- Resident 50 was admitted to the facility in July 2023 and transferred to another facility on 7/24/26; and- Resident 51 was admitted to the facility in June 2026 and transferred to another facility on 7/22/26.A review of Resident 37's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 5/8/26, indicated Resident 37's brief interview for mental status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 out of 15 with intact memory.During a concurrent observation and interview on 7/20/26 at 12:15 p.m. with Resident 37, Resident 37 stated the transfer to a facility 65 miles away was very stressful and the distance might prevent routine weekend visits with a friend. Resident 37 became visibly upset during the interview.A review of Resident 51's MDS, dated [DATE], indicated Resident 51's BIMS score was 15 out of 15 with intact memory.During a concurrent observation and interview on 7/20/26 at 12:37 p.m. with Resident 51 and her spouse, both Resident 51 and her spouse expressed distress due to the transfer. Resident 51's spouse stated they did not have a car and would be unable to visit Resident 51 if they moved far away. Resident 51 became teary and stated it would be very hard not seeing their spouse every day.A review of Resident 33's MDS, dated [DATE], indicated Resident 33's BIMS score was 15 out of 15 with intact memory.During a concurrent observation and interview on 7/21/26 at 10:16 a.m. with Resident 33, Resident 33 stated she was being transferred to a facility 100 miles away and cried while stating all their family lived nearby.A review of Resident 1's MDS, dated [DATE], indicated Resident 1's BIMS score was 11 out of 15 with mild memory impairment.During a phone interview on 7/23/26 at 12:11 p.m. with Resident 1's representative (RP), RP stated he received a phone call on 7/14/26 from Resident 1 who sounded extremely upset after being told a transfer would occur. The RP further stated they received a closure letter three days later, and the resident was transferred on 7/17/26. A review of an undated facility letter titled Facility's Name, indicated residents, residents' families and representatives were notified that the facility . recently identified issues with the facility roof that require immediate attention. The letter further indicated the facility . made the decision to temporarily relocate our residents . Please know that currently there is no immediate threat to any resident's health or safety . the relocation of residents will occur over approximately the next two weeks.During a phone interview on 7/29/26 at 1:08 p.m. with the Administrator (ADM), ADM confirmed the letters of closure were mailed to the residents, residents' families and their representatives on 7/14/26.A review of a facility's policy and procedure titled, Transfer and Discharge (including [Against Medical Advice] AMA), revised 5/2026, indicated, Notice should be provided at least 30 days prior to a facility-initiated transfer or discharge.

Based on interview and record review, the facility failed to employ a fully qualified nutrition professional who was employed full time (35 hours a week or more) to oversee the dietary department.This failure had the potential for unsafe food handling, and food borne illness in a highly susceptible population of 95 residents.FindingsDuring the initial kitchen tour on 7/6/26 at 8:49 a.m., a kitchen staff member pointed out the Dietary Services Manager (DSM) as the person in charge of the dietary department. DSM stated he had worked in the position for the past two and a half years. When asked about his qualifications for the position, DSM stated he was in school to become a Certified Dietary Manager (CDM) and his classes would start next semester. DSM clarified he worked under the guidance of a CDM who was located at a sister facility. DSM further stated the facility did not have an onsite Registered Dietitian (RD) and a dietitian was contracted to provide remote resident nutrition care but was not involved in the department's oversite. A review of the facility's organizational chart indicated the department was overseen by the RD. Under the RD position was listed a CDM, who oversaw the DSM, the four cooks and the eight dietary aides. During an interview on 7/6/26 at 4 p.m. with the sister facility's CDM, CDM confirmed facility lacked an onsite RD to oversee the dietary department and she oversaw the DSM. CDM also confirmed she was not at the facility full-time and was onsite for a few hours (two to four hours) a day. A review of the facility's Key Personnel List, dated 7/8/26, indicated the list only included the name and contact information for the DSM.During a phone interview on 7/8/26 at 12:34 p.m. with the contract RD, RD confirmed she worked for another company and could not physically come to the facility due to her other job responsibilities. A review of the facility's Dietitian job description (Med-Pass, Inc., 2003), indicated, the primary purpose . is to plan, organize, develop and direct the overall operation of Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations . to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner . Assist in the recruitment, interviewing, and selection of food service personnel . Determine staffing requirements necessary to meet the department's needs and schedule a sufficient number of personnel for each shift . Make weekly inspections of all food service functions to assure that quality control measures are continually maintained.A review of the facility's Director of Food Services job description (Med-Pass, Inc., 2003), indicated, the primary purpose . is to assist the Dietitian in planning, organizing, developing and directing the overall operation of Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations . to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner . Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association.The Centers for Medicare and Medicaid Services (CMS) established federal regulations for kitchen management in long-term care facilities which indicated a facility kitchen must employee a DSS full time (35 hours a week or greater). These regulations allowed states to implement their own specific regulatory frameworks. In California, long-term care facilities must employ a full-time Dietary Services Supervisor (DSS). A review of California's Health and Safety Code Section 1265.4 indicated DSS must be a graduate of a state-approved course providing at least 90 hours of classroom instruction in food services supervision prior to employment. It included seven pathways to becoming a dietary manager, all of which provide a certificate or degree to indicate that the graduate has achieved the skills and knowledge needed to manage a facility kitchen. The regulation also indicated DSS shall receive frequently scheduled consultation from a qualified dietitian.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions, when:Hair/facial hair was not properly secured;Bags used for bulk food items were not food grade;The red cutting board (used for meat) was found with a deep gouge;Food service items were stored wet;Counter and cart cleaning did not include a wash and rinse step prior to sanitizing; andThe red bucket used for sanitizer was not tested correctly.These failures had the potential of leading to food poisoning for the 95 vulnerable residents eating facility prepared meals.Findings:1. During the initial kitchen tour on 7/6/26 at 8:49 a.m., the Dietary Services Manager (DSS) was working in the dry storage area. DSS was observed with a beard that was not covered.During a return visit to the kitchen on 7/7/26 at 9:08 a.m., the shared Certified Dietary Manager (CDM) was in the dry storage/dietary office. CDM had a hair net on, but it was pulled back from the front hairline by 1-2 inches (a unit of measure) and loose hair was falling from the sides and back.During a return visit on 7/8/26 at 9:07 a.m. to the kitchen, DSS was preparing the lunch meal. No beard covering was observed. During a concurrent observation and interview on 7/8/26 at 1:31 p.m. with CDM, CDM's hair net was observed not covering the first inch of her hairline. CDM confirmed her hair net was not fully on, and DSS was not wearing a beard net. CDM stated hair nets were required in food services to keep hair out of food which could transfer bacteria to food.A review of the United States (US) Food and Drug Administration's (FDA) 2022 Food Code section 2-402 on Hair Restraints, indicated, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensil, and linens; and unwrapped single-service and single-use articles.2. During a concurrent observation and interview during the initial kitchen tour on 7/6/26 at 9:14 a.m. with DSS, plastic bags were observed holding the bulk food stored in containers. DSS was unsure if the plastic bags were food-grade. DSS provided information on the bags on 7/6/26 at 2:10 p.m., which indicated the bags used were trash bags. The information on the Sysco liner rolls trash bags (40 inches x 48 inches) included the following statement: Culinary application is not applicable as this is a non-food item.According to the United States Department of Agriculture (www.fsis.usda.gov/oa/pubs/meatpack.htm), the use of plastic trash bags is not recommended for food storage or cooking . because they are not food grade plastic and chemicals from them may leach into the food. 3. During a concurrent observation and interview during the initial kitchen tour on 7/6/26 at 9:25 a.m. with DSS, one out of six cutting boards appeared with deep gouges on the cutting surface. The red cutting board (used for beef products) was observed with an inch long gouge on the cutting surface. DSS confirmed the observation. A review of the US FDA's 2022 Food Code section 4-501.12 on Cutting Surfaces, indicated, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced . Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic (disease causing) microorganisms (microbes) transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces.4. During a concurrent observation and interview during the initial kitchen tour on 7/6/26 at 9:49 a.m. with DSS, one out of two food processor bowls was observed wet inside when the top cover was removed. DSS confirmed that it was wet inside.During a concurrent observation and interview during the initial kitchen tour on 7/6/26 at 10:02 a.m. with DSS, three steam table pans (one large and two small) were observed stored and ready to use but were wet inside. DSS confirmed and stated staff were trained to fully dry items before putting them away.A review of the US FDA's 2022 Food Code section 4-901.11 on Equipment and Utensils, Air-Drying Required, indicated, After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried . before contact with food; and (B) May not be cloth dried . Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils.5. During a return visit to the kitchen on 7/6/26 at 9:52 a.m., Dietary Aide (DA) 1 was observed cleaning the tray carts. DA 1 proceeded to grab a cloth from the red sanitizer bucket and wipe down the carts. No cleaning or rinsing was observed prior to wiping with sanitizing solution.During a return visit to the kitchen on 7/7/26 at 9:24 a.m., the [NAME] (CK) was slicing the pre-cooked Roast Beef before placing it in the oven for lunch. Once finished, CK moved on to clean up the counter from the accumulated drippings and meat residue. CK grabbed a cloth from the red sanitizer bucket and wiped down the counter, before moving on to the next cooking task. No cleaning or rinsing steps were observed prior to wiping with sanitizer solution.During a return visit to the kitchen on 7/8/26 at 9:12 a.m., DA 2 was asked about the process for cleaning carts and counters. DA 2 stated he would clean carts or counters by wiping them down with a cloth from the red sanitizer bucket. No other steps were given.During an interview on 7/8/26 at 1:31 p.m. with CDM, CDM stated the expected process for cleaning carts and counters was staff should first clean with soap and water and then follow with the sanitizer. CDM further stated cleaning was needed to remove food debris to make sanitizing effective.A review of the facility's policy titled, Sanitization (Med-Pass, Inc. 2001), indicated, All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils . The policy further indicated, For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: a. Equipment will be disassembled as necessary to allow access of the detergent . b. Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures.A review of the US FDA's 2022 Food Code section 4-603.15 on Equipment, Washing, Procedures for Alternative Manual Warewashing, indicated, Some pieces of equipment are fixed or too large to be cleaned in a sink. Nonetheless, cleaning of such equipment requires the application of cleaners for the removal of soil and rinsing for the removal of abrasive and cleaning chemicals, followed by sanitization.6. During a concurrent observation and interview during a return visit to the kitchen on 7/7/26 at 9:39 a.m. with CK and CDM, CK was asked to demonstrate the process for checking the sanitizer to determine if it was still effective. CK obtained the bottle of sanitizer testing strips and dropped a strip in the bucket and left in the solution for 15 seconds. When removed, the strip had changed to a lime green color that was not on the color chart for appropriate sanitation strength. CDM confirmed the correct strength had not been obtained. CK went on to refill the red bucket with new sanitizer. CDM showed CK the directions on the testing strip bottle which indicated leaving the strip in the solution for one to two seconds. During a concurrent observation and interview during a return visit to the kitchen on 7/8/26 at 9:12 a.m. with DA 2 and DSS, DA 2 demonstrated testing of the sanitizer in a red bucket in the cook's area. DA 2 removed a testing strip from the bottle and held it in the sanitizing solution for 10 seconds. When removed, the strip turned into a lime green color that was not on the chart. When prompted, DA 2 read the directions on the strip bottle and noted that he had left the test strip in solution too long. DSS confirmed the strip did not indicate effective sanitizing strength.A review of A Guide to Using Sanitizer Test Strips (https://www.cooksdirect.com/using-sanitizer-test-strips-in-foodservice) indicated in the section on the Importance of Proper Sanitization that Effective sanitization is crucial for preventing the spread of foodborne illnesses and maintaining a clean and healthy environment in your kitchen and beyond. By regularly checking sanitizer concentrations, you can be confident that your surfaces, utensils, and equipment are properly sanitized.Steps to Use Sanitizer Test Strips1. Dip and Retrieve: Dip the test strip into the sanitizing solution. Quickly retrieve the strip, ensuring it is fully wet.2. Wait for Reaction: Allow the test strip to react with the sanitizer for the specified time (usually a few seconds).3. Compare Colors: Compare the color of the test strip to the color chart provided by the manufacturer. Match the color as closely as possible to determine the concentration of the sanitizer.4. Adjust Concentration if Needed: If the concentration is below the recommended level, adjust the amount of sanitizer accordingly.

Based on observation, interview, and record review, the facility failed to follow the plan of care for one of 23 sampled residents (Resident 29), when a communication board/binder was not accessible for staff to communicate with Resident 29.This failure decreased the facility's potential to effectively communicate and meet Resident 29's needs.Findings:A review of Resident 29's admission Record, indicated she was admitted to the facility in June 2026 with multiple diagnoses including dependence with personal care and unsteady gait with history of repeated falls.During an observation on 7/6/26 at 12:20 p.m. in Resident 29's room during lunchtime, Certified Nurse Assistant (CNA) 3 was observed delivering the lunch tray and then exiting the room without responding to Resident 29's questions asked in Spanish.During an interview on 7/6/26 at 9:49 a.m. with Licensed Nurse (LN) 3, LN 3 stated Resident 29 communicates in Spanish. LN 3 further stated she did not use a communication board to interact with Resident 29, and instead she only used gestures and actions.During a concurrent observation and interview on 7/8/26 at 12:36 p.m. with the Speech Therapist (ST) in Resident 29's room, ST confirmed staff did not use a communication board/binder when communicating with Resident 29. ST stated she asked staff to use a communication board when interacting with Resident 29 as it would be beneficial during mealtimes and care provision.During a concurrent observation and interview on 7/8/26 at 1:30 p.m., with the Assistant Social Services Director (ASSD) and LN Supervisor (LNS), ASSD confirmed Resident 29 only speaks Spanish and no communication board/binder was available in her room. ASSD and LNS searched for the binder at the nurses' station, and both confirmed no communication board or binder was located at the station.During a concurrent interview and record review on 7/9/26 at 10 a.m. with the Assistant Director of Nursing (ADON), Resident 29's care plan dated 6/21/26 and speech therapy document dated 6/19/26, were reviewed. ADON stated Resident 29 should have been provided with a communication board/binder for staff use during care to ensure her needs were appropriately addressed.A review of the facility's policy titled, Translation and/or Interpretation of Facility Services, revised in 5/2017, indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility . The coordinator of this facility's language access program is the Director of Social Services, or his/her designee.

Based on observation, interview, and record review, the facility failed to ensure a physician order was followed for one of 23 sampled residents (Resident 29), when Resident 29's physician order for one-on-one feeding was not implemented.This failure increased Resident 29's potential for low meal consumption.Findings:A review of Resident 29's admission Record, indicated she was admitted to the facility in June 2026 with multiple diagnoses including cognitive communication deficit and dysphagia (difficulty in swallowing).A review of Resident 29's Order Summary Report (OSR), indicated a soft bite-sized texture diet order, dated 6/29/26, along with a directive for one-on-one feeding at every meal during each shift starting 6/20/26.During an observation on 7/6/26 at 12:20 p.m. in Resident 29's room, Certified Nurse Assistant (CNA) 3 was observed serving the lunch tray to Resident 29. CNA 3 left Resident 29 without assisting her with feeding.During concurrent observations and interviews on 7/6/26 at 12:35 p.m., 7/7/26 at 12:40 p.m., and 7/9/26 at 8 a.m. with CNA 4 and CNA 5 in Resident 29's room during mealtime, Resident 29 was observed staring at her tray on the table without eating. Both CNA 4 and CNA 5 stated Resident 29 eats independently and does not require help when eating.During a concurrent observation and interview on 7/9/26 at 8 a.m. with the Speech Therapist (ST), ST confirmed Resident 29 was not assisted while eating. ST stated Resident 29 required one-on-one feeding during mealtimes due to cognitive and swallowing concerns.During a concurrent interview and record review on 7/9/26 at 10 a.m. with the Assistant Director of Nursing (ADON), Resident 29's OSR dated July 2026, meal percentage log for July 2026, and speech therapy documents dated 6/19/26, 7/7/26, and 7/8/26, were reviewed. ADON confirmed Resident 29 consumed about 11 to 37 percent (a unit of measure) of each meal between 7/6/26 to 7/9/26. ADON stated Resident 29 should have received assistance during meals according to the ST recommendation. ADON further stated the physician orders should have been followed as prescribed to ensure residents maintain adequate nutrition and to prevent weight loss.A review of the facility's policy titled, Nutrition and Weight Management Policy, dated 10/2025, indicated, The facility provides care and services to each Resident to ensure the Resident maintains acceptable parameters of nutritional status . Develop and Implement approaches.

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1's) right to be free from misappropriation of property, when Certified Nursing Assistant (CNA) 1 cashed Resident 1's bank check without consent.This failure had the potential to negatively impact Resident 1's highest practicable mental and psychosocial wellbeing. Findings: A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility in 2024 with a diagnosis of hemiplegia and hemiparesis with left side nondominant weakness (total paralysis of the arm, leg, and trunk on the left side of the body). Resident 1 was responsible for himself. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/7/26, indicated Resident 1's Brief Interview of Mental Status (BIMS) score was 15 out of 15 with no memory impairment. A review of the facility's document titled, [State of California; a form to document suspected abuse of vulnerable adults] SOC 341, dated 5/21/26, indicated Resident 1 reported to staff that he lost a check a few months ago and never consented to any employee to cash it. During an interview on 6/30/26 at 3:40 p.m. with Resident 1 in his room, Resident 1 confirmed a check went missing from the drawer of his nightstand and stated he did not sign the check or gave it to staff for cashing it. During an interview on 6/30/26 at 10:15 a.m. with Licensed Nurse (LN) 1, LN 1 stated Resident 1 had a check in his nightstand that went missing and the business office took care of it. During an interview on 6/30/26 at 10:49 a.m. with CNA 3, CNA 3 stated last week Resident 1 told her his check went missing from his nightstand. A review of Resident 1's Social Services Director Progress Notes, dated 5/21/26, indicated there was a conversation with Resident 1 about missing his check. During an interview on 6/30/26 at 11:18 a.m. with Administrative Assistant (AA), AA stated Resident 1 mentioned missing a check when she handed him mail on 5/20/26, specifically a law firm check. AA contacted the law firm, which confirmed a $5,041.80 check had been cashed by CNA 1. A review of Resident 1's bank check, indicated five thousand forty-one and 80/100 dollars were paid to the order of CNA 1. Posted date was 2/27/26. A review of the facility's document titled, Resident Fund Management Service, dated 5/26/26, indicated Resident 1 authorized the facility on 5/26/26 to establish and manage a non-transferring account. During a concurrent interview and record review on 6/30/26 at 12:05 p.m. with Business Office Manager (BOM), Resident 1's document titled, Resident Statement Landscape, was reviewed. BOM confirmed a personal check was transferred from the facility to Resident 1's account on 5/27/26. Account balance was $5,041.80. During a concurrent interview and record review on 6/30/26 at 4:40 p.m. with Administrator (ADM), CNA 1's personnel file was reviewed. ADM confirmed Resident 1 lost a check from his nightstand and the missing check was cashed by CNA 1. ADM stated CNA 1 resigned on 4/7/26. A review of the facility's policy titled, Safeguarding Personal Property / Theft-and-Loss, dated 10/2025, indicated, . In the event of verified theft . the facility reserves the right to reimburse . If Loss . have caused by a facility employee . the facility shall be responsible for full reimbursement . These findings represent past noncompliance with this regulatory requirement. Interviews and record reviews confirmed Resident 1 lost a bank check and the check was cashed by CNA 1 without Resident 1's consent. SOC 341 was completed on 5/21/26. The California Department of Public Health, Police, Ombudsman, CNA Licensing Department, and Adult Protective Services were notified on 5/21/26. The facility fully reimbursed the money to Resident 1's account with his written permission on 5/26/26. Resident 1 was promptly reimbursed, and the funds were deposited into his account on 5/27/26. Resident 1 was monitored for any distress and psychosocial wellbeing after the recognition of incident. Resident 1 was satisfied and happy that the facility helped him. Theft and Loss in-service training was conducted on 5/21/26. There was sufficient evidence that the facility corrected the violation as of 5/27/26, and no other occurrences of noncompliance were identified. At the time of the survey, the facility was in substantial compliance with this regulatory requirement and therefore, this violation does not require a plan of correction.

Based on observation, interview, and record review the facility failed to ensure residents' rights to personal privacy and confidentiality of his or her personal medical information, when meal tray tickets were found thrown into the general trash. This had the potential to compromise resident privacy and confidentiality for the 95 residents residing in the facility.During a concurrent observation and interview on 7/27/25, at 9:13 a.m., with the Dietary Aide (DA) in the kitchen, DA was observed throwing away residents' meal tickets into a garbage can. DA stated meal tickets that are left on meal trays are thrown into the kitchen garbage can and the garbage can is then later emptied into the outside garbage bin. DA confirmed the meal tickets contained resident's names and diet information and that anyone can access them after the meal tickets are dumped into the outside garbage bins. During an interview on 7/27/25, at 10:23 a.m., with the Dietary Supervisor (DS), the DS stated the expectation was for staff to remove meal tickets from the meal trays and collect them in the DS's office for the DS to later shred. The DS confirmed the meal tickets contained resident's names and diet orders, and if they are leaked or dumped outside, the personal information will be exposed to the public. During a review of the facility's document titled, Resident [NAME] of Rights, undated, indicated, Patients shall have the right:.confidential treatment of financial and health records and to approve or refuse their release, except as authorized by law.

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 95 when:1. A total of 5 loose pills were found in medication cart 4;2. An opened Polymyxin B-tmp eye drop (an eye drop used to treat bacterial eye infections), an opened Incruse Ellipta inhaler (a medication used to treat airflow obstruction in adults), and an opened Symbicort inhaler (a medication used to treat breathing difficulty) had no opened date label; and,3. A used Latanoprost eye drop (a prescription medication used to manage elevated eye pressure) was not discarded after 28 days.These failures had the potential for diversion of the loose medications, and for residents to receive medication that was expired or with unsafe or reduced potency.1. During a concurrent observation and interview which started on 7/27/25 at 3:13 p.m. with Licensed Nurse (LN) 6, of medication cart 4, a total of five loose pills were found inside the second and third-right drawer of the medication cart. LN 6 confirmed the observation. LN 6 stated there should not be loose pills inside a medication cart because staff would not know what medication those are anymore.During an interview on 7/30/25 at 9:10 a.m. with the Consultant Pharmacist (CP), the CP stated it's not acceptable to have any loose pills inside the medication carts because loose tablets should not be reused, and the medication cart should be kept clean.During an interview on 7/30/25 at 10:08 a.m. with the Director of Nursing (DON), the DON stated that loose pills inside the medication carts should not be allowed because of safety concerns for residents. A review of the facility's P&P titled, Administering Oral Medications, revised 10/2010, indicated, Steps in the Procedure .5. Select the drug from the unit dose drawer or stock supply. 6. Check the label on the medication and confirm the medication name and dose with the MAR [medication administration record]. 7. Check the expiration date on the medication. Return any expired medications to the pharmacy .2. During a concurrent observation and interview which started on 7/27/25 at 3:13 p.m. with LN 6, of medication cart 4, an opened Polymyxin B-tmp eye drop, an opened Incruse Ellipta inhaler, and an opened Symbicort inhaler were found with no opened date label. LN 6 confirmed the observation. LN 6 stated the eye drop and inhalers should have been labeled with the opened date so staff would know when to discard it.During an interview on 7/30/25 at 9:10 a.m. with the CP, the CP stated staff should label the eye drop and inhalers with the medications' open date, so they know when to discard it. The CP further stated there would be a risk for the medications to be administered after the discard date if it was not labelled with the opened date.During an interview on 7/30/25 at 10:08 a.m. with the DON, the DON stated she would expect opened eye drops and opened inhalers should be labelled with the open date so nurses would know when to dispose the medication properly.A review of the Polymyxin B-tmp eye drop label indicated, .DISCARD UNUSED PORTION AFTER 28 DAYS ., and the area dedicated for the date it was opened was left blank.A review of the facility document titled. Guide for Special Handling of Medications, dated 1/2024, indicated, .Incruse Ellipta .Date when foil tray is opened and discard after 6 weeks or when the counter reads 0, whichever comes first. A review of the facility document titled. Guide for Special Handling of Medications, dated 1/2024, indicated, .Symbicort Inhalation .Date after opening the foil pouch and discard after 3 months or when the dose counter reads 0, whichever comes first. 3. During a concurrent observation and interview which started on 7/27/25 at 3:13 p.m. with LN 6, of medication cart 4, a used Latanoprost eye drop with an opened date of 6/25/25 was found stored in the medication cart. LN 6 confirmed the observation. LN 6 stated the eye drop should have been discarded. LN 6 further stated an eye drop passed the discard date would be less effective and would not achieve the full effect of the medication.During an interview on 7/30/25 at 9:10 a.m. with the CP, the CP stated the used eye drop with an opened date of 6/25/25 should have been discarded after 28 days.During an interview on 7/30/25 at 10:08 a.m. with the DON, the DON stated she would expect that used eye drops passed 28 days should have been discarded. The DON further stated the resident may have gotten expired medication and that was not the facility's protocol.A review of the Latanoprost eye drop label indicated, .DATE OPENED: 6/25/25 .DISCARD UNUSED PORTION AFTER 28 DAYS .

Based on observation, interview, and record review the facility failed to ensure safe medication administration practices when the facility's medication error rate was more than 5% (percentage- number or ratio that expressed as a fraction of 100) for a resident census of 95. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of five errors out of 34 opportunities which resulted in a facility wide medication error rate of 14.71% in four out of 11 residents (Resident 34, 40, 32, and 27) observed for medication administration.These failures had the potential for unsafe and ineffective medication use of Resident 34, 40, 32, and 27 and had the potential to negatively affect the residents' medical conditions.Findings:1. During a medication administration observation which started on 7/27/25 at 10:01 a.m. with Licensed Nurse (LN) 2, LN 2 administered a total of three pills to Resident 34 which included 1 tablet of baclofen (a medication used to treat muscle spasms, cramping, and tightness) 5 mg (milligrams- unit of measurement) and 1 capsule of gabapentin (a medication used to treat nerve pain and muscle spasm) 300 mg.A review of Resident 34's active physician's order, dated 4/9/25, indicated, Baclofen Oral Tablet 5 MG (Baclofen) Give 1 tablet by mouth three times a day for Muscle Spasticity.A review of Resident 34's active physician's order, dated 4/9/25, indicated, Gabapentin Oral Capsule 300 MG (Gabapentin) Give 1 capsule by mouth two times a day for Neuropathy [nerve pain].A review of Resident 34's medication administration records (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of July 2025 indicated Resident 34's morning dose of baclofen and gabapentin were both scheduled at 8 a.m.During a concurrent interview and medication order review on 7/27/25 at 1:36 p.m. with LN 2, LN 2 acknowledged the observed medication administration of baclofen and gabapentin to Resident 34 which were two hours after the scheduled time. LN 2 stated she was aware that the medications aware were administered late. LN 2 also stated nurses are supposed to administer the medications an hour before or after the scheduled time. LN 2 further stated there was a risk for a delayed effect of the medications when it was administered late to Resident 34.2. During a medication administration observation which started on 7/28/25 at 9:47 a.m. with LN 4, LN 4 administered a total of six pills to Resident 40 which included 1 tablet of apixaban (a medication used to treat and prevent blood clots) 5 mg.A review of Resident 40's active physician's order, dated 5/8/25, indicated, Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day related to OTHER PULMONARY EMBOLISM [blockage in one of the arteries in your lungs usually caused by a blood clot] .A review of Resident 40's MAR for the month of July 2025 indicated Resident 40's morning dose of apixaban was scheduled at 8 a.m.During a concurrent interview and medication order review on 7/29/25 at 9:51 a.m. with LN 4, LN 4 acknowledged the observed medication administration of apixaban to Resident 40 which was almost two hours after the scheduled time. LN 4 stated she was running late on administering the medications. LN 4 further stated Resident 40 would not be able to maintain the therapeutic level [the amount of the drug in the body that is considered to be effective in treating a condition] of the medication in the body if the medication was administered late.During an interview on 7/30/25 at 9:10 a.m. with the Consultant Pharmacist (CP), the CP stated nurses should give attention and follow the scheduled time of medication administration. The CP also stated nurses have a 1-hour window- before or after the scheduled time, to administer the medication and 2 hours was not acceptable.During an interview on 7/30/25 at 10:08 a.m. with the Director of Nursing (DON), the DON stated that scheduled medications should be administered either 1 hour before or after the scheduled time.Requested the facility's medication administration policies and procedures (P&P) discussing the timing of administering medications but none was provided.3. During a medication administration observation which started on 7/27/25 at 12:01 p.m. with LN 5, Resident 32 had a blood sugar reading of 166 milligrams/deciliter (md/dl- unit of measurement) and LN 5 administered 2 units (unit of insulin measurement) of insulin lispro (a fast-acting type of insulin used to manage high blood sugar) to Resident 32.A review of Resident 32's physician's order, dated 7/22/25, indicated, Insulin Lispro Injection Solution 100 UNIT/ML [milliliters- unit of measurement] (Insulin Lispro) Inject as per sliding scale [a method of managing blood sugar levels where insulin doses are adjusted based on current blood sugar reading]: .151 - 200 = 2 UNITS .subcutaneously [under the skin] before meals related to TYPE 2 DIABETESMELLITUS [a chronic condition causing too much sugar in the blood] .During an interview on 7/27/25 at 12:35 p.m. with Resident 32, Resident 32 stated he has not eaten yet and was still waiting for his lunch meal.During a concurrent observation and interview on 7/27/25 at 1:12 p.m. with Certified Nurse Assistant (CNA) 2, in Resident 32's room, CNA 2 was observed delivering Resident 32 his lunch meal. CNA 2 confirmed that observation and stated Resident 32 needs total assistance with his meal so she would need to assist Resident 32 with his lunch meal after she delivers all the lunch meals to other residents.During a concurrent observation and interview on 7/27/25 at 1:21 p.m. with CNA 2, in Resident 32's room, CNA 2 started to assist Resident 32 with his lunch meal. CNA 2 confirmed the observation.During an interview on 7/27/25 at 2:59 p.m. with LN 5, LN 5 confirmed that Resident 32's insulin lispro was administered too early. LN 5 stated that Resident 32's insulin lispro should have been administered before meals as per the doctor's order. LN 5 stated he was not sure why the lunch meal was late for today.4. During a medication administration observation which started on 7/27/25 at 12:29 p.m. with LN 2, Resident 27 had a blood sugar reading of 167 mg/dl and LN 2 administered a total of 9 units of insulin lispro to Resident 27.A review of Resident 27's physician's order, dated 3/4/25, indicated, Insulin Lispro Injection Solution 100 UNIT/ML . Inject 6 unit subcutaneously before meals related to TYPE 2 DIABETES MELLITUS .A review of Resident 27's physician's order, dated 3/4/25, indicated, Insulin Lispro Injection Solution 100 UNIT/ML . Inject as per sliding scale: .151 - 200 = 3 units .subcutaneously before meals related to TYPE 2 DIABETES MELLITUS .During an interview on 7/27/25 at 1:09 p.m. with Resident 27, Resident 27 stated he has not eaten his lunch meal yet.During a concurrent observation and interview on 7/27/25 at 1:21 p.m. with CNA 3, in Resident 27's room, CNA 3 was observed delivering Resident 27's lunch meal. CNA 3 confirmed that observation.During an interview on 7/27/25 at 1:37 p.m. with LN 2, LN 2 confirmed that Resident 27's insulin lispro was administered too early. LN 2 stated that Resident 27's insulin lispro should have been administered before meals as per the doctor's order to prevent hypoglycemia.During an interview on 7/30/25 at 9:10 a.m. with the CP, the CP stated insulin lispro is a fast-acting insulin and the general rule is that it should be given 15 minutes before meals.During an interview on 7/30/25 at 10:08 a.m. with the DON, the DON stated she would expect nurses to follow the standard of practice in administering insulin lispro which is 15 minutes before meals.A review of the facility's P&P titled, Insulin Administration, revised 9/2014, indicated, 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order .General Guidelines .Onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose .Type .Rapid-acting [fast- acting] .Onset .10-15 min [minutes] .A review of an online article from Drugs.com titled, How fast does insulin lispro work?, dated 6/16/25, indicated, Lispro starts working within 0 to 15 minutes of administration .Lispro can be given 15 minutes before a meal or with a meal . (https://www.drugs.com/medical-answers/fast-lispro-work-3544835/)

Based on observation, interview, and record review, the facility failed to provide safe, sanitary care for a census of 95 when:Resident 13's indwelling catheter (tube placed into the bladder to drain urine) drainage bag was uncovered and on the floor;Resident 19's nebulizer tubing was not changed every seven days; and Facility staff did not wear the required PPE when entering an isolation room. These failures increased the risk of infection. 1. Resident 13 was admitted to the facility early 2025 with diagnosis which included sepsis (life threatening complication of an infection), urinary calculus (mineral deposits that form in the urinary tract), and kidney infections. During a review of Resident 13's Order Summary Report [OSR], order date 7/25/25, the OSR indicated, Indwelling catheter .to bedside drainage .Left flank [side of a person's body between the ribs and hips] nephrostomy tube [thin tube placed into the kidney to drain urine] .). During a concurrent observation and interview on 7/27/25 at 10:39 a.m. in Resident 13's room with Licensed Nurse (LN1) of Resident 13. Resident 13 had an uncovered nephrostomy bag which hung from the bedrail, and an uncovered urinary catheter bag which was lying on the floor. LN1 confirmed the findings and stated catheters should not be touching the ground for infection control reasons and should be stored in a bag. During an interview on 7/29/25 at 3:45 p.m. with the Infection Preventionist (IP), the IP was shown a picture of Resident 13's catheter bag uncovered and touching the floor. The IP stated the catheter bag should not touch the floor because of cross contamination. During a review of the facility's policy and procedure (P&P) titled, URINARY CATHETER CARE, dated 3/21, the P&P indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections .be sure the catheter tubing and drainage bag are kept off the floor . 2. A review of Resident 19's clinical record indicated Resident 19 was admitted April of 2024 and had diagnoses that included dementia (memory loss that interferes with daily functions), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and congestive heart failure (a serious condition in which the heart does not pump blood as efficiently as it should). A review of Resident 19's Minimum Data Set (MDS– a federally mandated resident assessment tool) Cognitive Patterns, dated 6/11/25, indicated Resident 19 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 13 out of 15 which indicated Resident 19 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 19's active physician's order, dated 1/3/25, indicated, Ipratropium-Albuterol Solution [a combination medication used to treat difficulty breathing, chest tightness, and coughing] .inhale orally every 6 hours as needed for cough. During an observation on 7/27/25 at 8:37 a.m. in Resident 19's room, Resident 19's nebulizer face mask tubing was labelled 06/04. During a concurrent observation and interview on 7/27/25 at 10:28 a.m. with LN 2, in Resident 19's room, LN 2 confirmed that Resident 19's nebulizer face mask tubing was labelled 6/4 which was already more than 7 weeks. LN 2 stated nebulizer face mask tubing was supposed to be changed weekly for infection control. During an interview on 7/29/25 at 3:11 p.m. with the IP, the IP stated that the nebulizer face mask should be changed on a weekly basis to prevent respiratory infection. During an interview on 7/30/25 at 10:08 a.m. with the Director of Nursing (DON), the DON stated she would expect staff to change nebulizer face mask tubing weekly and as needed for infection control. A review of the facility's P&P titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised 10/2010, indicated, 30. Change equipment and tubing every seven days, or according to facility protocol. 3. During a concurrent observation and interview on 7/27/25 at 8:49 a.m., with LN 3, in front of room [ROOM NUMBER], room [ROOM NUMBER] has a signage posted on the wall on the left side of the door which indicated, STOP .CONTACT PRECAUTIONS .EVERYONE MUST: .PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit .Put on gown before room entry. Discard gown before room exit . LN 3 confirmed the observation. LN 3 stated the resident in room [ROOM NUMBER] Bed A was on a contact isolation precaution because of VRE infection (Vancomycin-Resistant Enterococci infection- an infection resistant to some powerful antibiotics) on the wound and possible C-Diff infection (infection with bacteria that can cause severe diarrhea and inflammation of the bowel). During a concurrent observation and interview on 7/27/25 at 9:15 a.m. with Activities Staff (AS) 1, AS 1 went inside room [ROOM NUMBER] not wearing any gloves or gown. AS 1 confirmed the observation. AS 1 stated he was aware about the signage posted in front of the room but was told they only need to wear gloves and gown when going in contact with the Resident in bed A. During a concurrent observation and interview on 7/27/25 at 9:57 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 went inside room [ROOM NUMBER] not wearing any gloves or gown. CNA 1 confirmed the observation. CNA 1 stated she knows that a resident in the room was on contact isolation precaution. CNA 1 further stated they were told that they only need to wear gloves and gown when going in contact with the Resident in bed A. During an interview on 7/29/25 at 3:11 p.m. with the IP, the IP confirmed that the resident in room [ROOM NUMBER] Bed A was on a contact isolation precaution because of VRE infection on the wound and possible C-Diff infection. The IP stated that their practice in the facility was that staff would only wear the required PPE only when directly caring for the infected resident. A review of the facility's P&P titled, Isolation – Categories of Transmission-Based Precautions, revised 10/2018, indicated, Contact Precautions .4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room .5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. A review of The Centers for Disease Control and Prevention (CDC- the national public health agency of the United States) online article titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 4/2/24, indicated, Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room . (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html#:~:text=Contact%20Precautions%20require%20the%20use,and%20Conditions%20of%20the%20guideline.)

Based on interview and record review, the facility failed to ensure two out of 25 sampled residents (Resident 110 and Resident 92) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 110 and Resident 92 pain medication orders were not consistently followed.This failure had the potential for Resident 110 and Resident 92 to develop medication dependence (the inability of the individual to function normally in the absence of the drug), overdose, not achieve pain relief, and not attain their highest practicable well-being.Findings:1a. A review of Resident 110's clinical record indicated Resident 110 was admitted July of 2025 and had diagnoses that included fracture (break in continuity of a bone) of left femur (thigh bone) and muscle weakness. A review of Resident 110's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 7/20/25, indicated Resident 110 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 110 had an intact cognition (mental process of acquiring knowledge and understanding).During an interview on 7/28/25 at 3:03 p.m. with Resident 110, in Resident 110's room, Resident 110 stated he has been experiencing pain and has been taking pain medications for it.A review of Resident 110's active physician's order, dated 7/16/25, indicated, Norco Tablet [a medication for pain which contains a combination of hydrocodone; a controlled pain medication, and Acetaminophen; a potent pain reliever] 5-325 MG [milligrams- unit of measurement] .Give 1 tablet by mouth every 4 hours as needed for Moderate pain 4-6/10 [numeric pain scale from 1 to 10; 1-3 is mild pain, 4-6 is moderate pain, 7-10 is severe pain] .A review of Resident 110's active physician's order, dated 7/16/25, indicated, Norco Tablet 5-325 MG . Give 2 tablet by mouth every 4 hours as needed for Severe pain 7-10/10 .A review of Resident 110's Care Plan Report, dated 7/22/25, indicated, Alteration in functional mobility and presence of pain related to .Fracture .Administer prescribed pain medication.A review of Resident 110's medication administration records (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of July 2025 indicated Resident 110 received 1 tablet of Norco which was indicated for moderate pain on the following occasion:7/18/25 at 11:20 a.m.- pain level was 8 (severe pain)A review of Resident 110's MAR for the month of July 2025 indicated Resident 110 received 2 tablets of Norco which was indicated for severe pain on the following occasion:7/29/25 at 2:37 a.m.- pain level was 6 (moderate pain)During a concurrent interview and record review on 7/29/25 at 1:04 p.m. with Licensed Nurse (LN) 3, Resident 110's clinical records were reviewed. LN 3 confirmed that Resident 110's pain medication orders were not consistently followed. LN 3 stated that nurses should follow the physician's order when administering pain medications.1b. A review of Resident 92's clinical record indicated Resident 92 was admitted June of 2023 and had diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), diabetic polyneuropathy (a nerve damage condition resulting from high sugar levels in the blood often causing pain, numbness, and tingling), and muscle weakness. A review of Resident 92's MDS Cognitive Patterns, dated 5/19/25, indicated Resident 92 had a BIMS score of 15 out of 15 which indicated Resident 92 had an intact cognition. A review of Resident 68's MDS Health Conditions indicated Resident 92 received scheduled and as needed pain medications and non-medication intervention for pain. During an interview on 7/29/25 at 3:03 p.m. with Resident 92, in Resident 92's room, Resident 92 stated she has been taking pain medications for her pain.A review of Resident 92's active physician's order, dated 12/30/24, indicated, Norco Oral Tablet 5-325 MG . Give 1 tablet by mouth every 8 hours as needed for moderate to severe pain 4-10/10 .A review of Resident 92's Care Plan Report, dated 6/8/23, indicated, Alteration in comfort due to pain related to: .Chronic Physical Disability, Diabetic Neuropathy .Administer prescribed pain medicationA review of Resident 92's MAR for the month of June and July 2025 indicated Resident 92 received Norco which was indicated for moderate to severe pain on the following occasions:6/15/25 at 2:41 a.m.- pain level was 0 (No pain)7/26/25 at 7:18 p.m.- pain level was 0 (No pain)During a concurrent interview and record review on 7/29/25 at 1:04 p.m. with LN 3, Resident 92's clinical records were reviewed. LN 3 confirmed that Resident 92's pain medication order was not consistently followed. LN 3 stated that nurses should always follow the physician's order when administering pain medications.During an interview on 7/29/25 at 3:20 p.m. with the Director of Staff Development (DSD), the DSD stated that nurses should always follow the physician's parameters when administering pain medications to resident. The DSD also stated that it would be a risk for over-medication if a resident was given too strong medication. The DSD further stated that if a resident was administered too little medication, the resident would still be in pain. During an interview on 7/30/25 at 10:08 p.m. with the Director of Nursing (DON), the DON stated that pain medication should be given as ordered. The DON further stated that residents would be a risk for either ineffective pain management or risk for medication tolerance if the pain medication order is not followed. A review of the facility's policy and procedures titled, Administering Pain Medications, revised 10/2022, indicated, Preparation .1. Review the resident's care plan to assess any special needs of the resident . General Guideline .1. The pain management program is .based on professional standards of practice, the comprehensive care plan .Steps in the Procedure .6. Administer pain medications as ordered .A review of the facility's P&P titled, Administering Oral Medications, revised 10/2010, indicated, 1. Verify that there is a physician's medication order for this procedure .

Based on observation, interview, and record review the facility failed to ensure safe and effective pharmaceutical services for two out of 25 sampled residents (Resident 110 and Resident 92) when Resident 110 and Resident 92's controlled drug (drug with potential for abuse) use and removal signed out from the Controlled Drug Record (CDR- a paper log of controlled drug removal for administration to resident) was not documented in their Medication Administration Record (MAR-a legal document that list administered drugs).This failed practice may contribute to unsafe medication use and handling, and risk of controlled drug diversion.Findings:1a. A review of Resident 110's clinical record indicated Resident 110 was admitted July of 2025 and had diagnoses that included fracture (break in continuity of a bone) of left femur (thigh bone) and muscle weakness. A review of Resident 110's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 7/20/25, indicated Resident 110 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 110 had an intact cognition (mental process of acquiring knowledge and understanding).A review of Resident 110's active physician's order, dated 7/16/25, indicated, Norco Tablet [a medication for pain which contains a combination of hydrocodone; a controlled pain medication, and Acetaminophen; a potent pain reliever] 5-325 MG [milligrams- unit of measurement] .Give 1 tablet by mouth every 4 hours as needed for Moderate pain 4-6/10 [numeric pain scale from 1 to 10; 1-3 is mild pain, 4-6 is moderate pain, 7-10 is severe pain] .A review of Resident 110's active physician's order, dated 7/16/25, indicated, Norco Tablet 5-325 MG . Give 2 tablet by mouth every 4 hours as needed for Severe pain 7-10/10 .A random audit of Resident 110's MAR and the CDR for Norco, for July 2025, indicated nursing staff did not document Norco administration on the MAR when signed out from CDR as follows: 2 tablets on 7/27/25 at 1 p.m., 2 tablets on 7/27/25 at 5 p.m., and 2 tablets on 7/27/25 at 9:04 p.m.During a concurrent interview and record review on 7/29/25 at 1:04 p.m. with Licensed Nurse (LN) 3, Resident 110's CDR and MAR were reviewed. LN 3 confirmed the finding of Norco being signed out of the CDR but was not accurately documented on the MAR on three occasions. LN 3 stated that Norco administration should be both signed out in the CDR and signed in the MAR for better records. 1b. A review of Resident 92's clinical record indicated Resident 92 was admitted June of 2023 and had diagnoses that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), diabetic polyneuropathy (a nerve damage condition resulting from high sugar levels in the blood often causing pain, numbness, and tingling), and muscle weakness. A review of Resident 92's MDS Cognitive Patterns, dated 5/19/25, indicated Resident 92 had a BIMS score of 15 out of 15 which indicated Resident 92 had an intact cognition.A review of Resident 92's active physician's order, dated 12/30/24, indicated, Norco Oral Tablet 5-325 MG . Give 1 tablet by mouth every 8 hours as needed for moderate to severe pain 4-10/10 .A random audit of Resident 92's MAR and the CDR for Norco, for July 2025, indicated nursing staff did not document Norco administration on the MAR when signed out from CDR as follows: 1 tablet on 7/16/25 at 12:30 p.m., and 1 tablet on 7/16/25 at 6 a.m.During a concurrent interview and record review on 7/29/25 at 1:04 p.m. with LN 3, Resident 92's CDR and MAR were reviewed. LN 3 confirmed the finding of Norco being signed out of the CDR but was not accurately documented on the MAR on two occasions. LN 3 stated that the Norco administration should have been signed on both CDR and MAR.During an interview on 7/29/25 at 3:20 p.m. with the Director of Staff Development (DSD), the DSD stated that nurses should always sign off the CDR and MAR when administering controlled medications. The DSD further stated there would be a risk for medication error or controlled drug diversion (unlawful channeling of regulated pharmaceuticals from legal sources to the illicit marketplace) if the CDR and MAR are not both signed.During an interview on 7/30/25 at 10:08 a.m. with the Director of Nursing (DON), the DON stated she would expect the nurse to sign both the CDR and MAR when administering controlled medications. The DON further stated that the process of administering controlled drug should be placing the narcotic medication in the cup, then signing the CDR, then administering the medication, and lastly signing the MAR.A review of the facility's policy and procedure (P&P) titled, Administering Pain Medications, revised 10/2022, indicated, Steps in the Procedure .6. Administer pain medications as ordered .Document the following in the resident's medical record: 1. Results of the pain assessment; 2. Medication; 3. Dose .Report other information in accordance with facility policy and professional standards of practice.A review of the facility's P&P titled, Administering Oral Medications, revised 10/2010, indicated, Steps in the Procedure .9. Prepare the correct dose of medication: .b. For narcotics. Check the narcotic record for the previous drug count and compare with the supply on hand. Report any discrepancies to the nurse supervisor .

Based on observation, interview and record review, the facility failed to ensure two of 25 sampled residents (Resident 32 and Resident 27) was free from significant medication error when Resident 32 and Resident 27 did not receive their prescribed insulin (medication used to manage blood sugar level) in accordance with the physician's order and standards of practice.This failure has the potential to result in Resident 32 and Resident 27 experiencing hypoglycemia (too low blood sugar level) and other unnecessary insulin side effects which could negatively affect the resident's health.Findings:1. A review of Resident 32's clinical record indicated Resident 32 was admitted July of 2025 and had diagnoses that included diabetes mellitus (a chronic condition causing too much sugar in the blood) and muscle weakness.A review of Resident 32's physician's order, dated 7/21/25, indicated, Resident does not have the capacity to understand and sign admission agreement, to participate in plan of care, and to make health care decisions d/t [due to] Diagnosis of: Altered mental status .A review of Resident 32's physician's order, dated 7/22/25, indicated, Insulin Lispro [a fast-acting type of insulin used to manage high blood sugar] Injection Solution 100 UNIT/ML [unit/milliliters- unit of measurement] .Inject as per sliding scale [a method of managing blood sugar levels where insulin doses are adjusted based on current blood sugar reading]: .151 - 200 = 2 UNITS [unit of insulin measurement] .subcutaneously [under the skin] before meals related to TYPE 2 DIABETES MELLITUS [a chronic condition causing too much sugar in the blood] .During a medication administration observation which started on 7/27/25 at 12:01 p.m. with LN 5, Resident 32 had a blood sugar reading of 166 milligrams/deciliter (md/dl- unit of measurement) and LN 5 administered 2 units of insulin lispro to Resident 32.During a concurrent observation and interview on 7/27/25 at 1:12 p.m. with Certified Nurse Assistant (CNA) 2, in Resident 32's room, CNA 2 was observed delivering Resident 32 his lunch meal. CNA 2 confirmed that observation and stated Resident 32 needs total assistance with his meal so she would need to assist Resident 32 with his lunch meal after she delivers all the lunch meals to other residents.During a concurrent observation and interview on 7/27/25 at 1:21 p.m. with CNA 2, in Resident 32's room, CNA 2 started to assist Resident 32 with his lunch meal. CNA 2 confirmed the observation.During an interview on 7/27/25 at 2:59 p.m. with LN 5, LN 5 confirmed that Resident 32's insulin lispro was administered too early. LN 5 stated that Resident 32's insulin lispro should have been administered before meals as per the doctor's order. LN 5 stated he was not sure why the lunch meal was late for today2. A review of Resident 27's clinical record indicated Resident 27 was admitted June of 2024 and had diagnoses that included diabetes mellitus, need for assistance with personal care, and muscle weakness.A review of Resident 27's physician's order, dated 6/20/24, indicated, Resident has the capacity to understand and sign admission agreement, to participate in plan of care, and to make health care decisions. A review of Resident 27's physician's order, dated 3/4/25, indicated, Insulin Lispro Injection Solution 100 UNIT/ML . Inject 6 unit subcutaneously before meals related to TYPE 2 DIABETES MELLITUS .A review of Resident 27's physician's order, dated 3/4/25, indicated, Insulin Lispro Injection Solution 100 UNIT/ML . Inject as per sliding scale: .151 - 200 = 3 units .subcutaneously before meals related to TYPE 2 DIABETES MELLITUS .During a medication administration observation which started on 7/27/25 at 12:29 p.m. with LN 2, Resident 27 had a blood sugar reading of 167 mg/dl and LN 2 administered a total of 9 units of insulin lispro to Resident 27.During an interview on 7/27/25 at 1:09 p.m. with Resident 27, Resident 27 stated he has not eaten his lunch meal yet.During a concurrent observation and interview on 7/27/25 at 1:21 p.m. with CNA 3, in Resident 27's room, CNA 3 was observed delivering Resident 27's lunch meal. CNA 3 confirmed that observation.During an interview on 7/27/25 at 1:37 p.m. with LN 2, LN 2 confirmed that Resident 27's insulin lispro was administered too early. LN 2 stated that Resident 27's insulin lispro should have been administered before meals as per the doctor's order to prevent hypoglycemia.During an interview on 7/30/25 at 9:10 a.m. with the CP, the CP stated insulin lispro is a fast-acting insulin and the general rule is that it should be given 15 minutes before meals.During an interview on 7/30/25 at 10:08 a.m. with the DON, the DON stated she would expect nurses to follow the standard of practice in administering insulin lispro which is 15 minutes before meals.A review of the facility's P&P titled, Insulin Administration, revised 9/2014, indicated, 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order .General Guidelines .Onset of action - how quickly the insulin reaches the bloodstream and begins to lower blood glucose .Type .Rapid-acting [fast- acting] .Onset .10-15 min [minutes] .A review of an online article from Drugs.com titled, How fast does insulin lispro work?, dated 6/16/25, indicated, Lispro starts working within 0 to 15 minutes of administration .Lispro can be given 15 minutes before a meal or with a meal . (https://www.drugs.com/medical-answers/fast-lispro-work-3544835/)

Based on interview and record review, the facility failed to ensure services were provided to meet professional standards of quality for one of eight sampled residents (Resident 1) when Resident 1's physician was not informed of a medication that was not available and not administered as prescribed. This failure had the potential to put Resident 1's health and safety at risk. Findings: A review of the admission record indicated Resident 1 was admitted with multiple diagnoses including encephalopathy (brain function is impaired), and pneumonia (an infection/inflammation in the lungs) due to pseudomonas (group of bacteria commonly found in soil and water). A review of Resident 1's Order Summary Report dated 4/15/24 indicated, Dornase Alfa [medication that thins mucus] Inhalation Solution 2.5 MG [milligram, unit of measurement]/2.5ML [milliliter] .2.5 ml inhale orally two times a day for Pneumonia . A review of Resident 1's Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for April 2024 indicated Dornase Alfa was scheduled for administration at 9 a.m. and 5 p.m. The MAR indicated there were nine times (9 x) the administration was marked as 9 for this medication. The code 9 indicated other/see progress notes. The medication code 9 was marked twice on 4/16, twice on 4/17, twice on 4/19, twice on 4/20, and one time on 4/23. A review of Resident 1's administration notes for Dornase Alfa indicated the following: -on 4/16/24 at 10:31 a.m., the note indicated, med [medication] not delivered this shift; -on 4/16/24 at 17:07 (5:07 p.m.), the note indicated the name, dose and indication of use for said medication. The note did not indicate if the medication was delivered or administered; -on 4/17/24 at 8:52 a.m., the note indicated, on order; -on 4/17/24 at 18:32 (6:32 p.m.), the note indicated, N/A [not available]; -on 4/19/24 at 9:43 a.m., the note indicated, ordered; -on 4/19/24 at 1700 (5 p.m.), there was no administration note; -on 4/20/24 at 8:06 a.m., the note indicated, medication not available; -on 4/20/24 at 16:23 (4:23 p.m.), the note indicated, ordered to pharmacy; -on 4/20/24 at 23:06 (11:06 p.m.), the note indicated, unavailable; and, -on 4/23/24 at 19:44 (7:44 p.m.), the note indicated, LOA [leave of absence] sent to [name of hospital] for eye exam. There was no documented evidence in Resident 1's clinical records of physician notification of the medication not available for administration. In a concurrent interview and record review on 2/20/25 at 3:10 p.m., the Director of Nursing (DON) confirmed Resident 1's Dornase was not given nine times for April. The DON further confirmed there was no documented evidence the physician was informed of Resident 1's medication not administered as ordered. The DON stated her expectation was for licensed nurses to have notified the physician right then if medication was not available for Resident 1. A review of the facility's policy & procedure (P & P) revised December 2012 and titled, Administering Medications indicated, Medications shall be administered in a safe and timely manner, and as prescribed .Medications must be administered in accordance with the orders, including any required time frame. A review of the facility's P & P effective April 2008 and titled, MEDICATION ORDERS indicated, .The prescriber is contacted for direction when the medication will not be available.

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for 1 of 8 sampled residents (Resident 3) when Resident 3's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was observed on the side of the bed, uncovered and undated when not in use. This failure increased the risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another). Findings: A review of the admission record indicated Resident 3 was initially admitted [DATE] with multiple diagnoses including congestive heart failure (a heart disorder which causes the heart to not pump the blood efficiently) and diagnosed early this year with acute respiratory failure with hypoxia (lungs unable to adequately exchange oxygen, leading to low level of oxygen in the blood). A review of Resident 3's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) dated 1/23/25 indicated resident was cognitively intact. A review of Resident 3's physician order dated 11/25/24 indicated, Oxygen via nasal cannula at 2 Liters/minute if oxygen saturation (used to assess effectiveness of oxygen therapy) less than 90% or for shortness of breath. A concurrent observation and interview was conducted on 2/20/25 at 10:44 a.m., inside Resident 3's room. The nasal cannula attached to an oxygen tubing was in between the side rail and the mattress. Resident 3 stated he was using oxygen once in a while and he had used oxygen 2 days ago. Resident 3 stated the nasal cannula should be in a clear bag. A concurrent observation and interview was conducted on 2/20/25 at 11:03 a.m. with the Licensed Nurse (LN) inside Resident 3's room. The LN confirmed Resident 3's nasal cannula was on the side of the bed. The LN stated the nasal cannula should be in a plastic bag to prevent contamination. The LN further stated the oxygen tubing was changed every week by night shift. The LN was unable to locate the date on the tubing. In an interview on 2/20/25 at 3 p.m., the Director of Nursing (DON) stated her expectation was for the nasal cannula to be dated and placed in a plastic bag when not in use. The DON further stated this was a potential for infections. A review of the facility's policy & procedure effective 11/15/2023 and titled, Respiratory Therapy - Prevention of Infection indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment .among residents and staff .Change the oxygen cannulae and tubing every seven (7) days, or as needed .Keep the oxygen cannulae and tubing used PRN [as needed] in a plastic bag when not in use.

Based on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal the need for help) was accessible for 1 of 8 sampled residents (Resident 2) when Resident 2 was not physically able to use the call light provided when it was out of reach. This failure had the potential to result in unmet resident needs and delayed staff response. Findings: A review of the admission record indicated Resident 2 was admitted [DATE] with multiple diagnoses including encounter for orthopedic aftercare following surgical amputation (a procedure to remove a body part) and acquired absence of left foot (loss due to surgery). A review of Resident 2's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 9 out of 15 indicated Resident 2 had moderate cognitive impairment. Resident 2's functional abilities dated 1/7/25 indicated he required both substantial/maximal assistance (staff does more than half of the effort for mobility needs) and partial/moderate assistance (staff provides less than half of the effort for mobility needs). A review of Resident 2's care plan dated 12/25/24 indicated, Self care deficit as evidenced by requiring assistance or is dependent in lower body dressing, oral hygiene, personal hygiene. putting on/taking off footwear, shower/bathe self, toileting hygiene, and upper body dressing. During an observation on 2/20/25 at 9:43 a.m., Resident 2 was calling the attention of State surveyor by pointing with his left index finger. In a follow-up observation and interview on 2/20/25 at 9:46 a.m., Resident 2 was lying in bed and his call button was on the floor underneath his bed. Resident 2 stated when he needs help he press the call button. Resident 2 further stated, it's around here, someplace and he had been looking for it for 2-3 days. A concurrent observation and interview was conducted on 2/20/25 at 9:51 a.m. inside Resident 2's room with the Director of Nursing (DON). The DON confirmed Resident 2's call button was on the floor. The DON stated the call button should not be on the floor. An interview was conducted on 2/20/25 at 9:53 a.m. with the Certified Nursing Assistant (CNA) inside Resident 2's room. The CNA stated she normally clips the call button in the blanket. The CNA further stated Resident 2 was constantly moving and she repositioned resident an hour ago. In a follow-up interview on 2/20/25 at 3:02 p.m., the DON stated her expectation was for call lights to be placed within reach at all times when resident is in the room. The DON confirmed Resident 2 will not be able to reach the call light when it was on the floor. A review of the facility's policy and procedure revised 12/2023 and titled, CALL LIGHT ANSWERING indicated, It is the policy of this facility to provide the resident a means of communication with nursing staff .Place the call device within resident's reach before leaving the room .The nursing staff will check the placement of the call light during care.

Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse for one of three sampled residents (Resident 1) when Resident 2 hit the leg and grabbed the arm of Resident 1. This failure resulted in an injury to Resident 1 ' s left arm. Findings: Resident 1 was admitted to the facility late 2023 with diagnoses which included heart failure and anxiety disorder. During a review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool) dated 11/27/24, the MDS indicated a Brief Interview for Mental Status (BIMS, a standardized test that screens for cognitive impairment) score of 14/15, which showed intact cognition. Resident 2 was admitted to the facility late 2024 with diagnoses which included stroke, depression, and communication difficulty caused by a cognitive impairment . During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated a BIMS score of 6/15, which showed severe cognitive impairment. During a review of Resident 1 ' s SBAR [Situation, Background, Appearance, Review and Notify] Communication Form, dated 12/15/24 at 9p.m., the SBAR indicated, [Resident 1] with an altercation with another resident .[Resident 1] with an abrasion to left lower arm. During a review of Resident 2 ' s SBAR Communication Form, dated 12/15/24 at 9p.m., the SBAR indicated, [Resident 2] was observed striking [Resident 1] on his arm and legs. During a review of Resident 1 ' s Progress Notes [PN] Type: IDT [Interdisciplinary Team], dated 12/16/24 at 10:30 a.m., the PN noted indicated, On 12/15/24 at [8 p.m.] , staff heard resident yelling out, when staff went into the room, [Resident 2] was observed striking [Resident 1] on his arms and legs .Abrasion noted to left forearm . During a review of Resident 1 ' s Order Summary Report [OSR], order date 12/17/24, the OSR indicated, Monitor abrasion to left forearm for s/s [signs and symptoms] of infection . During an interview on 12/30/24 at 10:52 a.m. with Resident 1 in his bedroom, Resident 1 was asked about the incident with Resident 2. Resident 1 stated, My bruise is gone now .He [Resident 2] came into my room and wouldn ' t leave .He was yelling at me .he came over to my bed and grabbed my arm and jerked me up out of the bed .The nurses came in .He grabbed my left wrist, it was bruised up, he punched me in the leg in front of the nurses .My arm was sore . During a phone interview on 12/30/24 at 11:59 a.m. with Licensed Nurse (LN1), LN1 stated, .I heard a patient yelling for help. [Resident 2] was in [Resident 1 ' s] room and he [Resident 2] was leaning over the bed. [Resident 1] was in bed and said [Resident 2] hit him. I saw [Resident 2] slap [Resident 1 ' s] legs and he was acting like he was going to hit him. He [Resident 2] was extremely hard to re-direct. We separated them. [Resident 2] kept lunging at [Resident 1] .We assessed [Resident 1]; he had redness on his arm . During an interview on 12/30/24 at 1:03 p.m. with the Director of Nursing (DON), the DON stated, Residents have the right to be free from any form of abuse. During a review of the facility ' s policy and procedure (P&P) titled, Resident-to-Resident Altercation, dated 11/22, the P&P indicated, .Resident-to-Resident physical altercations that must be reported include, any willful action that results in physical injury .Willful actions include .Hitting, Slapping .

Based on interviews, clinical record review, and facility documents review, the facility failed to ensure one of three Residents (Resident 1) was treated with dignity and respect when Certified Nursing Assistant (CNA) 1 raised her voice and cussed at Resident 1. This failure resulted in Resident 1 feeling scared. Findings: Resident 1 was admitted to the facility on [DATE]. During a review Resident 1 ' s Quarterly Minimum Data Set (MDS-an assessment tool), dated 10/20/24, described Resident 1 as having clear speech, able to make herself understood and as able to understand others. Resident 1 ' s BIMS (a brief screening that aids in detecting cognitive impairment) score was 15 which indicated she was cognitively intact. The MDS described Resident 1 as having no signs or symptoms of delirium or behavioral symptoms. During a review of Resident 1 ' s Progress Notes, dated 11/18/24 at 10:39 a.m., it Was reported to the DON [Director of Nursing] at 0815 11/18/24, by the resident that on 11/16/24 during lunchtime when the dining room only had a handful of residents that the resident (Resident 1) and C.N.A. (CNA 1) got into a verbal altercation. Resident was talking to another resident and was encouraging her to eat, when the C.N.A. told her to mind her own business and that the resident was fine. [Resident 1] continued to encourage resident in Spanish. [Resident 1] and another resident were at a different table discussing the other resident's upcoming Surgery when the CNA turned around and started to curse at her, [Resident 1] then told her that she was talking to the other resident to give her reassurance for her upcoming surgery, and she wasn't saying anything. CNA was feeding another resident at a different table when event happened. Per resident they argued back in forth for a few minutes when another staff member came in and the CNA left the room. During an interview on 11/25/24 at 9:52 a.m. with Resident 2, she stated the incident it was so upsetting and didn ' t want to be interviewed regarding what she witnessed or heard. Resident 2 stated she gave her statement to [DON]. During a review of the facility ' s interview with Resident 2, dated 11/21/24, regarding the incident on 11/18/24 during the lunch meal. Resident 2 stated, I was having a conversation with [Resident 1] regarding my upcoming surgery. [Resident 1] was trying to reassure me, and I was worried about managing my pain after surgery. We did notice a resident spilling food on herself, and I mentioned that she was dropping food on herself. [Resident 1] went and was trying to help the other resident and came back to our table and started to talk to me. [CNA 1] did start cussing at [Resdient1] and did use the F word, but I don't remember how she used it. I do remember that she did tell [Resident 1] if you don't like it here you can leave. The nurse then came in and [Resident 1] and I continued our discussion. During a review of the facility ' s interview with Resident 3, dated 11/18/24, regarding the incident on 11/16/24 during the lunch meal. Resident 3 stated, I was in the back dining room being assisted with lunch by [CNA 1] when she stopped feeding me and started to yell out to [Resident 1] telling her to shut her fucking mouth and to quit talking shit. [Resident 1] continued to antagonize and yell and curse at [CNA 1] . During an interview on 11/25/24 at 9:44 a.m. with Resident 3, she stated she was in the dining room eating her lunch, she was being fed by CNA 1. Res 1 started talking bad about the place (facility). CNA 1 starting cussing at Resident 1. Resident 3 was asked how this made her feel when CNA 1 stopped feeding her and started having words with other the resident. Resident 3 stated she was thinking just feed me and don ' t worry about Resident 1 was saying. During a telephone interview on 12/2/24 at 3:21 p.m. with Resident 1, she stated they were in the dining room and CNA 1 was feeding one of the residents their lunch. Resident 1 and another resident were sitting there talking about how the resident was going to have surgery. Resident 1 said she and the other resident (Resident 2) were talking about her aftercare and all that and how she was scared because she felt like she was not going to be taken care of properly. We were talking about different issues that happened here throughout the facility, it was mostly about her aftercare. Then all of a sudden, CNA (1) turns around in her seat and says, Are you going to be talking fucking shit all day? or something like that. Resident 1 said she said something like, Excuse me, are you talking to me? CNA (1) says, Yeah. CNA 1 said to me, you've been fucking talking shit about this fucking place and about how this fucking place is garbage and this and that and how administration is garbage. And I said, Wait a minute. Well, first of all, you are interfering in a conversation that is none of your business. I told the CNA that her name was not brought into this. I told her to get your facts straight and that we were talking about general stuff that happens around different facilities and that people don't get taken care of. I told her to mind her own business. She (CNA 1) started going off and she said nobody even fucking wants you here. She said you got such a fucking foul mouth, but she was the one cussing at me. She just kept going on and on and then I told her I didn ' t want to talk to her and for her to mind her own business. She was like, no, and started going off and we started going at it and then a nurse and another CNA rushed in. Resident 1 was asked how this made her feel when CNA 1 started yelling and cussing at her. Resident 1 stated, Like she was going to get up and come over .and I was just scared if she was going to do that or not .because of the way she cussed me out, you know. I was scared. I'm in a wheelchair and she is tall. During a review of the facility ' s policy and procedure (P&P) titled, Resident Rights revised 8/2022 indicated, Facility staff shall treat all residents with kindness, respect, and dignity.

Based on observation, interview, and record review, the facility failed to ensure medications were stored correctly for census of 87 when: 1. Two bottles of sodium chloride (a solution used to dilute medications) were found expired in the automatic dispensing system inside the medication room of station 1 and 2; and, 2. Multiple medications were found at the bottom of medication carts behind the medication drawers in medication carts 3 and 5. These failures had the potential for medication misuse, ineffectiveness, diversion, and missed dosages. Findings: 1. During a concurrent observation and interview on 8/14/24 at 12:05 p.m. with Licensed Nurse (LN) 4 in the medication room of station 1 and 2, an automatic dispensing system unit was inspected. Two bottles of sodium chloride each of 10 milliliters (a unit of measure) were expired on 8/1/2024. The LN 4 verified the expiration date. 2. During a concurrent observation and interview on 8/15/24 at 11:03 a.m. with LN 3 on station 1 and 2, medication cart 3 was inspected. One bubble pack of medications and a vial full of liquid medication in a plastic bag were found behind the bottom drawer of the medication cart 3. The LN 3 verified and stated residents might have missed a scheduled dose of these medications. During a concurrent observation and interview on 8/15/24 at 11:07 a.m. with LN 3 on station 3 and 4, medication cart 5 was inspected. Two bubble packs of medications were found behind the bottom drawer of the medication cart 5. The LN 3 verified and stated this might have caused misuse of medications. During an interview on 8/15/24 at 2:57 p.m. with the Director of Nursing (DON), the DON stated this might have caused residents missing dosages and misuse of medications. The DON also stated pharmacy staff should have checked automatic dispensing system for any expired medications and replaced them. During the review of facility's policy and procedure (P&P) titled, Storage of Medications, dated April 2007, the P&P indicated, .The nursing staff shall be responsible for maintaining medication storage . The facility shall not use .outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy . Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems .

Based on observation, interview, and facility policy review, the facility failed to ensure the competency of food and nutrition services for a census of 87 when: 1. Dietary Staff 2 (DS 2) did not know the chlorine sanitizing concentration when performing the three compartments of manual dish washing; 2. Dietary [NAME] 1 (DC 1) did not follow standardized recipes when cooking green beans; and, 3. DC 2 did not follow the recipes when making pureed bread. These failures had the potential to cause contamination of food resulting in food borne illness and provide food for residents which did not meet the nutrients according to the planned recipes resulting related medical issues. Findings: 1. During an interview on 8/14/24 at 8:26 a.m. with DS 2, DS 2 confirmed he did not know the chemical concentration for sanitizing dishes when manual dish washing. A review of the facility's policy titled, 3 Compartment Procedure for Manual Dish Washing, stipulated, The third compartment is for sanitizing. Test the concentration with appropriate test drip, which is dipped in the sanitizer solution 10 seconds before reading. Record on log. Must read 200 [part per million, a unit of measurement]. 2. A review of the Menu titled, Week 3 Regular, dated 9/8/24, stipulated, the lunch menu on Wednesday, 9/14/24 was lasagna, seasoned green beans, garlic bread stick, gelatin jewels with topping, and whole milk. During an observation on 8/14/24 at 8:58 a.m. in the kitchen with Dietary [NAME] 1 (DC 1), DC 1 put frozen green beans on a pan and into the steamer to cook for 15 minutes. During an observation of the pureeing process on 8/14/24 at 11:12 a.m. with DC 1, DC 1 poured eight scoops of four ounces (32 oz, a unit of measurement) green beans into the blender to puree. DC 1 did not add any seasonings of salt, pepper, or butter into the blender with the green beans. During a tray line observation on 8/14/24 at 12:50 p.m., there were not enough green beans so DC 1 needed to make more. DC 1 put some frozen green beans into the steamer. After cooking the green beans, DC 1 added three scoops of melted butter into the green beans. There was no salt and pepper seasoning added to the green beans. A review of an undated recipe titled, Seas [NAME] Beans, indicated the ingredients to use included green beans, salt, black pepper, and margarine. During a concurrent observation of the tray line and interview on 8/14/24 at 1:12 p.m. with Dietary Manager 1 (DM 1) and DC 1, both the DM 1 and DC 1 confirmed dietary staff should have used the recipe when cooking pureed green beans and bread. DC 1 confirmed he did not add salt, pepper, and butter to the cooked green beans when pureeing it. DC 1 confirmed they did not use salt and pepper in the second batch of cooked green beans. DC 1 stated the green beans without seasoning would not have any flavoring. 3. During an interview on 8/14/24 at 4:35 p.m. with DC 2 and DM 1, DC 2 confirmed he used three cups (a unit of measurement) of hot water, 1/4 cup of butter, and 16 oz or two cups of breadcrumbs to make six servings of the pureed bread. DM 1 confirmed DC 2 did not use the correct measurement of all the ingredients when making pureed bread and should have followed the recipe instructions. DM 1 stated there was no policy to follow recipe. A review of an undated recipe titled, P Bread (H) indicated, the recipe to use were 3/4 cup of puree bread mix, 1 and 1/8 cup of warm water, and 1/4 cup of canola oil for six servings of pureed bread.