Every finding on record at Eskaton Village Care Center

Based on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for one of four sampled residents (Resident 1), when the alleged abuse incident was reported to the Department of Public Health (CDPH) the following day.This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.Findings:A review of Resident 1's Face Sheet indicated Resident 1 was admitted to the facility in February 2026 with a diagnosis of fractured vertebra (bones of the spine).A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/14/26, indicated Resident 1'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 no memory impairment.During a concurrent interview and record review on 4/14/26 at 11 a.m. with Licensed Nurse (LN) 1, Resident 1's Progress Notes, dated 3/21/26 at 3:28 p.m. was reviewed. LN 1 stated Resident 1 informed her that Certified Nursing Assistant (CNA) 2 was being way to rough with him on the night shift. LN 1 further stated she did not fill out the required paperwork to report the incident.A review of a facility document titled, Resident Progress Notes, dated 3/22/26 at 7:22 a.m., indicated the facility faxed the Report of Suspected Dependent Adult/Elder abuse (SOC 341 Form) to CDPH.A review of a facility document titled, Fax cover sheet, dated 3/22/26 at 8:19 a.m., indicated a fax regarding an alleged abuse was sent to CDPH with a successful transmission.During an interview on 4/14/26 at 10:09 a.m. with the Administrator (ADM), ADM confirmed the SOC 341 was not sent to CDPH until the morning of 3/22/26. ADM stated reporting the suspected abuse should have been done within two hours to ensure resident safety.A review of the facility's policy and procedure titled, Elder and Dependent Adult Suspected Abuse and Reporting, revised 11/28/21, indicated, Reporting Requirements: In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made .These findings represent past noncompliance with this regulatory requirement. Interviews and record reviews confirmed Resident 1 had an abuse complaint. The Ombudsman, CDPH, Sheriff Department and family for Resident 1 were notified on 3/22/26. Resident 1's care plan was updated for alleged abuse on 3/22/26. The care plans indicated Resident 1 will be separated from suspected abuser. 72 hour monitoring was in place post incident for Resident 1. Reporting abuse in-service training was conducted on 3/22/26, 3/23/26 and 3/24/26. There was sufficient evidence that the facility corrected the violation as of 3/24/26, 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 interviews and record reviews the facility failed to ensure care plans (CP, a detailed document outlining a person's healthcare needs, goals, and the specific care and support they will receive) were reviewed and revised in a timely manner, for two of 12 sampled residents (Resident 5 and Resident 2), when:Resident 5's urinary catheter (a flexible tube inserted into the bladder to drain urine into a drainage bag) care plan was not updated or revised after removal;Resident 2's urinary catheter care plan was not revised after removal; andResident 2's trazodone care plan had not been reviewed or revised after 21 days, as indicated.These failures had the potential for Resident 5 and Resident 2 to receive inaccurate care and interventions.3. A review of Resident 2's FS indicated he was admitted to the facility in February 2026 with diagnoses which included multiple lumbar fractures (a break or crack in bones of the lower back), lower back pain, lack of coordination and weakness. A review of Resident 2's POs indicated an order for trazodone (a psychotropic medication, drugs that affects brain activities associated with mental processes and behaviors) 50 milligrams (mg, a unit of measurement), give 1 tablet at bedtime for depression manifested by insomnia, dated 2/9/26.\ A review of Resident 2's CP dated 2/10/26 indicated, Goal(s): Resident will exhibit less than 1 episodes of target behavior daily. (Target behavior: inability to sleep). Target Date: 3/10/26. Approach: IDT (interdisciplinary team) will meet to discuss and review psychoactive medication use within 21 days of admission. During a concurrent interview and record review on 3/19/26 at 1:54 p.m. with the DON, Resident 2's CP for trazodone and IDT notes were reviewed. The DON confirmed the CP indicated the IDT was to review the use of trazodone within 21 days of Resident 2's admission, and stated there was no evidence in the medical record to indicate it had been completed. During a review of the facility's policy and procedure (P&P) titled, Interdisciplinary Team/Care Plan Process, revised 12/15/21, the P&P indicated, Policy Interpretation and Implementation.Care Plan Review and Management: 1. Care plans are reviewed and revised as needed.c. During the weekly summary process. During a review of the facility's policy and procedure (P&P) titled, Interdisciplinary Team/Care Plan Process, revised 12/15/21, the P&P indicated, Policy Interpretation and Implementation.Care Plan Review and Management: 1. Care plans are reviewed and revised as needed.c. During the weekly summary process. Findings: 1. A review of Resident 5's Face Sheet (FS) indicated Resident 5 was admitted to the facility in December 2025 with diagnoses which included cerebral infarction (a serious medical emergency where blood flow to part of the brain is blocked, causing tissue death) and left sided hemiparesis (weakness on one side). A review of Resident 5's Physician's Order (PO), dated 12/14/25, indicated Resident 5 had an order for a urinary catheter. A review of Resident 5's CP, dated 12/14/25, indicated Resident 5 had urinary retention (the inability to fully or partially empty the bladder, causing pain, frequent urges, or an inability to urinate) and had a urinary catheter inserted. During an interview on 3/17/26 at 9:38 a.m. with Resident 5, Resident 5 confirmed the urinary catheter had been removed. 2. A review of Resident 2's FS indicated Resident 2 was admitted to the facility in February 2026 with diagnoses which included lumbar and thoracic fractures (serious injuries occurring in the mid-to-lower back) and muscle weakness. A review of Resident 2's PO, dated 2/9/26,indicated Resident 2 had an order for a urinary catheter. A review of Resident 2's CP, dated 2/10/26, indicated the potential for complications related to urinary catheter use. A review of Resident 2's Progress Notes (PN), dated 2/11/26 indicated a new PO had been received to discontinue Resident 2's urinary catheter. During an interview on 3/18/26 at 11:30 a.m. in Resident 2's room, Resident 2 confirmed the urinary catheter had been removed quite some time ago. During a concurrent interview and record review on 3/20/26 at 1:35 p.m. with LN (Licensed Nurse) 1, Resident 5's and Resident 2's POs and CPs were reviewed. LN 1 confirmed Resident 5 and Resident 2 had their urinary catheters discontinued and indicated the CPs had not been updated. LN 1 acknowledged CPs should be updated and revised when there are changes to the residents' treatments or health status. During a concurrent interview and record review on 3/20/26 at 2:36 p.m. with the Director of Nursing (DON), Resident 5's and Resident 2's POs and CPs were reviewed. The DON confirmed Resident 5's and Resident 2's urinary catheters had been discontinued by the physician, and their CPs should have been updated. The DON acknowledged CPs should be updated and revised when there are changes to the residents' care plan.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with the professional standards of nursing practice for two out of 12 sampled residents (Resident 5 and Resident 2), when the physician's orders (PO) were not updated and the care plans (CP, a personalized document outlining a person's health conditions, care goals, and necessary services to maintain quality of life) were not revised after urinary catheters (a flexible tube inserted into the bladder to drain urine into a drainage bag) had been discontinued.This failure had the potential for Resident 5 and Resident 2 to receive inadequate and unnecessary care. Findings: A review of Resident 5's Face Sheet (FS) indicated Resident 5 was admitted to the facility in December 2025 with diagnoses which included cerebral infarction (a serious medical emergency where blood flow to part of the brain is blocked, causing tissue death) and left sided hemiparesis (weakness on one side).A review of Resident 5's PO, dated 12/14/25, indicated Resident 5 had an order for a urinary catheter.A review of Resident 5's CP, dated 12/14/25, indicated Resident 5 had urinary retention (the inability to fully or partially empty the bladder, causing pain, frequent urges, or an inability to urinate) and had a urinary catheter inserted.During an interview on 3/17/26 at 9:38 a.m. with Resident 5, Resident 5 confirmed the urinary catheter had been removed.A review of Resident 2's FS indicated Resident 2 was admitted to the facility in February 2026 with diagnoses which included lumbar and thoracic fractures (serious injuries occurring in the mid-to-lower back) and muscle weakness.A review of Resident 2's PO, dated 2/9/26,indicated Resident 2 had an order for a urinary catheter.A review of Resident 2's CP, dated 2/10/26, indicated the potential for complications related to urinary catheter use.A review of Resident 2's Progress Notes (PN), dated 2/11/26 indicated a new PO had been received to discontinue Resident 2's urinary catheter.During a concurrent observation and interview on 3/17/26 at 9:38 a.m. at the nursing station, Resident 5's urinary catheter drainage bag was not observed and Resident 5 confirmed the urinary catheter had been removed.During an interview on 3/18/26 at 11:30 a.m. in Resident 2's room, Resident 2 confirmed the urinary catheter had been removed quite some time ago.During a concurrent interview and record review on 3/20/26 at 1:35 p.m. with LN (Licensed Nurse) 1, Resident 5's and Resident 2's Pos and CPs were reviewed. LN 1 confirmed Resident 5 and Resident 2 had their urinary catheters discontinued and indicated the POs had not been updated. LN 1 acknowledged the physician's order should be discontinued.During a concurrent interview and record review on 3/20/26 at 2:36 p.m. with the Director of Nursing (DON), Resident 5's and Resident 2's POs and CPs were reviewed. The DON confirmed Resident 5's and Resident 2's urinary catheters had been discontinued by the physician, and the POs should have been updated. The DON acknowledged resident orders should be initiated, updated or discontinued when received and followed per physician instructions.A review of the facility's policy and procedure (P&P) titled, Orders - Physician, revised 2/28/24, the P&P indicated, The nursing staff shall place the order for all prescribed medications and treatments.The nursing staff shall note and verify orders when orders are received by provider.

Based on observation, interview, and record review, the facility failed to ensure medications with discontinued orders were removed from facility drug supply and destroyed in a timely manner. This failure had the potential to result in medication errors and adverse events from residents receiving discontinued medications and the potential for diversion (the illegal transfer, theft, or misuse of medications) from medications not being disposed of.Findings: During an inspection of the Medication Storage Room on 3/17/26 at 9:58 a.m. with the Director of Nursing (DON), a three-drawer cart positioned immediately to the right of the entrance filled with medications was observed. Additional medications were stored in a plastic drawer situated on top of the cart and to the left of it, an orange bucket was found overflowing with more medications. On the shelves were multiple plastic bins and one soft maroon insulated bag, all filled with medications. One intravenous (IV, into the vein) bag sodium chloride (used for rehydration) 0.9% with a pharmacy label was comingled with the facility's stock of the same IV solution. The DON confirmed the findings and stated they were all discontinued medications that needed to be separated from facility stock and destroyed. The DON stated discontinued medications were destroyed every Friday with another nurse as witness; if a second nurse was unavailable, destruction would be delayed by a week.During the same inspection of the Medication Storage Room, two randomly selected discontinued medications were identified for further review. The sample included Resident 22's Benadryl (a medication to treat allergies) and Resident 20's hyoscyamine (a medication to treat excessive secretions in the mouth).During a concurrent interview and record review on 3/17/26 at 10:17 a.m. with DON, Resident 22's medical record was reviewed. Resident 22's medical record indicated a physician's order for Benadryl (a medication to treat allergies) 25 milligrams (mg, a unit of measurement), give 1/2 tablet every 6 hours as needed, dated 1/22/25 to 8/13/25. DON confirmed the medication had been long discontinued and should have been destroyed.During a concurrent interview and record review on 3/17/26 at 10:21 a.m. with DON, Resident 20's medical record was reviewed. Resident 20's medical record indicated a physician's order for hyoscyamine 0.125 mg sublingual (under the tongue) tablet, give 1 tablet twice a day, dated 4/4/25 to 5/28/25. DON confirmed the medication order was discontinued and should have been destroyed.During a telephone interview with the Consultant Pharmacist (CP) on 3/18/26 at 1:21 p.m., the CP stated he expected the Medication Storage Room to be clean of discontinued medications and facility staff were aware they were to be destroyed within 90 days.During a review of the facility's policy and procedure (P&P) titled, Medication Storage, Storage of Medication, undated, the P&P indicated, Procedures. 14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal. 15. Medications awaiting destruction. These medications should be stored in a secured area separate from active orders. 16. Medication storage areas should be kept clean, well lit, organized and free of clutter.

Based on observation, interview, and record review, the facility failed to ensure food textures and preferences were accommodated for four of 12 sampled residents (Resident 2, Resident 50, Resident 51, Resident 38) when:1. Resident 2's food texture was not accommodated; 2. Resident 50 did not receive food items indicated on the daily menu;3. Resident 51's food preferences were not followed when she received food items that were identified as disliked; and,4. Resident 38's did not receive her preference of biscuit listed on the meal ticket. This failure had the potential to negatively impact Resident 2's, Resident 38's, Resident 50's, and Resident 51's nutritional status.Findings: 1. A review of Resident 2's Face Sheet(FS) indicated Resident 2 was admitted to the facility in February 2026 with diagnoses which included lumbar and thoracic fractures (serious injuries occurring in the mid-to-lower back) and muscle weakness. A review of Resident 2's diet orders indicated the following: a. Regular diet with International Dysphagia Diet Standardization Initiative (IDDSI, a global framework that standardizes terminology and methods for texture-modified foods) Level 7 Texture (soft, tender foods), dated 2/9/26; b. Regular diet with IDDSI Level 5 (MM5, minced, moist foods), dated 2/27/26; and c. Regular diet with IDDSI Level 6 (SB6, soft, bite sized foods) dated 3/17/26. A review of Resident 2's Progress Notes (PN), dated 2/12/26, by the Registered Dietician (RD), indicated Resident 2 was not meeting his estimated nutrition needs to promote wound healing. A review of Resident 2's Nutritional Care Plan (NCP), created on 2/17/26 by the Registered Dietitian (RD), indicated Resident 2 was at risk for altered nutritional status related to gout (a painful, inflammatory form of arthritis), acute kidney failure (a sudden decrease in kidney function occurring over hours or days, causing waste buildup, fluid retention, and electrolyte imbalances) and to provide diet changes as appropriate, diet as ordered and liberalize as desired, offer substitutes as needed and review food preferences. During a concurrent observation and interview on 3/18/26 at 11:54 a.m. in Resident 2's room, Resident 2's lunch tray was delivered. Resident 2 stated, Most of the time I can't eat what they are serving because the food is pureed and if it's pureed again today, I can't eat it. Resident 2's lunch tray and meal ticket, which indicated the texture consistency of the diet,, were observed and reviewed. The meal ticket indicated the following food items: pureed salmon and potato chowder, soft and bite sized meatloaf, pureed seasoned broccoli florets, pureed cornbread, and pureed Dutch apple pie. Resident 2 stated, I don't know why they [kitchen staff] keep serving me pureed foods, I've never been on a pureed diet. 2. A review of Resident 50's FS indicated Resident 50 was admitted to the facility in March 2026 with diagnoses which included a left hemiarthroplasty (a surgical procedure, a partial hip replacement, after a fracture) and major depressive disorder (a serious mental health condition characterized by persistent sadness, low mood, and loss of interest in activities). A review of Resident 50's diet order, dated 3/10/26, indicated Resident 50 was on a No Added Salt (NAS)/Low Fat diet. A review of Resident 50'sNCP created on 3/18/26 by the RD indicated Resident 50 was at risk for altered nutritional status related to the left femur (thigh bone) fracture and to provide interventions which included: diet changes as appropriate, liberalize as desired, offer substitutes as needed and review food preferences. A review of the Week 4 Wednesday Therapeutic Spreadsheets Low Fat diet on 3/18/26 indicated the lunch menu was salmon and potato chowder, meatloaf, seasoned broccoli florets, cornbread and Dutch apple pie. During a concurrent observation and interview on 3/18/26 at 12:09 p.m. in Resident 50's room, Resident 50's lunch tray and meal ticket were observed. Resident 50's lunch tray and meal ticket included chicken, brown rice and seasoned broccoli florets. Resident 50 indicated she did not request chicken or brown rice for lunch and was disappointed she did not receive the meatloaf, which was indicated on the lunch menu. Resident 50 stated, I haven't received a dessert in several days either. During an interview on 3/18/26 at 2:16 p.m. with the Director of Culinary Experience (DCE), the DCE confirmed Resident 50's disappointment from not receiving meatloaf for lunch or a dessert item. The DCE indicated he expected menus and food preferences to be followed to increase the resident's overall experience and healing process while at the facility. 3. A review of Resident 51's FS indicated Resident 51 was admitted to the facility in March 2026 with diagnoses which included right knee replacement surgery and major depressive disorder. A review of Resident 51's diet order, dated 3/9/26 indicated Resident 51 was on a Consistent Carbohydrate Diet (CCHO, diabetes management plan diet designed to stabilize blood sugar by consuming a consistent, set amount of carbohydrates at the same meals each day). A review of Resident 51's N CP created on 3/18/26 by the RD, indicated Resident 51 was at risk for altered nutritional status related to anxiety disorder and morbid obesity (a complex chronic disease which typically involves being greater than 100 pounds over ideal body weight) and provide interventions which included: diet changes as appropriate, provide diet as ordered and liberalize as desired and review food preferences. A review of Resident 51's Nutritional Observation (NO), dated 3/11/26, indicated Resident 51 dislikes fish, spinach, broccoli and pies. A review of the Week 4 Wednesday Therapeutic Spreadsheets the CC (Controlled Carbohydrates) diet on 3/18/26 indicated the lunch menu was salmon and potato chowder, meatloaf, seasoned broccoli florets, cornbread and dutch apple pie. During a concurrent observation and interview on 3/18/26 at 12:08 p.m. in Resident 51's room, Resident 51's lunch tray and meal ticket were observed. Resident 51's lunch tray and meal ticket included salmon and potato chowder, meatloaf, cornbread, and sugar free chocolate pudding. Resident 51 stated, I don't eat fish or seafood, and today I received salmon and potato soup. Resident 51 further indicated a vegetable item had not been served. During an interview on 3/19/26 at 12:57 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 indicated dietary staff, or the RD, interviewed residents about their food preferences and stated alternatives are available if a resident did not like the meal that was served. CNA 1 confirmed residents were expected to receive the meal indicated on their meal ticket. CNA 1 acknowledged when residents do not enjoy the meals provided, they do not eat well which can lead to unintentional weight loss. During a concurrent interview and record review on 3/19/26 at 2:32 p.m. with the RD, Resident 2's, Resident 50's and Resident 51's diet orders and preferences were reviewed. The RD indicated residents' food preferences were documented on the initial NO and periodic updates would be documented under the dietary progress note and stated CNAs checked in with residents during mealtimes and should offer alternatives for residents with minimal intake or if they disliked the meal provided. The RD stated the pureed items served to Resident 2 were predetermined on the diet spreadsheet, and stated, The spreadsheet must be followed. The RD confirmed that therapeutic diets should include a dessert item and resident's food preferences should be followed and the expectation was for a resident's diet order, lunch tray and meal ticket to match. During an interview on 3/19/26 at 3:35 p.m. with the Food Services Manager (FSM) the FSM stated he expected the diet order, food tray and meal ticket to match. The FSM stated foods with an altered texture were identified on the menu spreadsheet and dietary staff were to always follow what's on the spreadsheet. A review of the facility's policy and procedure (P&P) titled, Therapeutic Diets/Texture Alterations, revised 10/29/18, the P&P indicated, Liberalize diets whenever possible per RD. Therapeutic diets are planned by a dietician and prepared per recipes an production guides. A review of the facility's P&P titled, Menus and Recipes, revised 3/18/26, the P&P indicated, Menus are approved by a Registered Dietician and are purchased and written by [Diet Manual].A copy of menus shall be posted in at least two (2) resident areas. Menus shall be posted low enough and in print large enough for residents to read them. 4. A review of Resident 38's FS indicated Resident 38 was admitted to the facility in Fall 2025 with a diagnosis of weakness. A review or Resident 38's MDS (a federally mandated resident assessment tool) indicated that Resident 38 had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 indicated Resident 38 had no memory impairment. A review of Resident 38's dietary notes indicated [Resident 38's] preferences are noted on the tray ticket to individualize her diet as much as possible. A review of Resident 38's diet orders, dated 11/6/25, indicated that Resident 38 was on a regular diet with thin liquids. A review of Resident 38's breakfast meal ticket, dated 2/17/26, indicated the morning meal was prune juice, orange juice, water, oatmeal, sausage gravy, biscuit, fruit, fried egg, and wheat toast. During an interview on 3/17/26 at 8:49 a.m. with CCNA 1, the CNA 1 confirmed resident 38 was missing her biscuit, and stated, It was needed for her weight gain. During a concurrent observation and interview on 2/17/26 at a.m., with Resident 38 in Resident 38's room, Resident 38's breakfast tray was observed served by staff. Resident 38 indicated she was missing her biscuit and she would like to have the biscuit. Resident 38 stated, I do not need to lose any more weight. During a concurrent interview and record review on 3/19/26 at 2:40 p.m., with the RD, the RD reviewed the weekly menu and confirmed Resident 38 should have received a biscuit for her preference and that it was the expectation what was on the menu to be on the residents meal tray unless it expressed otherwise. The RD stated that if residents did not have their preferences, that could lead to weight loss and loss of eating enjoyment. During an interview on 3/20/26 at 2:58 p.m. with the Director of Nursing (DON), the DON stated the expectation was Resident 38's meal ticket should have reflected the food choices in the meal tray. A review of the facility's policy titled, Nutritional Care, Screening and assessment, dated 2/9/2017, indicated, Food Preferences will be maintained in the tray card system.

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety in a census of 33 residents, when: The interior dispenser of ice machine had black, brown, and white substances on its surfaces in the facility kitchen; One kitchen staff touched the prepped food area with solid gloves after touching multiple surfaces in the kitchen;Ice buildup was found on the edge and frame of the doors of freezer in the main kitchen; andWet, dirty pans were found stored on the ready-to-use rack next to cooking area in the main kitchen. These failures had the potential risk for the spread of food-borne illnesses in a vulnerable population.Findings: 1. During a concurrent observation and interview on 2/17/26 at 3:10 a.m. with the Food Service Manager (FSM), the interior dispenser of ice machine in the kitchen was observed. The surface of the interior ice dispenser was found covered with black and brown substances. The FSM confirmed the interior dispenser of ice machine was dirty and ice was exposed to its dirty surfaces. The FSM stated the debris was not expected to be in the ice machine and that it was not good for the residents. During an interview on 2/20/26 at 9:19 a.m. with the Director of Maintenance (DOM), the DOM stated it was the expectation that the kitchen outside contracted technicians completed quarterly full cleaning that included the interior of the ice machine and it was the expectation for the ice machine to be clean to ensure the health and safety of vulnerable residents within the facility. During an interview on 3/20/26 on 3/20/26 at 1:46 p.m. with Director of Nursing (DON), the DON stated it was the expectation that ice machines were cleaned for infection control reasons and residents' health. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Cleaning, dated 10/29/18, the P&P indicated,.All equipment shall be kept clean. 2. During a concurrent observation and interview on 3/17/26 with [NAME] 1 and the FSM in the kitchen, [NAME] 1 was observed wearing single use gloves in the cooking area. [NAME] 1 touched the food prep area with soiled gloves after touching hot holding food door handle. [NAME] 1 confirmed he touched multiple surfaces and stated he should had removed his gloves before handling the resident's food. The FSM confirmed the handle of the hot holding food door handle was soiled with visible debris and that it was the expectation to change gloves after touching dirty surfaces. During a concurrent record review and interview on 3/19/26 with the Infection Prevention Nurse (IPN), the handwashing training facility record was reviewed. The IP Nurse confirmed all kitchen staff completed recent hand washing training and were expected to follow the practice of handwashing. During a review of the facility's P&P titled Personal Sanitary and Dress Standards, dated 3/24/24, the P&P indicated, .Gloves are not to be used as a replacement for frequent, proper hand washing and gloves must be changed when going from dirty to clean operations.3. During a concurrent observation and interview on 3/19/26 at 7:34 a.m. with the Executive Chef (EC), ice buildup was found on the rubber seals of the freezers holding ice cream in the main kitchen. The EC confirmed there was ice buildup on the edges and frames of the holding freezers and could pose a health risk for residents. During a interview with Director of Nursing (DON) on 3/20/26 on 3/20/26 at 1:46 p.m. with the DON, the DON stated it was the expectation that freezers were properly cleaned and did not have ice buildup to avoid contamination of food served to the residents. During a review of the facility's P&P titled, Sanitation and Cleaning, dated 10/29/18, the P&P indicated, All kitchens, kitchen areas .shall be kept clean, maintained in good repairs .freezers to be cleaned monthly . 4.During a concurrent observation and interview on 3/19/26 at 7:56 a.m., with the EC, a cooking pan and six hotel pans were found stored wet. The EC confirmed wet kitchen wares were stored on the ready-to-use rack next to the main kitchen's cooking area. During a interview on 3/20/26 on 3/20/26 at 1:46 p.m. with the DON, the DON stated she expected ready-to-use items to be dry and ready to use to avoid risk of infection to residents. During a review of the facility's P&P titled, Ware Washing, dated 7/7/15, the P&P indicated, .pans.washed.rinsed.sanitized.inverted on drain board. Let air dry.

Based on interview, record review, the facility failed to ensure one out of 12 sampled residents (Resident 2) was free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behaviors) when Resident 2 received trazodone (an antidepressant) for insomnia without adequate indication for use and without adequate monitoring for efficacy. This failure had the potential to result in the unnecessary use of psychotropic medication and increased risk of exposure to side effects such as drowsiness, dizziness, headache, dry mouth, nausea, and lightheadedness upon standing.A review of Resident 2's medical record indicated he was admitted to the facility in February 2026 with diagnoses which included multiple lumbar fractures (a break or crack in bones of the lower back), lower back pain, lack of coordination and weakness. A review of Resident 2's physician's orders indicated an order for trazodone (an antidepressant also used to treat insomnia) 50 milligrams (mg, a unit of measurement), give 1 tablet at bedtime for depression manifested by insomnia, dated 2/9/26. During a concurrent interview and record review on 3/19/26 at 12:12 p.m. with Licensed Nurse 1 (LN 1), Resident 2's physician's orders, and behavior monitoring related to trazodone were reviewed. LN 1 reviewed the physician's order for trazodone and stated it was indicated for Resident 2's depression and insomnia. LN 1 stated the efficacy of the medication was assessed by asking the resident how they were feeling, assessing their mood, and seeing if they were getting out of bed. LN 1 reviewed Resident 2's record and confirmed it was documented that the resident was sleeping but the number of hours were not documented. She agreed it would have been useful to know how many hours the resident slept per day to assess if medication was effective for his insomnia. She stated she expected to see a monitoring parameter for hours of sleep in a resident's chart if a medication was given for insomnia. During a concurrent interview and record review on 3/19/26 at 12:24 p.m. with the Director of Nursing (DON), Resident 2's diagnoses, physician's orders, and behavior monitoring related to trazodone were reviewed. DON reviewed Resident 2's order for trazodone and confirmed it indicated for depression manifested by insomnia. She reviewed Resident 2's record and confirmed there was no documentation to support the clinical diagnosis of depression. She stated the order indicated it was for depression because Medical Records had given guidance that since trazodone was an antidepressant the order needed to include a diagnosis of depression even though it was given to Resident 2 to treat insomnia. DON agreed the physician's order should not have read for depression without a clinical diagnosis. DON confirmed Resident 2 was not monitored for hours of sleep but should have been to assess the efficacy of the medication. During a concurrent telephone interview and record review on 3/19/26 at 1:10 p.m. with the Consultant Pharmacist (CP), the CP agreed all elements of a prescriber's order must be accurate. He stated without a depression assessment the resident could not be diagnosed with depression. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, revised 5/16/20, the P&P indicated, Policy Interpretation and Implementation. 2. Residents on psychotropic medications will be monitored for appropriate use, effectiveness, side effects and possible dose reduction. 4. The physician order for psychotropic medications will include the name of the medication, dose, route, frequency, diagnosis, and the specific behavior manifestation to be treated. 6. Monthly, the licensed nurse will evaluate the resident for overall effectiveness of the psychotropic medication and record side effects noted. 7. Based on a comprehensive assessment of a resident, the community will ensure that: a. residents who have not used psychotropic drugs are not given those drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the residents record.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (CP, a personalized document outlining a person's health conditions, care goals, and necessary services to maintain quality of life) for one of 12 sampled residents (Resident 7), when Resident 7's nutritional status CP was not individualized to meet Resident 7's specific medical needs.This failure had the potential for Resident 7 to receive inappropriate and inaccurate nutritional and dietary interventions.Findings:A review of Resident 7's Face Sheet (FS) indicated Resident 7 was admitted to the facility in January 2026 with diagnoses which included pneumonitis (lung inflammation) due to inhalation of food and vomit, and gastronomy placement (GT, a feeding tube placed through the abdominal wall directly into the stomach, providing nutrition for people unable to eat normally).A review of Resident 7's Nutritional Observation, dated 2/10/25, indicated Resident 7 was NPO (nothing by mouth, no food or fluid intake) and received tube feedings (liquid nutrients delivered directly into the stomach or small intestine when oral intake is impossible or insufficient).A review of Resident 7's diet order, dated 2/25/26, indicated Resident 7's diet as NPO.A review of Resident 7's CP, dated 1/20/26, indicated Resident 7 required a feeding tube related to oropharyngeal dysphagia (difficulty swallowing or moving food from the mouth to the throat, often causing coughing and choking), and to check the placement and patency of the feeding tube every shift and before each feeding.A review of Resident 7's Nutritional CP (NCP), dated 1/22/26, indicated Resident 7 was at risk for altered nutritional status related to pneumonitis, dysphagia and use of a feeding tube. Two goals were identified: 'no significant weight changes in 1 and 6 months' and 'will consume at least 70% of meals daily.' Interventions for Resident 7 to meet these goals included: offer bedtime snacks daily, diet as ordered and liberalize as desired, encourage oral intake, offer food substitutes as needed and review Resident 7's food preferences.During an interview on 3/17/26 at 2:23 p.m. in Resident 7's room, Resident 7 confirmed he received tube feeding for nutrition, and stated, I do the feedings myself, through the [GT] tube, unfortunately I can't eat regular food yet.During an interview on 3/20/26 at 11:27 a.m. with the Director of Staff Development (DSD) the DSD indicated CPs should be personalized for each resident and coordinated with physician's orders and the medical diagnoses identified. The CP should also include preventative measures for potential problems which include goals, interventions used and a time frame for the expected outcome. The DSD confirmed that NPO residents should not have interventions that encourage oral intake on the CP. The DSD stated if a NPO resident received food or fluids by mouth they were at risk for aspiration (the accidental breathing in of foods or liquids into the airway and lungs) or choking.During an interview on 3/20/26 at 1:50 p.m. with Licensed Nurse (LN) 2, LN 2 confirmed Resident 7 was NPO and received tube feedings for nutrition. LN 2 stated Resident 7's CP should not include interventions to encourage food, fluids or to provide a bedtime snack. LN 2 stated if Resident 7 was provided with food or fluids as indicated on his CP it could have a drastic negative outcome for the resident such as choking, respiratory distress or even death.During a concurrent interview and record review on 3/20/26 at 2:36 p.m. with the Director of Nursing (DON), Resident 7's diet order and CP were reviewed. The DON confirmed Resident 7 was not to receive food or fluids by mouth and interventions on the CP which included the encouragement of oral intake or to provide a snack at bedtime was inappropriate and unsafe. The DON stated Resident 7 has an increased risk for choking which could lead to death, due to his inability to swallow food and fluids safely.During a review of the facility's policy and procedure (P&P) titled Interdisciplinary Team/Care Plan Process revised 12/15/21, the P&P indicated, Each resident will have a care plan that is initiated upon admission. Nursing participates in the interdisciplinary assessment process by initiating an assessment of the resident, reviewing the physician's orders (e.g., diet.) and other transferring information.The care plan is developed by an interdisciplinary team which includes, but is not limited to: b. Licensed nurse who has responsibility for the resident, d. Dietary manager/Registered Dietician.The comprehensive care plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems.

Based on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported to the facility irregularities related to the medication regimen for one of 12 sampled residents (Resident 2) during the medication regimen review (MRR). This failure resulted in inadequate monitoring and indication for use of psychotropic medication (drugs that affects brain activities associated with mental processes and behaviors) for Resident 2.Findings: A review of Resident 2's medical record indicated he was admitted to the facility in February 2026 with diagnoses which included multiple lumbar fractures (a break or crack in bones of the lower back), lower back pain, lack of coordination and weakness. A review of Resident 2's physician's orders, dated 2/9/26, indicated an order for trazodone (an antidepressant also used to treat insomnia) 50 milligrams (mg, a unit of measurement), give 1 tablet at bedtime for depression manifested by insomnia. During a concurrent interview and record review on 3/19/26 at 12:12 p.m. with Licensed Nurse 1 (LN 1), Resident 2's physician's orders, and behavior monitoring related to trazodone were reviewed. LN 1 reviewed the physician's order for trazodone and stated it was indicated for Resident 2's depression and insomnia. LN 1 stated the efficacy of the medication was assessed by asking the residents how they were feeling, assessing their mood, and seeing if they were getting out of bed. LN 1 reviewed Resident 2's record and confirmed it was documented that the resident was sleeping but the number of hours were not documented. She agreed it would be useful to know hours of sleep to assess if medication was working or not. She stated she would normally expect to see a monitoring parameter for hours of sleep in a resident's chart if a medication was being given for sleep. During a concurrent interview and record review on 3/19/26 at 12:24 p.m. with the Director of Nursing (DON), Resident 2's diagnoses, physician's orders, and behavior monitoring related to trazodone were reviewed. The DON reviewed Resident 2's order for trazodone and confirmed it indicated depression manifested by insomnia. She reviewed Resident 2's record and confirmed there was no documentation to support the clinical diagnosis of depression. She stated the order indicated it was for depression because Medical Records had given guidance that since trazodone was in the drug category of antidepressants the order needed to include that even though it was being given to treat insomnia. The DON agreed the physician's order should not have read for depression without a clinical diagnosis. The DON confirmed Resident 2 was not monitored for hours of sleep but should have been to assess the efficacy of the medication. During a telephone interview on 3/19/26 at 1:10 p.m. with the CP, the CP agreed all elements of a prescriber's order must be accurate. He stated without a depression assessment the resident could not be diagnosed with depression. A review of the Consultant Pharmacist's Medication Regimen Review: Listing of Residents Reviewed with No Recommendations. For Recommendations Created Between 2/1/2026 and 2/23/2026, indicated the CP did not identify or report that there was no documentation to support the clinical diagnosis of depression for Resident 2. The report also indicated CP did not identify that Resident 2 was not being adequately monitored for the efficacy of trazodone. During a second telephone interview and record review on 3/19/26 at 2:40 p.m. with the CP, Resident 2's recommendations and diagnosis were reviewed. CP confirmed he did not identify or report any irregularities for either the diagnoses or monitoring related to trazodone for Resident 2's. CP confirmed he did not see clinical justification documented for the use of trazodone for depression in Resident 2's record. CP stated he did not typically evaluate the diagnostic criteria used by a physician to diagnose a resident for new psychotropic medication orders. CP stated for new psychotropic medication orders he reviewed the list of diagnoses in a resident's medical record to confirm a diagnosis was listed for the medication ordered. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, revised 5/16/20, the P&P indicated, Policy Interpretation and Implementation. 2. Residents on psychotropic medications will be monitored for appropriate use, effectiveness, side effects and possible dose reduction. 4. The physician order for psychotropic medications will include the name of the medication, dose, route, frequency, diagnosis, and the specific behavior manifestation to be treated. 7. Based on a comprehensive assessment of a resident, the community will ensure that: a. residents who have not used psychotropic drugs are not given those drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the resident's record. During a review of the facility's policy and procedure (P&P) titled, Medication Monitoring Medication Regimen Review and Reporting, undated, the P&P indicated, Policy: 'Medication Regiment Review (MRR)' or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes a review of the medical record in order to prevent, identify, report and resolve medication related problems, medication errors, or other irregularities. Procedures. 2. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist utilizing a variety of sources including medication administration records (MAR), prescriber's orders, progress notes, nurse's notes, the Resident Assessment Instrument (RAI), Minimum Data Set (MDS), laboratory and diagnostic test results, behavior monitoring information and information from the nursing care center staff and other health professionals involved in the resident's care. 3. In performing medication regimen review, the consultant pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards.

Based on observation, interview, and record review, the facility failed to properly store medications for three residents (Resident 14, Resident 148, and Resident 149) of a census of 33, when three opened inhalers were not dated with open and discard dates. This failure decreased the facility's potential to properly store residents' medications and ensure medication potency. Findings: A review of Resident 14's Resident Face Sheet indicated Resident 14 was admitted to the facility in October 2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and asthma (chronic disease of the lungs that makes it difficult to breathe). A review of Resident 148's Resident Face Sheet indicated Resident 148 was admitted to the facility in December 2024 with a diagnosis of COPD. A review of Resident 149's Resident Face Sheet indicated Resident 149 was admitted to the facility in January 2025 with a diagnosis of COPD. During a concurrent observation and interview on 1/7/25 at 1:01 p.m. with Licensed Nurse 4 (LN 4), LN 4 confirmed the following opened medications were stored in medication cart three without open or discard dates: - Resident 14's fluticasone furoate, umeclidinium, and vilanterol inhaler (treats asthma and COPD) indicated to discard six weeks after opening the foil tray; - Resident 148's fluticasone and salmeterol inhaler (treats asthma and COPD), indicated to discard one month after opening the foil pouch; and - Resident 149's fluticasone furoate inhaler (treats asthma and COPD), indicated to discard six weeks after opening the foil tray. LN 4 stated opened medications might not be effective if given past the discard date and might not treat the respiratory condition. LN 4 further stated open and discard dates should have been written on the medications according to manufacturer's recommendations. During an interview on 1/8/25 at 12:40 p.m. with the Interim Director of Nursing (IDON), IDON stated medications should have open and discard dates to ensure been given for the maximum effect. IDON further stated residents might not get the maximum effect of medications if given past discard date. A review of the facility's policy and procedure titled, Medication Administration General Guidelines, dated 1/21, indicated, The nurse shall place a 'date opened' sticker on the medication . and certain products have specified shortened end-of- use dating, once opened, to ensure medication purity and potency.

Based on observation, interview, and record review, the facility failed to ensure the nutritive values of food were conserved during preparation for a census of 33 residents, when [NAME] 1 prepared quiche (an entree for lunch) without measuring the ingredients and following the recipe. This failure decreased the facility's potential to meet the residents' nutritional needs. Findings: During a concurrent observation and interview on 1/8/25 at 9:45 a.m. with [NAME] 1 in the main kitchen, [NAME] 1 was observed mixing the ingredients when cooking quiche. [NAME] 1 did not follow the recipe and poured unmeasured amounts of liquid eggs and heavy cream in a pot. [NAME] 1 confirmed she did not follow the recipe to cook quiche and stated she did not need to measure the amounts of liquid eggs and heavy cream. [NAME] 1 also stated she was unable to tell the exact numbers of servings to be prepared. A review of the facility's recipe titled, Quiche [NAME] Jour, dated 2024, indicated, one gallon (a unit of measure) plus three and quarter of a quart (a unit of measure) of liquid eggs, and three quarts plus three cups (a unit of measure) of heavy cream should be used to prepare 180 servings of quiche. During an interview on 1/8/25 at 10 a.m. with Executive Chef (EC), EC stated [NAME] 1 should have followed the quiche recipe with correct measured amounts of both ingredients. EC also stated the unmeasured amounts of ingredients might have altered the nutritive values of food. During an interview on 1/9/25 at 8:29 a.m. with the Administrator (ADM), ADM stated the expectation was [NAME] 1 should have followed the recipe and measured the amounts of ingredients to maintain the nutritive values of quiche cooked for the residents. ADM further stated foods with altered nutritive values might not meet the residents' nutritional needs. A review of the facility's policy titled, Menus and Recipes, revised in 2017, indicated, . Standardized recipes will be used in preparation of the menu . A review of the facility's policy titled, Food Preparation and safety, revised in 2015, indicated, . Foods are prepared per the recipes which include . amounts of ingredients . based on the diet counts which are available from the computerized tray card system .

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for a census of 33 residents, when; 1. Unlabeled, expired, incorrectly dated, and soiled food items were found stored in the ready-to-cook area in the main kitchen; 2. Wet, dirty, and damaged cooking pans were found stored on the ready-to-use rack next to cooking area in the main kitchen; 3. A can-opener was found dirty, ready-to-use, and attached to the kitchen counter in the main kitchen; 4. The interior dispenser of ice machine had black, brown, and white substances on its surfaces in Skilled Nursing Facility (SNF) kitchen; 5. One kitchen staff touched the clean cutting board and knife with soiled gloved hands after touching multiple surfaces in the main kitchen; and 6. Ice buildup was found on the edges and frames of entry doors and on food boxes inside the walk-in freezers in the SNF and main kitchens. These failures decreased the facility's potential to provide sanitary conditions to store and prepare food for its residents. Findings: 1. During a concurrent observation and interview on [DATE] at 9:54 a.m. with Executive Chef (EC), foods and spices were observed in the main kitchen's cooking area. A bottle of citrus seasoned dressing and sauce was found partially used but unlabeled for open and expiry dates. A fish sauce bottle was found expired in 2024. A dark chili powder container was found with two labels indicating two different open and expiry dates. A box of kosher salt was found crumbled with moistened salt inside it. EC confirmed there were unlabeled, expired, incorrectly labeled, and soiled food items stored in the ready-to-cook area in the main kitchen. During an interview on [DATE] at 8:29 a.m. with Administrator (ADM), ADM stated any unlabeled, expired, incorrectly labeled, and soiled food items stored in the ready-to-cook area were unsafe. ADM also stated unsafe food items might cause food born illnesses and kitchen staff should have labeled all food items correctly once been opened. A review of the facility's policy titled, Food Storage, dated [DATE], indicated, . Opened packages of dry food which are to be stored will be dated upon opening . 2. During a concurrent observation and interview on [DATE] at 10:05 a.m. with EC, cooking pans were observed on the ready-to-use rack next to the main kitchen's cooking area. Fifteen hotel pans size six and 20 hotel pans size three were found stored wet. Seven frying pans were found stored dirty with interior surfaces covered with oil and food crumbs. Twenty nonstick frying pans were found stored with eroded interior surfaces. One big cooking pan was found stored with interior surface covered with yellowish-orange colored substance. EC confirmed wet, dirty, and damaged pans were stored on the ready-to-use rack next to the main kitchen's cooking area. During an interview on [DATE] at 8:29 a.m. with ADM, ADM stated staff should have not stored wet, dirty, and damaged cooking pans. ADM also stated wet, dirty, and damaged pans might become sources of food contamination and all cooking pans stored on the ready-to-use rack should have been undamaged, clean, and dry. A review of the facility's policy titled, Ware Washing, dated [DATE], indicated, . pans . washed . rinsed . sanitized . inverted on drain board. Let air dry . 3. During a concurrent observation and interview on [DATE] at 9:37 a.m. with EC, a can-opener was observed attached to the kitchen counter and ready to be used in the main kitchen. The can-opener tip and other parts were found covered with brownish-black substance. EC confirmed the can-opener was dirty and needed to be cleaned. During an interview on [DATE] at 8:29 a.m. with ADM, ADM stated a dirty can-opener should have not been placed for ready to use. ADM further stated dirty equipment might cause food contamination and food born illnesses among residents and expected all equipment to be kept clean for food safety. A review of the facility's policy titled, Sanitation and Cleaning, dated [DATE], indicated, . All equipment shall be kept clean . 4. During a concurrent observation and interview on [DATE] at 10:21 a.m. with Dietary Manager (DM) and Director of Environmental Services (DES), the interior dispenser of ice machine in SNF kitchen was observed. The surfaces of interior dispenser were found covered with black, brown, and white substances. Both DM and DES confirmed the interior dispenser of ice machine was dirty and ice was exposed to its dirty surfaces. DM stated the interior of ice machine needed immediate cleaning. During an interview on [DATE] at 8:29 a.m. with ADM, ADM stated dirty interior of ice machine might cause contamination of the ice. ADM also stated contaminated ice could cause food borne illnesses among residents and expected the interior of ice machine to be maintained clean at all times A review of the facility's policy titled, Ice, dated [DATE], indicated, . Maintenance is responsible for thoroughly cleaning the ice machine . and will keep a cleaning log . 5. During a concurrent observation and interview on [DATE] at 8:35 a.m. with [NAME] 2 and EC in the main kitchen, [NAME] 2 was observed wearing single use gloves in the cooking area. [NAME] 2 touched the clean cutting board and knife with soiled gloves after touching multiple surfaces. [NAME] 2 confirmed he cleaned the kitchen counter, touched his apron and face with same pair of gloves, did not change the soiled gloves and then touched the clean cutting board and knife. [NAME] 2 stated he was getting ready to use that cutting board and knife to chop the sausage. EC confirmed [NAME] 2 touched the clean cutting board and knife with soiled gloves and the food preparation surfaces might have been contaminated. During an interview on [DATE] at 8:29 a.m. with ADM, ADM stated [NAME] 2 should have not touched the food preparation utensils and surfaces with soiled gloves because touching food preparation areas and surfaces might have caused cross contamination to the food cooked in the main kitchen. ADM also stated [NAME] 2 should have changed his single-use gloves after each task. A review of the facility's policy titled, Personal-Sanitary and Dress Standards, dated [DATE], indicated, . Gloves are not to be used as a replacement for frequent, proper hand washing and gloves must be changed when going from dirty to clean operations . 6. During a concurrent observation and interview on [DATE] at 8:45 a.m. with DM in SNF kitchen, the walk-in freezer was observed. Ice built-up was found on the door edges and frame of walk-in freezer. Big chunks of ice were also found on boxes containing food. DM confirmed the door edges and frame of walk-in freezer were covered with ice built-up and ice chunks were found on top of food boxes inside the freezer. During a concurrent observation and interview on [DATE] at 3:07 p.m. with EC in main kitchen, the walk-in freezer was observed. The door edges and frame of walk-in freezer were found covered with ice built-up. Ice was also found accumulated on the food boxes inside the freezer. EC confirmed the walk-in freezer door in main kitchen was not closing properly due to ice built-up and ice accumulated on food boxes. During an interview on [DATE] at 8:29 a.m. with ADM, ADM stated no built-up ice should have been on the doors, frames, or food boxes inside the walk-in freezers in the SNF and main kitchens. ADM expected kitchen staff to report this issue to the maintenance staff on a routine basis and stated ice built-up on the edges and frames of walk-in freezer doors interfere with door closing and might affect the quality of food stored inside. A review of the facility's policy titled, Sanitation and Cleaning, dated [DATE], indicated, All kitchens, kitchen areas . shall be kept clean, maintained in good repairs . and freezers to be cleaned monthly .

Based on observation, interview, and record review, the facility failed to safely operate the dryer for a census of 33 residents, when the dryer's lint compartment was not cleaned accordingly. This failure decreased the facility's potential to prevent a fire hazard. Findings: During a concurrent observation and interview on 1/8/25 at 11:04 a.m. with Laundry Staff (LS) in the laundry room, the three lint compartments of the dryers were inspected. LS opened the lint compartment, rolled up two thick layers of lint, and discarded it. LS confirmed she did not clean the lint compartment at the beginning of her shift. During a concurrent interview and record review on 1/9/25 at 8:41 a.m. with the Housekeeping Supervisor (HS), the lint compartment log was reviewed. HS expected staff to clean the lint compartment every two hours and stated it would have been a fire hazard if staff did not clean the lint compartment frequently. A review of the facility's Cleaning the Lint Compartments Log for January 2025, indicated morning and evening laundry staff should have cleaned the lint trap every two hours and documented it. The log further indicated there was missing documentation of removing lint every two hours on seven occasions at evenings during the month of January 2025. A review of the facility's policy titled, Supplies and Equipment, dated 12/29/18, indicated, Housekeeping/Laundry/Nursing department supplies, and equipment shall be readily available so that department personnel can perform necessary tasks. Equipment must be ready for use at all times of the day and night to serve the residents' needs. Care should be exercised in the handling and in the use of equipment to prevent damage or breakage.

Based on observation, interview, and record review, the facility failed to provide a homelike environment for one of 22 sampled residents (Resident 248), when the light switch behind Resident 248's bed was broken and kept in a non-operational drawer. This failure had the potential to negatively impact Resident 248's psychosocial well-being, ability to read, and access to personal belongings. Findings: A review of Resident 248's Resident Face Sheet indicated she was admitted to the facility on [DATE] with a diagnosis of right femur (the large bone in the upper part of your leg) fracture. A review of Resident 248's Physician Order Report, dated 12/1/24-12/31/24, indicated she had the capacity to understand choices and make health care decisions. During a concurrent observation and interview on 1/6/25 at 10:57 a.m. with Resident 248 in her room, Resident 248's wall light behind her bed was broken and the light's switch was kept in the nightstand's top drawer. Resident 248 stated the nightstand's top drawer was stuck and she could not open it on her own. Resident 248 further stated it bothered her that she could not turn on the light to read or reach her personal items without calling for assistance and she asked staff to fix the light and drawer several times. During a concurrent observation and interview on 1/06/25 at 1:05 p.m. with Licensed Nurse 2 (LN 2) in Resident 248's room, LN 2 confirmed the nightstand's top drawer was very hard to open and the light switch was not operational. LN 2 stated Resident 248 should be able to open the drawer on her own to reach her personal items and to turn on the light. LN 2 further stated it was very important that Resident 248 feels welcomed and comfortable and to maintain as much independence as possible. During a concurrent observation and interview on 1/8/25 at 10:16 a.m. with the Director of Environmental Services (DES) in Resident 248's room, DES confirmed the light switch was broken and stated the expectation was it should have been a priority repairing the items because it might have affected the quality of residents' stay at the facility. DES further stated the goal was to keep residents' environment as comfortable and homelike as possible. A review of the facility's policy titled, Safe Environment, revised 1/2025, indicated, The facility will provide: A . homelike environment, allowing the resident to use his or her personal belongings . adequate levels of illumination suitable for tasks the resident chooses to perform . maintain all mechanical, electrical . equipment . in safe operating condition.

Based on observation, interview, and record review, the facility failed to develop a person-centered care plan for one of 22 sampled residents (Resident 148), when Resident 148's care plan did not indicate he was receiving oxygen therapy. This failure decreased the facility's potential to meet Resident 148's care needs. Findings: A review of Resident 148's Resident Face Sheet indicated he was admitted to the facility in December 2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and dependence on supplemental oxygen. During an observation on 1/6/25 at 2:35 p.m. in Resident 148's room, Resident 148 was observed receiving oxygen at two liters per minute via nasal cannula (a device that gives you additional oxygen through your nose). A review of Resident 148's General Order, dated 1/3/25, indicated Resident 148 was on oxygen at two liters per minute every shift. During concurrent interview and record review on 1/8/25 at 12:16 p.m. with Licensed Nurse 4 (LN 4), Resident 148's care plan was reviewed. LN 4 confirmed there was no oxygen care plan in the clinical record and stated a care plan was needed so staff would know Resident 148's care needs. During an interview on 1/8/25 at 1:06 p.m. with the Interim Director of Nursing (IDON), IDON stated his expectations were all residents should have care plans; otherwise, there was a potential for nurses not to be able to provide the residents' care needs. A review of the facility's policy titled, Care Plan Process, revised 12/15/21, indicated, Each resident will have a care plan that is initiated upon admission . to assure that the resident's immediate care needs are met and maintained.

Based on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of 22 sampled residents (Resident 198), when Licensed Nurse 1 (LN 1) prepared a medication for Resident 198 taken from another resident's medication supply. This failure decreased the facility's potential to safely administer medications to residents. Findings: A review of Resident 198's Resident Face Sheet indicated Resident 198 was admitted to the facility in December 2024 with diagnoses including right hip fracture and chronic constipation. A review of Resident 198's Prescription Order, dated 12/22/2024, indicated an order for polyethylene glycol (medication used to treat constipation) once a day. During a concurrent observation and interview on 1/6/25 at 9:17 a.m. with LN 1, LN 1 was observed preparing polyethylene glycol for Resident 198. LN 1 removed the medication from a plastic bag and the bag's label indicated a different resident's name. LN 1 confirmed she prepared Resident 198's medication after taking it from another resident's bag and stated she should have taken it from the facility's medications stock; otherwise, the medication might have the wrong dose and Resident 198 might have an adverse effect. During an interview on 1/8/25 at 12:38 p.m. with the Interim Director of Nursing (IDON), IDON stated his expectations were nurses should have followed the five rights of medication administration (right patient, right medication, right time, right dose, and right route); otherwise, there was a potential for residents experiencing adverse effects if given medications that did not belong to them. A review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 1/21, indicated, Read medication label three times before preparing medication, when pulling medication package from med cart, when dose is prepared and before dose is administered. P&P further indicated, Medications supplied for one resident are never administered to another resident.

Based on observation, interview, and record review, the facility failed to provide adequate assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) for one of 22 sampled residents (Resident 248), when Resident 248 was not offered or given showers as scheduled. This failure had the potential to negatively impact Resident 248's cleanliness, discomfort, and psychosocial well-being. Findings: A review of Resident 248's Resident Face Sheet indicated she was admitted to the facility on [DATE] with a diagnosis of right femur (the large bone in the upper part of your leg) fracture. A review of Resident 248's Physician Order Report, dated 12/1/24-12/31/24, indicated she had the capacity to understand choices and make health care decisions. The report further indicated Resident 248 should have showered twice a week on Monday and Friday. During a concurrent observation and interview on 1/6/25 at 10:57 a.m. with Resident 248 in her room, Resident 248 was lying in bed and wearing a hospital gown with a large brown area on the upper chest site. Resident 248's hair was unkempt and matted on the back of her head. Resident 248 stated she did not have a shower since her accident and would love to have a shower and her hair to be washed. Resident 248 further stated she asked staff on several occasions for a shower and none of them discussed a shower schedule with her. A review of Resident 248's Care Plan, dated 12/29/24, indicated Resident 248 needed assistance with bathing and personal hygiene and to be showered/bathed two times a week as scheduled. During a concurrent interview and record review on 1/7/25 at 2:28 p.m. with Certified Nursing Assistant 1 (CNA 1), Resident 248's shower sheets and clinical record were reviewed. CNA 1 stated she did not recall offering a shower or bath to Resident 248 during her stay and could not find a documentation in the clinical record that a shower or bath was offered, refused, or given on the shower's scheduled dates 12/30/24, 1/3/25, and 1/6/25. CNA 1 stated it was the CNA's responsibility to check Resident 248's shower schedule, to offer her a shower or bath and assist her as needed. During a concurrent interview and record review on 1/7/25 at 2:33 p.m. with Licensed Nurse 1 (LN 1), Resident 248's shower sheets and clinical record were reviewed. LN 1 could not find a documentation in the clinical record that a shower or bath was offered, refused, or given on the shower's scheduled dates 12/30/24, 1/3/25, and 1/6/25. LN 1 stated CNAs should have offered Resident 248 a shower or bath according to the shower calendar and documented on the Shower Day Skin Inspection Sheet whether it was given or refused. LN 1 further stated Resident 248 might become depressed or might develop skin issues because of uncleanliness and not been offered a shower. A review of the facility's policy titled, Necessary Care and Services: Activities of Daily Living, dated 11/2024, indicated, The facility will ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good . grooming . and personal hygiene.

Based on observation, interview, and record review, the facility failed to ensure safety measures were in place for one of 22 sampled residents (Resident 15), when Resident 15 fell to the floor during transfer and sustained a blunt head injury (when the head hit a hard object or surface without breaking the skull) and a scalp abrasion (cut of the scalp). This failure decreased the facility's potential to prevent Resident 15's fall and injury. Findings: A review of Resident 15's Resident Face Sheet indicated Resident 15 was admitted to the facility in 2019 with a diagnosis of paraplegia (loss of movement and/or sensation, to some degree, of the legs). A review of Resident 15's Physician Order Report, dated [DATE] to [DATE], indicated Resident 15 had no capacity to understand choices and make health care decisions due to dementia (a progressive state of decline in mental abilities). Resident 15 had an order to be up in chair daily as tolerated. A review of Resident 15's John Hopkins Fall Risk Assessment Tool, dated [DATE], indicated Resident 15 had moderate fall risk. During an interview on [DATE] at 11:56 a.m. with Certified Nursing Assistant 4 (CNA 4), CNA 4 confirmed witnessing one of the loops from the head of the sling broke during Resident 15's transfer and as a result, Resident 15 fell to the floor and hit his head. CNA 4 stated there was no written expiration date on the sling during inspection. A review of Resident 15's Observation Detail List Report, dated [DATE], indicated Resident 15 had a fall on the morning of [DATE] during a mechanical lift from bed and sustained a bleeding from head. A review of Resident 15's Resident Progress Notes, dated [DATE], indicated, . [Resident 15] fell during transfer from [mechanical lift's] sling . The sling from [mechanical lift] malfunctioned and [Resident 15] fell landed on the floor . hit his head and is bleeding. A review of Resident 15's hospital Discharge Instructions Document, dated [DATE], indicated Resident 15 was in the hospital for fall, scalp abrasion, and blunt head injury. A review of Resident 15's Care Plan History, dated [DATE], indicated Resident 15 had a witnessed fall with head injury. During an interview on [DATE] at 9:59 a.m. with the Director of Staff Development (DSD) and Interim Director of Nursing (IDON), DSD confirmed Resident 15 fell during transfer due to a broken sling. IDON stated the expectations were staff should have inspected Resident 15's sling to make sure it was intact, had no damage, no break, and was not expired. A review of the facility's policy titled, Mechanical Lift Policy, dated [DATE], indicated, Slings will be maintained in appropriate condition for use with residents. Slings will be documented with a (in use start date) upon initial use by community. Slings will be inspected prior to each use for compromised material including frayed sling loops, frayed/loose seams, and weakness in fabric. A review of the facility's policy titled, Fall Prevention Program, dated [DATE], indicated, Residents will be provided an environment which will reasonably maximize safety while maintaining an optimal level of independence.

Based on observation, interview, and record review, the facility failed to ensure food preferences were accommodated to one of 22 sampled residents (Resident 15), when Resident 15's meal ticket did not match with lunch's meal tray. This failure had the potential to negatively impact the resident's nutritional status. Findings: A review of Resident 15's Resident Face Sheet indicated Resident 15 was admitted to the facility in 2019 with a diagnosis of paraplegia (loss of movement and/or sensation, to some degree, of the legs). A review of Resident 15's Physician Order Report, dated 1/1/25 to 1/31/25, indicated Resident 15 had no capacity to understand choices and make health care decisions due to dementia (a progressive state of decline in mental abilities). The report further indicated Resident 15 had fortified diet (food that have nutrients added to them), mechanical soft (food that is easy to eat and does require lots of chewing) chopped, and bit size texture. During a concurrent observation and interview on 1/6/25 at 12:38 p.m. with Certified Nursing Assistant 2 (CNA 2) in the dining room, CNA 2 confirmed Resident 15's meal tray had chicken tamales with green sauce, refried beans, extra sauce, orange juice, milk, and water. CNA 2 also confirmed the meal tray had different food choices compared to the meal ticket. A review of Resident 15's lunch meal ticket, dated 1/6/25, indicated the noon meal was potato soup, chicken supreme, herbed quinoa, green peas, garlic bread, coffee, whole milk, orange juice, apple juice, cranberry juice, and margarine with extra gravy sauce. During an interview on 1/9/25 at 2:01 p.m. with the Interim Director of Nursing (IDON), IDON stated the expectation was Resident 15's meal ticket should have reflected the food choices in the meal tray. A review of the facility's policy titled, Nutritional Care, Screening and Assessment, dated 2/9/2017, indicated, Food Preference will be maintained in the tray card system.

Based on observation, interview, and record review, the facility failed to maintain infection control practices for a census of 33 residents, when Certified Nursing Assistant 3 (CNA 3) did not use gown and gloves in an isolation (separation of residents with an infection from residents without an infection) room. This failure had the potential to increase the spread of infection among residents. Findings: A review of Resident 31's Resident Face Sheet, indicated Resident 31 was admitted to the facility in 2023 with a diagnosis of pneumonia (an infection/inflammation in the lungs). During a concurrent observation and interview on 1/6/25 at 9:30 a.m. with CNA 3, Resident 31's room had a contact isolation sign on the door. The sign indicated staff to use gown and gloves when entering the room. CNA 3 went inside Resident 31's room and collected the meal tray from the bedside without using gown and gloves. CNA 3 confirmed she should have used gown and gloves while providing care in an isolation room. During an interview on 1/8/25 at 10:46 a.m. with the Infection Preventionist (IP), IP stated the expectation was staff to wear gown and gloves when providing care to residents in isolated precaution rooms. IP further stated there could have been a chance for cross contamination to other residents when not using gown and gloves. During an interview on 1/9/25 at 2:01 p.m. with the Interim Director of Nursing (IDON), IDON stated staff should have used gown, gloves, and/or face shield when providing care to residents in contact isolation rooms. IDON further stated there could have been cross contamination of infection among other residents when staff did not use gown and gloves. A review of the facility's policy titled, Categories of Isolation Precautions, dated 6/24/2024, indicated, . All staff must wear appropriate Personal Protective Equipment (PPE) to include glove (clean, nonsterile) when entering the room, regardless of tasks being performed . Wear a gown (clean, nonsterile) when entering the room .

Based on observation, interview, and record review, the facility failed to provide adequate assistance, per the plan of care to prevent a fall, for 1 of 2 sampled residents (Resident 1) when he was left unattended in the bathroom and fell . This failure resulted in Resident 1 sustaining a painful leg fracture and required hospitalization for surgical treatment of [REDACTED]. Findings: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His 12/18/14 Minimum Data Set (MDS- an assessment tool) indicated he had experienced 2 or more non-injury falls in the 3 month period prior to 12/18/14. The clinical record for Resident 1 contained the following information: A care plan for fall prevention, initiated on 6/18/14, noted Resident 1 had a potential for falls and injuries due to dementia with poor memory and poor safety awareness. The care plan had been updated on 6/20/14 to direct staff to use alarming devices on both his bed and his wheelchair at all times in the event he tried to rise unassisted. On 7/21/14, the care plan was updated to indicate an alarm had been placed on the bathroom door to alert staff if the bathroom was accessed. The care plan had been further updated on 9/24/14 directing staff "Res(ident) will not be left unattended in the bathroom due to a high fall risk." Physician orders, dated 6/19/14, directed staff to walk with Resident 1 twice a day, every day. A Care Area Assessment Summary of an MDS assessment, completed on 9/27/14, indicated Resident 1 was at risk of falls relating to dementia, Parkinson's disease, an unsteady gait, unsteadiness when transitioning, and a history of falls. A 12/23/14 nursing note, written at 10:38 p.m. documented Resident 1 had been found on the floor just outside the bathroom. He was "in toilet and attempted to get up by himself took a few steps and fell on to floor." The nurse had assessed Resident 1 and determined there was no injury. A 12/23/14 Observation Report, written at 11:37 p.m. indicated Resident 1 had fallen from the toilet. Prior to the fall his mental status was confused. His usual ambulatory status involved walking with the assistance of one person. The licensed nurse had summarized the potential factors that led to the fall with "left on toilet". Under the section of the form titled "Describe measures to prevent further falls", the licensed nurse had written "resident not to be left alone while on toilet needs supervision." A 12/24/14 nursing note, written at 9:21 a.m. noted Resident 1 had been complaining of pain to his left hip Resident 1 was unable to move his left leg without pain. He refused to get out of bed or eat his breakfast because of the pain. A 12/24/14 nursing note written at 3:28 p.m. indicated Resident 1's left hip was x-rayed, revealing a left hip fracture with mild displacement (the bone had moved out of alignment from its normal position). The physician was notified and Resident 1 was to be transferred to the hospital for surgery. The hospital clinical records for Resident 1 included a History and Physical (H&P) dated 12/24/14. The H&P noted Resident 1 had been admitted after falling at the nursing home. Further review indicated Resident 1 was experiencing significant pain on his left side. The records indicated Resident 1 would be admitted to the hospital. Review of Resident 1's acute care facility Operative Report, dated 12/25/14, indicated Resident 1's fractured left hip was surgically repaired. Review of the facility's 12/21/10 policy titled "Fall Prevention Program" revealed "Residents residing in our communities are at risk for falls. Residents will be provided an environment which will reasonably maximize safety while maintaining an optimal level of independence." The employee record for Certified Nursing Assistant 1 (CNA 1) contained a document titled "(Facility) Expectations for CNAs." Item number 26 indicated "Confused residents should never be left alone on the toilet." CNA 1 had signed the form on 12/3/14. On 12/30/14 at 2:20 p.m., Resident 1's room was observed. Alarms were observed attached to his bed, his wheelchair, and to the bathroom door. In an interview with the Director of Nursing (DON) on 12/30/14 at 1:35 p.m. she reported Resident 1 had fallen from the toilet and fractured his hip. She reported staff had been with him, but left him when another alarm sounded. The DON stated Resident 1 ambulated with assistance and was not supposed to be ambulating without assistance. She further stated the CNA staff were not to leave confused residents alone on the toilet. In an interview with LN 2, the MDS coordinator, on 12/30/14 at 1:55 p.m. she reported Resident 1 had been experiencing a gradual decline recently and his mobility was limited. When asked if Resident 1 could take himself to the toilet she stated "Safely, no." In an interview with CNA 3 on 12/30/14 at 2:15 p.m., she reported she would walk with Resident 1. Resident 1 required a staff person by his side, and he was not supposed to be walking without assistance. In an interview with CNA 2 on 12/30/14 at 2:25 p.m. she reported Resident 1 could stand up by himself, but he was a fall risk and the staff were not supposed to leave him unattended when he was on the toilet. In an interview with CNA 1 on 12/30/14 at 2:45 p.m. she reported she had assisted Resident 1 to the bathroom on the evening shift of 12/23/14. She reported after she had assisted Resident 1 to the toilet, she had heard an alarm go off in another room. The second CNA who was working with her was on her break, and CNA 1 left Resident 1 on the toilet to attend to the alarm. She reported she returned to Resident 1 within 1-2 minutes as he sat on the toilet and she waited for him just outside the bathroom door. While CNA 1 was waiting, Licensed Nurse 1 (LN 1), the charge nurse, entered the room to inform CNA 1 a resident in another room needed bathroom assistance. CNA 1 left Resident 1's room and returned approximately 3-4 minutes later to find Resident 1 had fallen near the bathroom. CNA 1 reported she had not communicated to LN 1 that she was still attending to Resident 1 because the CNAs were expected to follow orders from a nurse. In an interview with LN 1 on 12/30/14 at 3:05 p.m. she reported she was the charge nurse on duty on the 12/23/14 evening shift. She stated she had found CNA 1 in Resident 1's room and she informed CNA 1 that another resident needed bathroom assistance. She reported CNA 1 had not informed her that Resident 1 was still using the toilet. She further stated she was unaware "the other girl was on her break." When asked, she reported, "The girls work out their breaks whenever they can fit them in," and she was typically unaware when there was only 1 CNA on the floor.