Every finding on record at Fresno Postacute Care

Based on observation, interview, and record review, the facility failed to have an effective pest control program when three live cockroaches were killed in a 35-minute period in one of one resident rooms (room [ROOM NUMBER]) that had been treated for cockroaches by a pest control company seven days prior. This failure resulted in multiple live cockroaches being observed in a resident room, increasing the risk for bringing and spreading disease-causing germs throughout the facility, despite a recent pest treatment just seven days earlier.During a concurrent interview and observation on 7/29/26, between 10:05 a.m. and 10:40 a.m., in room [ROOM NUMBER], with Resident 1, three live, juvenile cockroaches were noted crawling on the floor. The cockroaches were stepped on and killed during the interview and observation. Resident 1 confirmed that she had seen cockroaches in her room.During a concurrent interview and observation on 7/29/26, at 10:40 a.m., with the Maintenance Supervisor (MS), the three dead cockroaches were noted in room [ROOM NUMBER]. The MS confirmed they were cockroaches. The MS stated, Sometimes there are small ones.During a record review of the document titled Pest Control Service Report (PCSP) from Pest Control Company A (PCCA), dated 7/22/26, the PCSP indicated room [ROOM NUMBER] had been treated for Ants, Black Widows, Cockroaches, Earwigs, Pill bugs/Sowbugs, Spiders. The PCSP indicated the service was provided by Pest Control Service Technician (PCST).During an interview on 7/29/26, at 12:55 p.m., with PCST, he stated he recalled treating room [ROOM NUMBER] in the facility on 7/22/26.During a concurrent record review and interview, on 7/29/26, at 1:20 p.m., with the Housekeeping Supervisor (HS), the HS stated staff put cockroach sightings in the Maintenance Book. The Maintenance Book was reviewed and the document titled Maintenance Request Form indicated, Roaches were seen in room [ROOM NUMBER] on 3/18/26. The HS stated, There's no excuse for cockroaches.During a review of the facility's Policy and Procedure (P&P) titled, Pest Control, dated 1/18, the P&P indicated, Our facility shall maintain an effective pest control program.

Based on observation, interview, and record review, the facility failed to ensure a homelike environment was provided to one of three sampled residents (Resident 1) when her personal belongings were not put away in her room's closet or bedside cabinet, and were left in bags on her bed for over two weeks after moving into the room. This failure had the potential for Resident 1 to feel her environment was temporary and not homelike, and the facility did not care enough about her to place her belongings in the room properly.During a concurrent observation and interview on 7/29/26, at 10:05 a.m., in Resident 1's room, room [ROOM NUMBER], Resident 1 was noted to be in bed surrounded by several bags of her belongings in the bed with her. When asked why her belongings were in bed with her, Resident 1 stated, Where am I supposed to put them? I moved into this room on 7/14/26. Look in my closet. See those clothes? Those are not my clothes. Look at that cabinet. The top drawer is full of possessions that do not belong to me. The closet was observed to be half full of men's clothing on hangers. The top drawer of the cabinet was filled with numerous items.During a review of the facility document titled 5-Day Report, dated 7/17/26, the 5-Day Report indicated Resident 1 moved to another room on 7/14/26.During a concurrent observation and interview on 7/29/26, at 10:20 a.m., with Certified Nursing Assistant (CNA), in Resident 1's room, CNA opened the closet and stated, Those are men's clothing. I will remove them now. I will also empty [the bedside cabinet's top drawer]. Those possessions are not hers.During an interview on 7/29/26, at 1:20 p.m., with the Housekeeping Supervisor (HS), the HS stated Resident 1's bags of belongings were now being sorted. The HS stated, The previous resident of room [ROOM NUMBER], his belongings should have been moved out before Resident 1 moved in.During a review of the facility's Policy and Procedure (P&P), dated 1/18, titled, Homelike Environment the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike, setting.During a review of the facility's Policy and Procedure (P&P), dated 1/26, the P&P indicated, Resident belongings are treated with respect by facility staff, regardless of perceived value.

Based on observation, interview, and record review, the facility failed to meet professional standards of quality and practices by not following facility's policy and procedures (P&Ps) for four of 19 sampled residents (Residents 32, 64, 59 and 1) and other residents when:1.Resident 32 was administered 5 LPM (liter per minute-a unit of measurement for the flow rate of oxygen) of oxygen therapy (a colorless, tasteless gas essential to living organisms) through a nasal cannula (a thin, flexible tube with two prongs that fit into the nostrils and deliver oxygen) without a physician's order.This failure resulted in Resident 32 receiving oxygen therapy without a physician's order which had the potential to result in shortness of breath, oxygen toxicity (lung damage that happens from breathing in too much extra oxygen therapy), and other serious medical conditions.2. LVN 2 did not follow Resident 64's physician's order to check heart rate prior to administering Metoprolol Tartrate (medication used to treat high blood pressure [hypertension], angina [chest pain], and to improve survival after a heart attack. It works by slowing the heart rate and relaxing blood vessels to improve blood flow) to Resident 64 on 4/9/26.This failure placed Resident 64 at risk for low pulse rate and low blood pressure and had the potential for negative outcomes such as heart failure and falls.3. LVN 1 did not follow physician's order for Aspirin 81 mg Chewable when Aspirin 81 mg Enteric Coated was administered to Resident 59 on 4/9/26. This failure resulted in a medication error by administering wrong medication to Resident 59.4. LVN 2 left and kept the medication cart computer screen containing resident's electronic health information visible for unauthorized staff, residents and families.This failure had the potential to place the facility at risk for unauthorized access to residents' health information.5. Resident 1 was not assessed by Licensed Nurses for significant weight gain of 10% (percent) in six months and 7.5% in three months for the months of March and April 2026. This failure had the potential for Resident 1 to experience unrecognized negative outcomes including fluid retention, decline in oral intake, worsening of shortness of breath, decrease in functional mobility and delay in implementing necessary interventions to prevent further weight gain.1.During an observation on 4/7/26 at 12:38 p.m. in Resident 32's room, Resident 32 was observed lying in bed with a nasal cannula in his nose. Resident 32's nasal cannula was observed connected to the oxygen concentrator (medical device that helps residents breathe). The oxygen concentrator was observed on the right side of the bed turned on at 5 LPM. During an observation on 4/8/26 at 10:15 a.m. in Resident 32's room, Resident 32 was observed lying in bed with a nasal cannula in his nose. Resident 32's nasal cannula was observed connected to the oxygen concentrator. The oxygen concentrator was observed on the right side of the bed turned on at 5 LPM. During a concurrent observation and interview on 4/8/26 at 11:25 a.m. with Registered Nurse (RN) 4, in Resident 32's room, Resident 32 was observed lying in bed with a nasal cannula in his nose. Resident 32's nasal cannula was observed connected to the oxygen concentrator. The oxygen concentrator was observed on the right side of the bed turned on at 5 LPM. RN 4 stated Resident 32's nasal cannula was administering 5 LPM of oxygen therapy. RN 4 stated licensed nursing staff administered oxygen to Resident 32 and were responsible for ensuring oxygen therapy was administered per physician orders. During a concurrent interview and record review on 4/8/26 at 11:36 a.m. with RN 4, Resident 32's, Order Summary Report (OSR), dated 4/8/26, was reviewed. RN 4 stated Resident 32 did not have an active order for nasal cannula oxygen therapy. RN 4 stated oxygen was a medication and required a physician order to administer. RN 4 stated Resident 32 received nasal cannula oxygen therapy without a physician order. RN 4 stated Resident 32 did not have any documented history of administering or titrating oxygen therapy on his own. RN 4 stated Resident 32 had acute respiratory failure (condition in which lungs cannot adequately exchange oxygen and carbon dioxide), chronic obstructive pulmonary disease (COPD- progressive, long term-lung disease that causes obstructed airflow, making it difficult to breathe), and congestive heart failure (CHF- chronic, progressive condition where heart muscle is too weak to pump blood) which placed him at risk of increased carbon dioxide levels, hyperventilation, and respiratory distress if administered oxygen therapy outside of physician prescribed treatments and plan of care. During an interview on 4/10/26 at 8:32 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated oxygen was a medication and required a physician order to be administered. LVN 1 stated it was not within licensed nursing scope of practice to administer oxygen without a physician order. LVN 1 stated administering oxygen without a physician's order placed residents at risk for oxygen toxicity (lung damage that happens from breathing in too much extra [supplemental] oxygen) which could lead to serious medical conditions. During an interview on 4/10/26 at 3:02 p.m. with the Interim Director of Nursing (IDON), the IDON stated oxygen was a medication and a prescribed treatment which required a physician's order. The IDON stated it was not within licensed nursing scope of practice to administer medication, including oxygen therapy, without a physician's order. The IDON stated a physician order for oxygen therapy was essential to ensure oxygen therapy was administered at the correct dose, or LPMs, and duration to be safe and effective for Resident 32. The IDON stated safe and effective oxygen therapy administration prevented hypoxemia (low blood oxygen), oxygen toxicity, and ensured appropriate equipment was used for resident specific needs. The IDON stated facility policy and procedure, as well as standards of practice, were not followed when Resident 32 was administered 5 LPM of oxygen therapy through a nasal cannula with no physician order. During a review of Resident 143's Order Summary Report (OSR), dated 4/9/26, the OSR indicated Resident 32 did not have a physician's order for oxygen therapy through a nasal cannula. During a review of Resident 32's Care Plan Report (CP), undated, the CP indicated, Resident 32 had a diagnosis of acute respiratory failure with hypoxia, COPD, and CHF. The CP indicated, .give medications as ordered by physician. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 1/2018, the P&P indicated, .verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. During a review of the facility's P&P titled, Physician Orders, dated 1/2018, the P&P indicated, .physician orders are obtained to provide a clear direction in the care of the resident.all orders must be documented. During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse . 2.During an observation on 4/9/26 at 8:43 a.m. with LVN 2, in Resident 64's room, LVN 2 wrapped the blood pressure cuff ( a medical device consisting of a piece of rubber or similar material that is wrapped around a patient's arm and then inflated in order to measure their blood pressure) around Resident 64's right upper arm with blood pressure reading of 130/58. LVN 2 went to the medication cart parked in front of Resident 64's room, prepared Resident 64's two medications of Metoprolol Tartrate and Vitamin D (a fat-soluble nutrient essential for bone health, immune function, and calcium absorption) and placed in medication cup. During an observation on 4/9/26 at 8:56 a.m. with LVN 2, in Resident 64's room, LVN 2 asked Resident 64's name and stated, I have your medicine for your blood pressure and Vitamin D. LVN 2 assisted Resident 64 to sit up at the edge of the bed and administered the two medications. During an observation on 4/9/26 at 8:59 a.m., outside Resident 64's room, LVN 2 was signing the Electronic Medication Administration Record (EMAR- an electronic daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for Metoprolol Tartrate, the EMAR indicated to check Resident 64's pulse rate. LVN 2 went back to Resident 64 and started checking pulse rate in her right wrist. During a concurrent interview and record review on 4/9/26 at 12:40 p.m. with LVN 2, Resident 64's EMAR, dated 4/9/26 was reviewed. The EMAR indicated, Metoprolol Tartrate oral tablet 25 mg (milligrams -metric unit of measurement, used for medication dosage and/or amount) give one tablet by mouth two times a day related to Essential (Primary) Hypertension (abnormally high blood pressure [the amount of force the heart uses to pump blood through the arteries] that is not the result of a medical condition) hold if sbp (systolic blood pressure < (less than)100 and HR< 60. LVN 2 stated the physician ordered a parameter when to hold the medication. LVN 2 stated she did not check Resident 64's pulse rate before administering the Metoprolol Tartrate. LVN 2 stated she should check and verify Resident 64's pulse rate prior to administering the Metoprolol Tartrate to prevent low blood pressure and low pulse rate. LVN 2 stated she should follow the physician's order to prevent negative outcomes such as heart failure to Resident 64. During a review of Resident 64's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/10/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of essential (primary) hypertension. During a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/10/26, the MDS section C indicated Resident 64 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 6 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 64's cognition was severely impaired. During an interview on 4/10/26 at 3:09 p.m. with the Interim Director of Nursing (IDON), the IDON stated her expectation for the licensed nurses is to follow the P&P for administering medication and following physician's orders. The IDON stated LVN 2 should check and verify Resident 64's pulse rate prior to administering Metoprolol per physician's order to prevent a drop in pulse rate and blood pressure. The DON stated it is important to follow the P&P for medication administration to prevent negative outcome to residents including falls. During a review of facility's P&P titled, Administering Medication, dated 1/2018, the P&P indicated, Medications shall be administered in a safe and timely manner, ad as prescribed.3. Medications must be administered in accordance with the orders. 8. The following information must be checked/verified for each resident prior to administering medications: b. vital signs, if necessary. During a review of the facility's P&P titled, Physician Orders, dated 1/2018, the P&P indicated, .physician orders are obtained to provide a clear direction in the care of the resident. 3.During an observation on 4/9/26 at 5:05 p.m. with LVN 1, in Resident 59's room, LVN 1 wrapped the blood pressure cuff around Resident 59's left upper arm and got a blood pressure reading of 122/67. LVN 1 went to the medication cart parked outside Resident 59's room and started preparing Resident 59's p.m. medication. LVN 1 opened a bottle of Aspirin 81 mg Enteric Coated (orange and shiny tablet) and placed one pill inside the medication cup. LVN 1 continued to prepare two more medications for Resident 59. During an observation on 4/9/26 at 5:09 p.m. with LVN 1, in Resident 59's room, LVN 1 administered three medications including Aspirin 81 mg enteric coated to Resident 59. Resident 59 swallowed the three medications with a cup of water. During a concurrent observation and interview on 4/9/26 at 5:10 p.m. with LVN 1, in front of the medication cart parked outside Resident 59's room. LVN 1 was signing Resident 59's EMAR for Aspirin 81 mg Chewable tablet. LVN 1 stated she administered Aspirin 81 mg enteric coated to Resident 59. LVN 1 stated she will change the order for Aspirin 81 mg chewable to Aspirin 81 mg enteric coated. During a concurrent interview and record review on 4/10/26 at 9:18 a.m. with LVN 1, Resident 59's EMAR, dated 4/9/26 was reviewed. The EMAR indicated LVN 1's initials for Aspirin Oral Tablet Chewable 81 mg give 1 tablet by mouth in the evening related to Cerebral Infarction (damage to tissues in the brain due to a loss of oxygen to the area). LVN 1 stated she signed Resident 59's EMAR for Aspirin 81 mg chewable tablet but she administered Aspirin 81 mg enteric coated to Resident 59 yesterday (4/9/26). LVN 1 stated physicians order should be followed, and she should administer Aspirin 81 mg chewable tablet to Resident 59 as indicated in the EMAR. LVN 1 stated Aspirin enteric coated cannot be crushed and does not absorb quickly while Aspirin chewable absorbs quickly. LVN 1 stated she believed it was not a medication error because the name and dose of medication were the same and stated she will consult her supervisor. During an interview on 4/10/26 at 12:01 p.m. with the Pharmacy Consultant (PC), the PC stated Aspirin enteric coated and chewable have different formulations. The PC stated chewable are crushable with quick absorption while enteric coated are not crushable with delayed absorption. The PC stated it was considered a medication error when Aspirin enteric coated was administered instead of Aspirin chewable as ordered by the physician. The PC stated licensed nurses should contact the physician for the medication error. During an interview on 4/10/26 at 3:09 p.m. with the IDON, the IDON stated Aspirin chewable and enteric coated were not the same medication. The IDON stated Aspirin chewable dissolves faster while Aspirin enteric coated is long acting with slow absorption. The IDON stated it was a medication error when licensed nurse administered Aspirin 81 mg enteric coated with a physician's order of Aspirin 81 mg chewable tablet. The IDON stated she spoke with LVN 1 and change of condition was completed for Resident 59's medication error. The IDON stated it was her expectation for licensed nurses to follow the P&P for medication administration and following physician's orders to prevent medication error. During a review of Resident 59's AR, dated 4/14/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with primary diagnosis of Cerebral Infarction. During a review of Resident 59's MDS, dated [DATE], the MDS section C indicated Resident 59's BIMS - was not conducted with a code of 0 indicating No (resident is rarely/never understood). Resident 59's BIMS Summary Score was blank. During a review of facility's P&P titled, Administering Medication, dated 1/2018, the P&P indicated, Medications shall be administered in a safe and timely manner, ad as prescribed.3. Medications must be administered in accordance with the orders. 7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. During a review of the facility's P&P titled, Physician Orders, dated 1/2018, the P&P indicated, .physician orders are obtained to provide a clear direction in the care of the resident. 4.During an observation on 4/9/26 at 12:19 p.m. with LVN 2 at the end of Station 1 hallway, LVN 2 left the computer screen open showing the EMAR of the residents and was pushing the medication cart with computer screen showing residents EMAR including residents' names and photos remained visible until reaching nursing station 1. LVN 2 needed to stop three times while passing by the hallway to give way for other facility's staff and family, the computer screen was kept open, and residents' information was visible. During an interview on 4/9/26 at 12:37 p.m. with LVN 2, LVN 2 stated medication cart's computer screen should be hidden and not visible for other staff, families and residents and stated, HIPPA (Health Insurance Portability and Accountability Act - applies to healthcare providers, insurers, and other organizations handling patient data, mandating safeguards to prevent unauthorized access or misuse of sensitive information) compliance. LVN 2 stated resident health information should be protected. LVN 2 stated when licensed nurses were away from their medication cart and in areas where other people can see residents' information like in the hallway, computer screen should be closed or hidden. LVN 2 stated Station 1 hallway was a high traffic area where staff, families and residents were constantly passing by. During an interview on 4/10/26 at 3:09 p.m. with the IDON, the IDON stated medication cart's computer screen should be closed when not in use. The IDON stated residents' EMAR contains personal health information and should not be visible to other residents, families, and unauthorized staff to protect residents' health information. During a review of the facility's P&P titled Confidentiality and Non-Disclosure Agreement, dated 1/2028, the P&P indicated, Users who are granted access to our facility's protected health and financial information will be required to sign a confidentiality and non-disclosure agreement. 1. The purpose of this policy is to maintain an adequate level of security to protect residents and facility information from unauthorized access, use or disclosure. 2. Only authorized users are granted access to resident and facility information. During a review of professional reference retrieved from https://www.ncbi.nlm.nih.gov/books/NBK500019/ tilted Health Insurance Portability and Accountability Act (HIPAA) Compliance, dated, indicated, The US Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996, was established to safeguard patient privacy and secure health information. HIPAA sets strict standards for managing, transmitting, and storing protected health information. HIPAA applies to healthcare providers, insurers, and other organizations handling patient data, mandating safeguards to prevent unauthorized access or misuse of sensitive information. 5. During an observation on 4/7/26 at 9:40 a.m. with Resident 1, in Resident 1's room, Resident 1 was lying in bed, asleep. Resident 1's body was covered by white sheets. During an observation on 4/8/26 at 5:00 p.m., Resident 1 was not in the room. During a review of Resident 1's electronic medical record titled, OSR, undated, indicated, Dialysis Days: (Monday, Wednesday and Friday) chair time: 5:15 p.m. During a concurrent interview and record review on 4/9/26 at 5:16 p.m. with LVN 5, Resident 1's weights, dated 10/11/25 – 4/30/26 were reviewed. The weights indicated, 04/02/2026 173 lbs. ( (pounds-a unit of weight and mass) +10.0% change [ Comparison Weight 10/06/2025, 145.0 lbs., +19.3%, +28.0 lbs.] +7.5 change [ Comparison Weight 01/06/2026, 13.0 lbs., +13.1%, +20.0 lbs.] 03/02/2026 167 lbs. +10.0% change [ Comparison Weight 09/22/2025, 150.0 lbs., +11.3%, +17.0 lbs.] +7.5% change [ Comparison Weight 12/02/2025, 154.0 lbs., +8.4%, + 13.0 lbs.]. LVN 5 stated Resident 1 had a significant weight gain of 10% for six months and 7.5% for three months. LVN 5 stated Resident 1 was receiving dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), on fluid restriction of 1200 ml/day and had chronic bilateral lower extremities edema (swelling caused by fluid in your body's tissues. It usually occurs in the feet, ankles and legs, but it can involve your entire body). During a concurrent interview and record review on 4/9/26 at 5:19 p.m. with LVN 5, Resident 1's Nursing-SBAR (Situation Background Assessment Request) Communication Form and progress note, dated 3/2026 – 4/2026 were reviewed. LVN 5 indicated and stated there was no change of condition SBAR completed for Resident 1's significant weight gain of 10% for 6 months and 7.5% for three months. LVN 5 stated a significant weight gain was considered a change of condition. LVN 5 stated licensed nurses should assess Resident 1 for a change of condition SBAR for the month of March and April 2026 to monitor Resident 1 for fluid retention and overload. During a review of Resident 1's AR, dated 4/14/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), essential (primary) hypertension (abnormally high blood pressure [the amount of force the heart uses to pump blood through the arteries] that is not the result of a medical condition), dysphagia (difficulty swallowing), and edema. Resident 1's diagnosis information did not indicate diagnosis of kidney failure, Resident 1 was receiving dialysis. During a review of Resident 1's MDS, dated [DATE], the MDS section C indicated Resident 1 had a BIMS score of 11, which indicated Resident 1's cognition was moderately impaired. During a concurrent interview and record review on 4/10/26 at 9:18 a.m. with LVN 1, Resident 1's Nursing Weekly Summary Notes, dated 4/8/26 was reviewed. The Nursing Weekly Summary Notes indicated, . Cardiac (relating to heart)/circulation.edema present.location +3 edema to bilateral lower extremities. pitting 3+pit edema (a medical sign of moderate-to-deep fluid retention (swelling), indicating a 5–6 mm [millimeters -unit of measurement] indentation (pit) that remains for 15 to 60 seconds after pressure is removed) .dependent extremity swollen. LVN 1 stated Resident 1 had no edema to bilateral lower extremities. LVN 1 stated she worked yesterday (4/9/26) a.m. and p.m. shift and did not notice edema to bilateral lower extremities. LVN 1 stated night shift license nurses were responsible in assessing residents to complete the Nursing Weekly Summary Notes. During concurrent observation and interview on 4/10/26 at 9:36 a.m. with LVN 1, in Resident 1's room with CNA 2 as interpreter (Resident 1 was speaking in Spanish), LVN 1 assessed Resident 1's bilateral lower extremities and stated there was no edema to bilateral lower extremities. LVN 1 stated Resident 1's +3 edema to bilateral lower extremities were resolved. During a concurrent interview and record review on 4/10/26 at 9:40 a.m. with LVN 1, Resident 1's weights and SBAR were reviewed. The weights indicated, 04/02/2026 173 lbs. (Dialysis Weight) and 03/02/2026 167 lbs. (Dialysis Weight). LVN 1 stated Resident 1 has a weight gain of 6 lbs. in a month and had a significant weight gain 10% in six months and 7.5% in three months for the months of March and April 2026. LVN 1 stated there was no change of condition SBAR done for Resident 1's significant weight gain. LVN 1 stated Resident 1 should be assessed for a change of condition SBAR due to significant weight gain to monitor Resident 1 for 72 hours and identify the cause of significant weight gain. During an interview on 4/10/26 at 3:09 p.m. with the IDON, the IDON stated it was her expectation for licensed nurses to complete a change of condition SBAR for significant weight changes. The IDON stated that a significant weight change applies to loss and gain of 5% in one month, 7.5% in three months, and 10% for 180 days or six months. The IDON stated licensed nurses should accurately assess residents with significant weight changes to identify the root cause and to prevent a delay in implementation of appropriate and necessary interventions and services to prevent further weight loss/gain. During a review of the facility's P&P titled Change in a Resident's Condition, dated 1/2018, the P&P indicated, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. 3. Prior to notifying the Physician or healthcare provider, the nurse will make observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR Communication Form. During a review of Nursing World.org Professional Reference titled, The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) the reference indicated, .The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse's decision-making. Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with accepted professional standards of practice for one of eight sampled residents (Resident 21) and other residents when: Resident 21 stored over the counter (OTC) medications ( medicines you can get without a prescription) of two jars of expired medicated vapor rub (an OTC medicated topical ointment used to temporarily relieve coughs, nasal congestion, and minor aches/pains using medicated vapors) without physician's order and four colored tablets of Calcium Carbonate (an OTC antacid used to treat heartburn, acid indigestion, and sour stomach) in a medication cup at her bedside table. Resident 21 had no physician's order for self-administration of medications stored at her bedside. This failure placed Resident 21 at an increased risk of improper self-administration of medications which could result in medication errors (any preventable event causing inappropriate medication used or patient harm) and side effects (undesirable effects of drugs), and had the potential for other residents, staff and visitors accessing medications stored at bedside. 2. The medication cart parked at station 1 hallway was not locked and unattended by authorized staff.This failure had the potential to result in unauthorized access and drug diversion (occurs when a medication is taken for use by someone other than whom it is prescribed or for an indication other than what is prescribed) of medications.1. During a concurrent observation and interview on [DATE] at 9:06 a.m. with Resident 21, in Resident 21's room, Resident 21 was sitting in the middle of her bed, alert and oriented x 4 (name, time, place and situation). Resident 21's primary language was Spanish and she was able to understand and speak English. Resident 21's bedside table had a blue basket containing multiple personal belongings and one jar of brand name vapor rub with expiration date of 9/2025. Resident 21 had a basket container on top of her cabinet containing one jar of medicated chest rub with expiration date of 9/2025. Resident 21 stated she had been applying the vapor rub into her nose when she needed it. Resident 21 stated she had used it last week for flu (also called influenza-an infection of the nose, throat and lungs). Resident 21 stated she was not aware of the expiration date and that it had been expired. During a concurrent observation and interview on [DATE] at 9:36 a.m. with Resident 21, in Resident 21's room, Resident 21was self-propelling her wheelchair. Resident 21 had four round tablets (three yellow and one orange color) in a medication cup on top of her bedside table. Resident 21 stated the brand name of the medication, and she was taking it for her stomach pain.During an observation and interview on [DATE] at 9:38 a.m. with Licensed Vocational Nurse (LVN) 3, in Resident 21's room, LVN 3 was talking to Resident 21 in Spanish l about the four tablets of antacid medication in a medication cup at her bedside table. LVN 3 stated that antacid medications were stored at her bedside for two days as indicated by Resident 21. LVN 3 stated he administered an antacid medication to Resident 21 this morning and she took it. LVN 3 stated he was not aware that Resident 21 was keeping antacid medications in her bedside table and taking it when she needed it. During a concurrent interview and record review on [DATE] at 9:40 a.m. with LVN 3, Resident 21's Electronic Medical Records (EMR - a digital version of a patient's paper chart) titled, Order Summary Report, undated, and Nursing admission Assessment, dated 6/2023 were reviewed. The Order Summary Report indicated, . Calcium Carbonate (Antacids) Oral tablet chewable. give 2 tablets by mouth three times a day related to Epigastric pain (a discomfort in the upper abdomen, just below the ribs). LVN 3 stated there was no physician's order for vapor rub or to perform self-administration of her medications. The Nursing admission Assessment indicated, self-administration: No. LVN 3 stated Resident 21 cannot perform self-administration and should not be self-administering her OTC medications at bedside without physician's orders. LVN 3 stated Resident 21 was alert oriented but forgetful. LVN 3 stated Resident 21 should not be storing and self-administering OTCs due to safety concerns. LVN 3 stated medications should not be left and stored at bedside. LVN 3 stated licensed nurses were responsible for administering Resident 21's medications and should ensure medications were taken in front of them to prevent potential risk of medication errors. LVN 3 stated Resident 21 could double the dose or not take the medications on time. During a concurrent interview and record review on [DATE] at 9:46 a.m. with Registered Nurse (RN) 4, Resident 21's care plan report, undated, was reviewed. The care plan report indicated, there was no care plan for self-administration of medications. RN 3 stated Resident 21's OTC medications should not be left and stored at bedside without a physician's order and self-administration assessment. RN 3 stated Resident 21's improper storage of OTC medications at bedside had a potential risk of medication errors and access to OTC medications by other residents and staff.During a review of Resident 21's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated [DATE], the AR indicated Resident 21 was admitted to the facility on [DATE] with acute upper respiratory infection (a short-term, contagious illness affecting the nose, throat, or airways, typically caused by viruses like the common cold or influenza).During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE], the MDS section C indicated Resident 21 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 21 was cognitively intact.During an interview on [DATE] at 3:09 p.m. with the Interim Director of Nursing (IDON), the IDON stated it was her expectation for the licensed nurses to follow the facility's Policy and Procedure (P&P) for proper medication storage. The IDON stated OTC medications should not be left and stored at bedside to prevent access to the medications by other residents. The IDON stated other residents can walk into the room and access the medications which could cause side effects and medication errors. The IDON stated OTC medications require a physician order. The IDON stated Resident 21 should not perform self-administration of OTC medications at bedside without physician's order and assessments. During a review of facility's P&P titled, Storage of Medications, dated 1/2018, the P&P indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepare and administer medications have access to locked medications. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 6. Compartments (including, but not limited to drawers, cabinets, rooms, carts.) containing medications and biologicals are locked when not in used. 2.During an observation on [DATE] at 8:43 a.m. with LVN 2, at station 1 hallway, LVN 2 opened the medication cart and was looking for a disinfectant wipe. LVN 2 asked LVN 1 for a disinfectant wipe to clean the blood pressure monitor (a device used to measure blood pressure).During an observation on [DATE] at 8:44 a.m. with LVN 1, at nursing station 1, LVN 1 went to the medication cart parked in the hallway, opened the medication cart and took a container of the disinfectant wipe and handed it to LVN 2. LVN 1 closed the drawer of the medication cart and did not lock the medication cart. LVN 1 left and went back to the nursing station 1.During an observation on [DATE] at 9:00 a.m. at station 1 hallway, the medication cart remained unlocked and unattended. During a concurrent observation and interview on [DATE] at 9:09 a.m. with LVN 2, in front of the medication cart parked at the hallway, LVN 2 was cleaning the blood pressure monitor with the disinfectant wipes. LVN 2 went to another medication cart parked in the hallway, opened the bottom drawer and placed the blood pressure monitor in the drawer. LVN 2 stated the medication cart was not locked. During an interview on [DATE] at 9:13 a.m. LVN 2 stated LVN 1 forgot to lock the medication cart. LVN 2 stated medication cart should be locked when unattended because it contained medications. LVN 2 stated the medication cart was parked in the hallway where unauthorized staff (housekeeping and laundry, managers and certified nursing assistants), residents and families were constantly passing by. LVN 2 stated unauthorized staff, residents and families can access the medication cart when unlocked and had the potential to cause medication errors.During an interview on [DATE] at 9:16 a.m. with LVN 1 and LVN 2, LVN 2 validated and informed LVN 1 that her medication cart was not locked. LVN 1 stated medication cart should be locked at all times. LVN 1 stated licensed nurses should keep medication cart locked when unattended to prevent access to medications by unauthorized staff and residents. LVN 1 stated there will be an increased risk of accessing the medications when medication cart is unlocked and stated, anyone can open the med cart. get medicine, which could lead to medication errors and side effects.During an interview on [DATE] at 3:09 p.m. with the IDON, the IDON stated it was her expectation for the licensed nurses to follow the facility's P&P for proper medication storage by keeping medication cart locked when unattended. The IDON stated it was not an acceptable practice for licensed nurses not locking their medication carts when not in use and unattended. The IDON stated there was an increased risk of accessing the medication cart when unlocked by unauthorized staff, residents and visitors. The IDON stated residents can open the medication cart and get the medications which could cause side effects and medication errors. During a review of facility's P&P titled, Storage of Medications, dated 1/2018, the P&P indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepare and administer medications have access to locked medications. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 6. Compartments (including, but not limited to drawers, cabinets, rooms, carts.) containing medications and biologicals are locked when not in used. Unlocked medication carts are not left unattended.

Based on observation, interview, and record review, the facility failed to ensure food was stored, distributed, and served safely when the ice machine was observed with pale pink colored residue on the ice grate (a compartment within the ice machine that determines the size of the ice cubes that are produced).This failure resulted in the facility ice machine not being in a clean safe operating condition which can lead to the growth of microorganisms and result in foodborne illness for 69 out of 70 residents eating ice at the facility. During a concurrent observation and interview on 4/7/26 at 9:06 a.m. with the Maintenance Director (MND), the Kitchen Supervisor (KS), and the Registered Dietician (RD), the ice machine was observed in the kitchen. The MND was observed removing the ice grate cover. A pale pink colored residue was observed at the top of the ice grate. The MND was observed removing the pale pink residue with a white napkin. The KS stated the ice machine was expected to always be free from discoloration and/or residue.During a concurrent interview and record review on 4/9/26 at 11:42 a.m. with the KS, the kitchen documents titled, Maintenance Request Form (MRF), [Brand Name] Ice Machine Cleaning & Sanitation Log, and Ice Machine Sanitation Log undated, were reviewed. The KS stated on 1/7/26 the ice machine needed a new ice machine filter and was removed from service. The KS stated on 1/9/26 the MND ordered a new ice machine filter. The KS stated the kitchen documents did not indicate the exact date the ice machine was placed back into service, but the KS stated it was approximately the first week of 3/2026. The KS stated kitchen staff maintained a [Brand Name] Ice Machine Cleaning & Sanitation Log which indicated when the external portion of the ice machine was cleaned by kitchen staff. The KS stated kitchen staff maintained a Ice Machine Sanitation Log, posted on the ice machine, which indicated when the internal portion of the ice machine was cleaned by maintenance. The KS stated the Ice Machine Sanitation Log did not indicate the ice machine was cleaned before the ice machine was placed back into service. The KS stated the ice machine was expected to be cleaned internally before placing back into service to ensure it was clean and sanitized before use. The KS stated kitchen staff maintained the outside of the ice machine and the MND maintained the inside of the ice machine. The KS stated facility policy and procedure, and expectation was to clean the ice machine internally once a month. The KS stated the expectation for the ice machine was to inspect the internal components in between cleanings to ensure there was no discoloration and/or residue. The KS stated it was important to ensure the ice machine did not have any pale pink residue within the ice machine because it could lead to contamination of the ice. The KS stated if contaminated ice was consumed by residents it could result in food borne illness.During an interview on 4/9/26 at 11:50 a.m. with the RD, the RD stated the ice machine was removed from service on 1/7/2026 and was not placed back into service until 3/2026. The RD stated ice machine cleaning logs did not indicate the ice machine was internally cleaned before it was placed back into service during the first week of 3/2026. The RD stated if the ice machine internal cleaning was not documented, it could not be guaranteed it happened. The RD stated the ice machine was expected to be cleaned monthly and after periods of inactivity to ensure the internal components were free from contamination. The RD stated the ice machine was expected to always be clean and free from signs of discoloration and/or residue. The RD stated the pale peach colored discoloration on the ice grate was at risk of contaminating the ice. The RD stated if residents ate contaminated ice they were at risk for food borne illness. During an interview on 4/9/26 at 11:56 a.m. with the MND, the MND stated the ice machine was removed from service on 1/7/26 and placed back into service the first week of 3/2026. The MND stated maintenance did not maintain a separate internal ice machine sanitation log than the kitchen. The MND stated the internal ice machine cleaning log, Ice Machine Sanitation Log, was posted on the front of the ice machine. The MND stated the Ice Machine Sanitation Log, did not indicate the ice machine was internally cleaned before being placed back into service the first week of 3/2026.During an interview on 4/10/26 at 3:02 p.m. with the Interim Director of Nursing (IDON), the IDON stated ice was food and all food was expected, per policy, to be served under sanitary conditions. The IDON stated the ice machine was expected to be cleaned after periods of inactivity to ensure any potential contamination during service was removed before placing the ice machine back into use. The IDON stated the ice machine was expected to always be free from discoloration and/or debris to prevent contamination of ice which could result in foodborne illness if consumed.During a review of the facility's document titled, Diet Type Report, dated 4/9/26, the document indicated there were sixty-nine residents with diets. The document indicated one resident had a diet for nothing by mouth (NPO).During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning Procedures, dated 2023, the P&P indicated, .the ice machine needs to be cleaned and sanitized monthly.the internal components cleaned monthly or per manufacturer's recommendation, and the date recorded when cleaned.the maintenance supervisor can keep this record or it can be posted on the ice machine.During a review of the facility's ice machine manufacturer's guideline (MFG) titled, [Brand Name] Ice Machine Handbook & Maintenance Log, undated, the MFG indicated, .if the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company.an extremely dirty ice machine must be taken apart for cleaning and sanitizing .removal from service/winterization.special precautions must be taken if the ice machine is to be removed from service for an extended period of time or exposed to an ambient temperature of 32 [Fahrenheit].

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for two of six sampled residents (Resident 4 and Resident 69) when: 1. Resident 4 was not placed on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities) for documented Methicillin Resistant Staphylococcus Aureus (MRSA-a type of bacteria that could cause an infection and was harder to treat because some antibiotics [medication used to treat infections] did not work against it).This failure placed Resident 4 at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect), and placed other residents at risk for exposure to MRSA.2. Resident 69 was not placed on EBP for her tracheostomy stoma (a surgically created hole in the front of the neck to allow a person to breathe) which required cleaning and dressing changes.This failure placed Resident 69 at risk for cross-contamination and infection (an invasion of the body by germs that cause disease).Findings:During a concurrent observation and interview on 4/7/2026 at 9:22 a.m. in Resident 4's room. No EBP signage was observed on Resident 4's room door. Resident 4 was observed in bed dressed and asleep, covered with her blanket and padded bed rails up at the head of her bed. Certified Nursing Assistant (CNA) 2 stated Resident 4 had amplified earphones to hear when spoken to and attempted to place them in Resident 4's ears. Resident 4 did not want to answer any questions and fell back to sleep. CNA 2 stated she tried to get Resident 4 up for activities, but Resident 4 liked to sleep and would get angry and yell. CNA 2 was observed to not be wearing a gown or gloves while attempting to wake Resident 4 and take her to activities via her wheelchair.During a review of Resident 4's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/10/26, the AR indicated Resident 4 was admitted to the facility from an acute care hospital on 8/6/25 with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness), hallucination (a sight, sound, smell, taste, or touch that a person believes to be real but is not real), neoplasm of the brain (abnormal masses of tissue that grow in the brain due to excessive overgrowth of brain cells), diabetes mellitus (when the blood sugar levels in the body are too high), artificial hip (surgery to remove damaged sections of the hip joint and replace them), arthritis (joint inflammation) due to other bacteria, right hip, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities).During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/23/26, the MDS section C indicated Resident 4 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 5 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 4 was severely cognitively impaired.During a concurrent interview and record review on 4/8/2026 at 4:23 p.m. with Registered Nurse (RN) 2, Resident 4's Order Summary Report (OSR), undated was reviewed. The OSR indicated Resident 4 was taking doxycycline hyclate (a drug used to treat many types of bacterial infections)100mg 1 tablet by mouth two times a day for one year for MRSA. RN 2 stated Resident 4 was on antibiotics for a diagnosis of right hip arthritis from bacteremia (the presence of bacteria in the blood). RN 2 stated Resident 4 was to take doxycycline for one year for MRSA to her right hip. RN 2 stated any resident who was on EBP required staff to wear appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments), which included gloves, gown, and to perform proper hand hygiene before and after providing care to the residents. RN 2 stated Resident 4 was not on EBP.During a concurrent interview and record review on 4/9/2026 at 11:05 a.m. with the Infection Preventionist (IP), Resident 4's OSR, undated was reviewed. The OSR indicated, .doxycycline Hyclate oral tablet 100 milligrams [mg - a unit of measurement] give 1 tablet by mouth two times a day for a year for MRSA to right hip. The IP stated residents were placed on EBP for indwelling medical devices and open wounds. The IP stated all staff should have been monitored for wearing appropriate PPE during patient care. The IP stated she discussed infection prevention with department supervisors, such as housekeeping, and the supervisors gave the in-services to their staff. The IP stated appropriate PPE was important for residents on EBP to prevent cross contamination of germs, which increased the risk of infection and superbugs (a strain of bacteria that has become resistant to antibiotic drugs).During an interview on 4/10/2026 at 9:32 a.m. with the Laundry Aide (LDA) , the LDA stated Staff used a separate container for soiled laundry of residents on isolation precautions and their clothes and linens were washed separately from residents not on isolation precautions. The LDA stated she asked questions if a resident was on isolation precautions, on what type of infection the resident had and what PPE was needed because she did not want to get germs on herself and take them to another resident or to her home.During an interview on 4/10/2026 at 10:15 a.m. with CNA 1, CNA 1 stated the CNAs brought resident's soiled linens out of their room and placed them in the bins in the hallway, and laundry staff picked up the bins. CNA 1 stated if a resident was on isolation precautions, the CNAs bagged their soiled linens and placed them in a bin inside the room. CNA 1 stated staff did not remove the bin from the room until the end of the day. CNA 1 stated staff bagged up all the soiled linen from the isolation precaution room and took it to a bin outside the laundry room. CNA 1 stated staff wore appropriate PPE for resident care and changing linens of residents on isolation precautions. CNA 1 stated residents in isolation had a sign on their door of the type of isolation precautions the resident was on and a cart with PPE outside the resident's room.During a concurrent interview and record review on 4/10/2026 at 11:47 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 4's OSR dated 4/10/26 was reviewed. The OSR indicated .doxycycline Hyclate oral tablet 100mg give 1 tablet by mouth two times a day for a year for MRSA to right hip. LVN 1 stated Resident 4 was not on any isolation precautions. LVN 1 stated Resident 4 was taking antibiotics for bacteria to her right hip for one year for MRSA. LVN 1 stated Resident 4 came to the facility with MRSA. LVN 1 stated EBP signs were no longer on Resident 4's door. LVN 1 stated she did not get notified when residents were no longer on isolation precautions.During a concurrent interview and record review on 4/10/2026 at 11:56 a.m. with the IP, Resident 4's Care Profile, undated was reviewed. The Care Profile indicated Resident 4 was ordered doxycycline hyclate 100 mg on 8/6/25 for staphylococcal (a type of bacteria that causes infection) arthritis in the right hip. The IP stated Resident 4 was admitted on antibiotics and was still receiving antibiotics. Resident 4's Progress Notes, dated 9/15/25 from the Infectious Diseases and Internal Medicine physician were reviewed. The Progress Notes indicated, .diagnosis [dx] periprosthetic joint infection [when bacteria or other microorganisms infect the area in and around a joint implant] of hip/MRSA.discontinue intravenous [I.V.-through the vein] antibiotic.start oral doxycycline. The IP stated if Resident 4 was colonized (the presence of bacteria on a body surface [like on the skin, mouth, intestines or airway] without causing disease in the person) she should have been placed on EBP.During an interview on 4/10/2026 at 3:39 p.m. with the Interim Director of Nursing (IDON), the IDON stated residents were placed on EBP if they had any implanted devices, open wounds with dressings or Multi-drug Resistant Organisms (MDROs such as MRSA). The IDON stated nursing and the IP determined who was placed on EBP. The IDON stated nurses should have been looking at the physician orders to see why Resident 4 was on antibiotics and should have notified the IP if Resident 4 was not on EBP. The IDON stated all staff were trained on what conditions required EBP. The IDON stated wearing appropriate PPE was important so staff did not spread infections to other staff and residents and so the infection was contained. The IDON stated if a resident with infection was not placed on EBP and staff were not wearing the appropriate PPE while caring for the resident, there was a risk of spreading the infection to other residents and staff.During a review of the facility's policy and procedure (P&P), titled, Enhanced Barrier Precaution, dated 6/2022, the P&P indicated, .the purpose of this policy is to establish and provide guidelines for isolation precautions as well as prevent transmission of infectious agents in the facility.Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities.EBP may be indicated [when Contact Precautions do not otherwise apply] for residents with any of the following.wounds or indwelling medical devices, regardless of MDRO colonization status.infection or colonization with an MDRO.PPE used for these situations .dressing .bathing/showering . transferring.providing hygiene.changing linens.changing briefs or assisting . toileting .device care or use.wound care: any skin opening requiring a dressing.required PPE .gloves and gown prior to the high-contact care activity.change PPE before caring for another resident.position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.post clear signage at the door or wall outside the resident room.2. During a concurrent observation and interview on 4/07/2026 at 9:10 a.m. in Resident 69's room, Resident 69 was observed in bed, wearing a gown, with a dressing over her tracheostomy stoma site. Resident 69 was unable to speak, but was able to makes sounds, and nodded yes when asked if she was doing ok.During a review of Resident 69's AR, dated 4/10/26, the AR indicated Resident 69 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body), dysphagia (difficulty swallowing), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), and subarachnoid hemorrhage (bleeding in the space between the brain and the membrane that covers it).During a review of Resident 69's MDS, dated 2/9/26, the MDS section C - Cognitive Patterns indicated Resident 69 was unable to complete the interview. The MDS section O - Special Treatments, Procedures, and Programs indicated, .E.1 Tracheostomy care.while a resident.During an interview on 4/8/2026 at 11:42 a.m. with CNA 4, CNA 4, stated she had worked with Resident 69 and Resident 69 said yes and no to question and had a communication board that Resident 69 would point to the pictures for her needs. CNA 4 stated she checked Resident 69's tracheostomy dressing and if it was soiled, she let the nurse know.During a concurrent observation and interview on 4/8/2026 at 4:08 p.m. in Resident 69's room, with Resident 69, no EBP signage or Personal Protective Equipment (PPE- gowns, gloves, eye protection) cart was observed outside Resident 69's room. Resident motioned she used the paper with pictures posted on her wall to communicate with staff when she needed something.During a concurrent interview and record review on 4/8/2026 at 4:17 p.m. with RN 2, Resident 69's OSR, undated was reviewed. The OSR indicated, .cleanse trach stoma site with normal saline [n/s] pat dry apply dry dressing daily and as needed [prn] for wrinkle and soilage every day shift.order status.active.order date.10/26/2021. RN 2 stated every morning and evening the nurse cleaned and changed Resident 69's dressing. RN 2 stated Resident 69 should have been on EBP since she had an opening in her skin and to prevent infection. RN 2 stated Resident 69 could have obtained an infection. RN 2 stated residents should have been placed on EBP if they had a catheter (a type of indwelling catheter inserted into the bladder, used to drain urine), a gastrostomy (g-tube - the surgical formation of an opening through the abdominal wall into the stomach for nutritional support), or an open wound. RN 2 stated the nurse assessed the resident and if the resident had any opening, the nurse told the IP, and the IP set up carts, and put an EBP sign on the resident's room door. RN 2 stated the CNAs were notified of a resident on EBP by the door signs and education from the nurses. During an interview on 4/10/2026 at 3:39 p.m. with the IDON, the IDON stated residents were placed on EBP if they had any implanted devices, open wounds with dressings or Multi-drug Resistant Organisms (MDROs such as MRSA). The IDON stated nursing and the IP determined who was placed on EBP. The IDON stated all staff were trained on what conditions required EBP. The IDON stated wearing appropriate PPE was important so staff did not spread infections to other staff and residents and so the infection was contained. The IDON stated if staff did not wear the appropriate PPE while caring for residents requiring EBP, there was a risk of spreading the infection to the resident, other residents and staff.During a review of the facility's policy and procedure (P&P), titled, Enhanced Barrier Precaution, dated 6/2022, the P&P indicated, .the purpose of this policy is to establish and provide guidelines for isolation precautions as well as prevent transmission of infectious agents in the facility.Enhanced Barrier Precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities.EBP may be indicated [when Contact Precautions do not otherwise apply] for residents with any of the following.wounds or indwelling medical devices, regardless of MDRO colonization status.infection or colonization with an MDRO.PPE used for these situations.during high-contact resident care activities.dressing.bathing/showering.transferring .providing hygiene.changing linens.changing briefs or assisting . toileting .device care or use.tracheostomy/ventilator.wound care: any skin opening requiring a dressing.required PPE .gloves and gown prior to the high-contact care activity.change PPE before caring for another resident.position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.post clear signage at the door or wall outside the resident room.During a review of professional reference (PR) titled, Implementation of Personal Protective Equipment [PPE] Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms [MDROs], dated 7/12/2022, retrieved from: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, the PR indicated, .multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs.EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status.infection or colonization with an MDRO.residents in nursing homes are at increased risk of becoming colonized and developing infection with MDROs.more than 50% of nursing home residents may be colonized with an MDRO, nursing homes have been the setting for MDRO outbreaks, and when these MDROs result in resident infections, limited treatment options are available.focusing only on residents with active infection fails to address the continued risk of transmission from residents with MDRO colonization, who, by definition, have no symptoms of illness. MDRO colonization may persist for long periods of time.which contributes to the silent spread of MDROs. PPE used for these situations.device care or use.tracheostomy/ventilator.wound care: any skin opening requiring a dressing.

Based on observation, interview, and record review, the facility failed to ensure residents' drug regimen must be free from unnecessary drugs for one of eight sampled residents (Resident 21) when Resident 21 was receiving an opioid (or narcotics, are potent substances derived from or mimicking the poppy plant) pain medication (used to treat moderate to severe pain) for excessive duration without adequate indication and monitoring.These failures placed Resident 21 at an increased risk of receiving unnecessary medications and had the potential to experience negative effects such as drug addiction, overdose, and fatal respiratory depression. During a concurrent observation and interview on 4/8/26 at 9:36 a.m. with Resident 21, in Resident 21's room, Resident 21 was self-propelling her wheelchair. Resident 21 had four round tablets (three yellow and one orange color) in a medication cup on top of her bedside table. Resident 21 stated the brand name of the medication, and she was taking it for her stomach pain.During a concurrent interview and record review on 4/8/26 at 9:40 a.m. with LVN 3, Resident 21's Electronic Medical Records (EMR - a digital version of a patient's paper chart) titled, Order Summary Report, undated, and Nursing admission Assessment, dated 6/2023 were reviewed. The Order Summary Report indicated, . Hydrocodone-Acetaminophen (a combination medication that contains hydrocodone [an opioid] and acetaminophen [an analgesic] used to manage moderate to severe pain) oral tablet 5-325 mg (milligrams -metric unit of measurement, used for medication dosage and/or amount) Give 1 tablet by mouth every 8 hours related to Epigastric pain (a discomfort in the upper abdomen, just below the ribs),.Tramadol (an opioid pain-relief medicine used for moderate to severe pain) oral tablet 50 mg Give 1 tablet by mouth two times a day related to other chronic pain, .Calcium Carbonate (Antacids - used to treat heartburn, acid indigestion, and sour stomach) Oral tablet chewable. give 2 tablets by mouth three times a day related to Epigastric pain. LVN 3 stated Resident 21 was receiving Hydrocodone-Acetaminophen as scheduled every 8 hours not for epigastric pain only and was given for other chronic pain such as generalized pain. LVN 3 stated Resident 21 was getting antacid medication due to epigastric pain. LVN 3 stated Resident 21 was receiving two strong pain medications for pain. LVN 3 stated Resident 21's physician order should be followed, and physicians should be notified of any changes in condition. During a concurrent interview and record review on 4/8/26 at 9:46 a.m. with Registered Nurse (RN) 4, Resident 21's care plan report, undated, was reviewed. The care plan report indicated, The resident is on brand name (Hydrocodone-Acetaminophen oral tablet 5-325 mg) related to epigastric pain.Interventions/Tasks-Evaluate the effectiveness of pain interventions Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results. Identify and record previous pain history and management of that pain. Monitor for adverse effects of opioid use: nausea, vomiting, and constipation. Monitor/document for probable cause of each pain episode. Monitor/record pain characteristics q (every) shift and PRN (as needed): Quality. RN 4 stated the care plan indicated that resident was receiving Hydrocodone-Acetaminophen oral tablet 5-325 mg related to epigastric pain and should not be given for other pain. RN 4 stated licensed nurses should assess and document the location, characteristics, and the root cause of the pain to administer appropriate medications. During a concurrent interview and record review on 4/8/26 at 9:55 a.m. with LVN 3, Resident 21's Electronic Medication Administration Record (EMAR- a digital version of daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/2026 and 4/2026. The EMAR indicated, .Hydrocodone-Acetaminophen oral tablet 5-325 mg Give 1 tablet by mouth every 8 hours related to Epigastric pain.Hours: 12:00 a.m. 8:00 a.m. and 4:00 p.m. 3/1/26 to 3/31/26 and 4/1/26 to 4/8/26 Pain level of 0 (zero). LVN 3 stated Resident 21's pain levels were 0s indicating no pain. LVN 3 stated Resident 21's narcotic pain medication should be evaluated by the physician for correct indication and should be changed.During a review of Resident 21's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/10/26, the AR indicated Resident 21 was admitted to the facility on [DATE] with acute upper respiratory infection (a short-term, contagious illness affecting the nose, throat, or airways, typically caused by viruses like the common cold or influenza), migraine (a headache that can cause intense throbbing pain or a pulsing feeling, usually on one side of the head), and pain in leg. Resident 21's Diagnosis information did not indicate diagnosis of Epigastric pain and Other Chronic Pain. During a review of Resident 21's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 4/1/26, the MDS section C indicated Resident 21 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 21 was cognitively intact.During a concurrent interview and record review on 4/9/26 at 9:39 a.m. with LVN 4, Resident 21's EMAR, dated 4/1/26 to 4/9/26. The EMAR indicated, Hydrocodone-Acetaminophen oral tablet 5-325 mg Give 1 tablet by mouth every 8 hours related to Epigastric pain.Hours: 12:00 a.m. 8:00 a.m. and 4:00 p.m. 4/1/26 to 4/9/26 Pain level of 0 (zero). LVN 4 stated he was assigned to Resident 21 on night shift, and he administered Hydrocodone-Acetaminophen for her headache and generalized body pain. LVN 4 stated he was not aware that Resident 21's Hydrocodone-Acetaminophen should be given for Epigastric pain. LVN 4 stated he administered antacid medication for her epigastric pain and not the Hydrocodone-Acetaminophen. LVN 4 stated he administered Hydrocodone-Acetaminophen because it was scheduled, she's been getting it routinely with pain level of zero. LVN 4 stated the EMAR was asking for the pain level and not the pain location. LVN 4 stated he should verify the pain medication order with physician. During an observation on 4/9/26 at 11:38 a.m. with LVN 3, in Resident 21, LVN 2 asked Resident 21 in Spanish about her pain, Resident 21 stated her head hurts a lot. LVN 2 assessed the pain level, Resident 21 stated eight out of 10. LVN 3 administered Tramadol 50 mg to Resident 21. During an interview on 4/9/26 at 11:52 a.m. with Resident 21, in Resident 21's room with LVN 3, Resident 21 stated she was getting Hydrocodone-Acetaminophen for her headache and not for stomach pain. Resident 21 stated she was getting Calcium Carbonate for her Epigastric pain. Resident 21 stated she had stomach pain when she was constipated (a problem with passing stool) and after she ate a lot of food. Resident 21 stated she had kidney stones 11 years ago. During a review of Resident 21's EMAR, dated 12/2025 to 3/2026. The EMAR indicated, Hydrocodone-Acetaminophen oral tablet 5-325 mg Give 1 tablet by mouth every 8 hours related to Epigastric pain.Hours: 12:00 a.m. 8:00 a.m. and 4:00 p.m. Pain level 0.During an interview on 4/10/26 at 11:42 a.m. with the Pharmacy Consultant (PC), the PC stated she's been the facility's PC since 2015 and was familiar with Resident 21. The PC stated she conducts a monthly drug regimen review and sends the report to the DON and Administrator. The PC indicated she reviewed resident's EMR including the EMAR, physicians' orders and laboratory results. The PC stated licensed nurses should follow the physician's order, if the pain medication was indicated for epigastric, it should be given for epigastric pain only and not for other chronic pain. The PC stated she had no recommendations for Resident 21's used of pain medications with a pain level of 0 from 12/2025 to 4/2026, and stated, I missed it. The PC stated if resident's EMAR documentation of pain level of 0 for two to three months which indicates no pain, pain is being controlled, or medication is working but it should trigger for a PC to send a recommendation for the physician to reassess the need of the pain medication. The PC stated there should be discussion with the physician to reduce or discontinue the pain medication to prevent unnecessary medication. The PC stated the goal was to decrease opioid use as much as possible, provide comfort, and not to over medicate the residents. The PC stated routine or scheduled pain medications could be changed to PRN and eventually discontinued. The PC stated Resident 21's epigastric pain could overlap other chronic pain. The PC stated Resident 21's other chronic pain should be assessed for the kind of chronic pain she had. The PC stated opioid medications can have side effects such as stomach irritation and falls for elderly residents. During an interview on 4/10/26 at 3:09 p.m. with the Interim Director of Nursing (IDON), the IDON stated it was her expectation for the licensed nurses to follow the facility's Policy and Procedure (P&P) for pain assessment and management, and following physician's orders. The IDON stated licensed nurses should follow the physician's order for Resident 21's Hydrocodone-Acetaminophen related to epigastric pain. The IDON stated Resident 21's Hydrocodone-Acetaminophen should only be given specifically for epigastric pain and not other pain. The IDON stated licensed nurses should assess resident for pain including the pain location when giving pain medication regardless of if pain medication was routine. The IDON stated pain assessment of 0 for more than a month should require a re-evaluation from the physician to prevent unnecessary medications.During a review of facility's P&P titled, Administering Pain Medications, dated 1/2018, the P&P indicated, The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. 6. Administer pain medications as ordered.During a review of facility's P&P titled, Pain Assessment and Management, dated 1/2018, the P&P indicated, The purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. 3. Pain management is a multidisciplinary care process that includes the following: c. Identifying the characteristics of pain; d. Addressing the underlying causes of the pain; e. Developing and implementing approaches to pain management; g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. 6. For stable chronic pain the resident's pain and consequences of pain are assessed at least weekly. Assessing Pain: 1. During the comprehensive pain assessment gather the following information: b. Characteristics of pain: 1. Location of pain. Monitoring and Modifying Approaches: 5. If pain symptoms have resolved or there is no longer an indication for pain medication, the multidisciplinary team and physician shall try to discontinue or taper analgesic medications to the extent possible.During a review of facility's P&P titled, Pain-Clinical Protocol, dated 1/2028, the P&P indicated, Assessment and Recognition. 1. The physician and staff will identify individuals who have pain or who are at risk for having pain. a. This includes reviewing known diagnoses and conditions that commonly cause pain. 3. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Monitoring. 4.a. The physician will adjust or discontinue medications, accordingly, based on effectiveness and side effects.

Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice when Resident 54 received medication from unauthorized staff and was not monitored and assessed by Licensed Nurses for effective medication and treatment.This failure had the potential for Resident 54 not to receive necessary care, treatment, and services based on comprehensive assessment and comprehensive person-centered care plan.During a concurrent observation and interview on 4/7/26 at 9:46 a.m. with Resident 54, in Resident 54's room, Resident 54 was lying flat on low air loss mattress (a specialized medical surface that combines alternating pressure with a steady, low-volume airflow to treat or prevent pressure ulcers (bedsores) and manage moisture) in his bed. Resident 54 was awake, watching a program on television. Resident 54 was not verbally responsive and had no eye contact during conversation. Resident 54's forehead with creamy yellowish plaque (abnormal buildup or deposit, either a solid patch on the skin/organs) buildup and yellowish flakes in his hair. Resident 54 had bilateral lower extremities contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff).During a concurrent observation and interview on 4/8/26 at 11:38 a.m. with CNA 7, in Resident 54's room, CNA 7 was cleaning Resident 54's forehead. CNA 7 stated Resident 54 had a thick and creamy yellowish buildup on his forehead and multiple dry yellow skin flakes on his hair like dandruff (a skin condition of scaly white or grayish flakes of dead skin of the scalp). CNA 7 stated Resident 54 was totally dependent on staff for his activities of daily living (Activities of Daily Living (ADLs- routine tasks/activities such as grooming, bathing, dressing and toileting a person performs daily to care for themselves). CNA 7 stated he will notify the license nurse to assess Resident 54's skin and scalp because it was difficult to remove.During a concurrent observation and interview on 4/8/26 at 11:39 a.m. with Licensed Vocational Nurse (LVN) 2, in Resident 54's room, LVN 2 checked Resident 54's head and forehead. LVN 2 stated Resident 54's forehead was red with buildup of thick yellowish plaques and skin flakes on his hair. LVN 2 stated Resident 54 was at risk for skin breakdown and licensed nurses should conduct skin assessments on shower days. LVN 2 stated she will notify the wound doctor to assess and evaluate Resident 54 skin condition.During a concurrent interview and record review on 4/8/26 at 11:40 p.m. with LVN 2, Resident 54's Nursing Weekly Summary Notes, dated 4/7/26 was reviewed. The Nursing Weekly Summary Notes indicated, L. Skin -Is skin clean and intact? Yes. LVN 2 stated the large amount of buildup of thick yellowish plaques on Resident 54's was not documented. LVN 2 stated Resident 54's skin assessment should reflect Resident 54's skin condition to evaluate if current interventions and treatment were effective.During an observation on 4/8/26 at 4:31 a.m. with CNA 5, in Station 1 hallway, CNA 5 informed CNA 6 that Resident 54 had a special shampoo and she would get it to the nurse.During an observation on 4/8/26 at 4:33 p.m. with Registered Nurse (RN) 3, in Station 1 hallway, RN 3 opened the treatment cart and handed a white bottle to CNA 5.During an interview on 4/8/26 at 4:45 p.m. with CNA 5, CNA 5 stated she assisted CNA 6 in providing a shower for Resident 54. CNA 5 stated she gave a bottle shampoo to CNA 6 and CNA 6 applied the shampoo to Resident 54's hair like a regular shampoo. CNA 5 stated CNAs were not authorized to apply a medicated shampoo to the residents and only licensed nurses can apply a medicated shampoo. During a concurrent interview and record review on 4/8/26 at 5:05 p.m. with RN 3, Resident 54's Electronic Medication Administration Record (EMAR- a digital version of daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/8/26 was reviewed. The EMAR indicated, .Ketoconazole External Shampoo 2% (Topical) Apply to scalp topically in the evening every Wednesday and Saturday for Seborrheic dermatitis (a common, chronic inflammatory skin condition causing itchy, flaky, greasy patches, often appearing as dandruff or rash on oily areas like the scalp, face, and chest) apply shampoo to scalp lather leave for 5 minutes and Rinse -Start Date- 02/28/2026. RN 3 stated she signed the EMAR at 4:48 p.m. which indicated she administered the medicated shampoo to Resident 54's scalp. RN 3 stated she did not apply the medicated shampoo to Resident 54. RN 3 stated she should not allow CNA 5 and CNA 6 to apply the medicated shampoo because it contains medications. RN 3 stated she did not provide instructions and directions to CNAs on how to properly apply the medicated shampoo which could result in improper application of medicated shampoo. RN 3 stated incorrect application of medicated shampoo would not have a desired effectiveness and could result in worsening of his skin condition.During an interview on 4/8/26 at 5:13 p.m. with CNA 6, CNA 6 stated she was assigned to Resident 54. CNA 6 stated CNA 5 assisted her with Resident 54's transfers and showers. CNA 5 applied the shampoo to Resident 54's hair, on top of his hair. CNA 6 stated CNAs were not allowed and trained to administer medicated shampoo because it is a medication. CNA 6 stated licensed nurses were responsible in administering medicated shampoo. CNA 6 stated Resident 54 had a thick buildup of creamy, sticky and scaly plaques on the back of his head. CNA 6 stated the shower chair needed to be clean and sanitized by housekeepers due to presence of large amount of creamy, sticky and scaly flakes. CNA 6 stated Resident 54 should be provided with shower more than twice a week or needed a daily shower to clear the creamy, sticky and scaly plaques on the back of his head.During an interview on 4/9/26 at 9:34 a.m. with RN 4, RN 4 stated medicated shampoo should be administered by licensed nurses because it contains medication. RN 4 stated CNAs were not trained and authorized to administer medications. RN 4 stated licensed nurses should monitor and assess Resident 54 after each shower to evaluate if the medication was effective or not.During a concurrent interview and record review on 4/9/26 at 9:21 a.m. with LVN 1, Resident 54's bottle label of medicated shampoo was reviewed. The bottle label of medicated shampoo indicated, .Ketoconazole Shampoo 2% (Topical) Apply to scalp topically in the evening every Wednesday and Saturday for Seborrheic dermatitis apply shampoo to scalp lather leave for 5 minutes and Rinse Filled Date: 12/3/25. LVN 1 stated Resident 54 had been using the medicated shampoo since 12/3/25. LVN 1 stated licensed nurses were responsible in applying for the medicated shampoo because it contains medication and should follow the direction of application according to the physician's order. LVN 1 stated CNAs were not authorized and trained to apply medicated shampoo which could result in improper application. LVN 1 stated licensed nurses should assess Resident 54's skin and scalp during application of the medicated shampoo to evaluate if the treatment is effective. LVN 1 stated there was no monitoring in Resident 54's EMR about the skin condition of his scalp-related diagnosis of Seborrheic dermatitis. LVN 1 stated physicians should be notified if medication or treatment was not effective. LVN 1 stated she was not aware of Resident's 54's buildup of yellowish plaques on his forehead.During an interview on 4/10/26 at 3:09 p.m. with the Interim Director of Nursing (IDON), the IDON stated her expectation for the licensed nurses to follow facility's policies and procedures to ensure medications were administered by authorized and trained staff. The IDON stated medicated shampoo contains medication and should be administered by licensed nurses and not by CNAs. The IDON stated it was not on CNAs scope of practice to administer medications. The IDON stated licensed nurses were responsible in administering medications including medicated shampoo to ensure it was applied correctly according to the physician's order. The IDON stated licensed nurses should monitor and properly assess resident for efficacy of medications and treatments and to notify the physician if the medications and treatments were not effective. The IDON stated licensed nurses should monitor residents for any adverse effects of medications. The IDON stated monitoring and assessment is important to identify and implement necessary care, treatment and services to the residents. During a review of Resident 54's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/10/26, the AR indicated Resident 54 was admitted to the facility on [DATE] with diagnosis of autistic disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave), and right and left lower leg contractures. Resident 54's diagnosis information did not indicate a diagnosis of Seborrheic dermatitis.During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/7/26, the MDS section C indicated Resident 54 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) was not conducted with a code of 0 indicating No (resident is rarely/never understood). Resident 54's BIMS Summary Score was blank.During a review of Resident 54's shower sheet, dated 4/8/26, indicated, .visual check: reddened area, dryness, other.was blank.During a review of Resident 54's care plan report, undated, indicated, Focus. The resident has an ADL self-care performance deficit r/t total dependent with bed mobility, transfers, non-ambulatory.Interventions/Tasks. SKIN INSPECTION: Check SKIN with ADL care. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse.During a review of facility's lesson plan titled, Medication Administration, dated 8/12/25, indicated, .CNAs cannot administer any type of medicated creams, soaps, shampoos.Nurses must apply these items.During a review of facility's P&P titled, Administering Medication, dated 1/2018, the P&P indicated, Medications shall be administered in a safe and timely manner, ad as prescribed.3. Medications must be administered in accordance with the orders. 7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.During a review of the facility's P&P titled, Physician Orders, dated 1/2018, the P&P indicated, .physician orders are obtained to provide a clear direction in the care of the resident.During a review of the facility's P&P titled, Resident Examination and Assessment, dated 1/2018, the P&P indicated, The purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. 1. Review the resident's admission assessment and/or preliminary care plan to assess for any special situations regarding the resident's care. 7. Skin: a. intactness; b. moisture; c. color; d. texture; and e. presence of bruises, pressure sores, redness, edema, rashes. During a review of Nursing World.org Professional Reference titled, The American Nurses Association- Nursing: Scope and Standards of Practice, Third Edition, dated July 2015, (found at https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf) the reference indicated, .The Standards of Practice describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process. The nursing process includes the components of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. Accordingly, the nursing process encompasses significant actions taken by registered nurses and forms the foundation of the nurse's decision-making. Standard 1. Assessment The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation.During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. vital to positive patient outcomes. the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition.

Based on observation, interview and record review, the facility failed to ensure activities of daily living (Activities of Daily Living (ADLs- routine tasks/activities such as grooming, bathing, dressing and toileting a person performs daily to care for themselves) were not provided for two of eight sampled residents (Resident 79 and 17) when: 1.Resident 79's fingernails were long, jagged (sharp, uneven edges) and dirty with brownish to blackish dirt built up underneath the nails and toenails were long and thick.This failure had potential for Resident 79 in obtaining avoidable skin related injuries (including cuts (laceration), scrapes (abrasion), scratches, etc.) and infection (the invasion and growth of germs in the body).2. Resident 17's beard (the growth of hair on the chin and lower cheeks of a man's face) were silvery thick and long. Resident 17 stated he requested to be shaved two weeks ago.This failure had the potential for Resident 17 in harboring microorganisms (bacteria) in his beard that could cause infection.1.During a concurrent observation and interview on 4/7/26 at 8:51 a.m. with Resident 79, in Resident 79's room, Resident 79 was lying in bed with head of bed elevated. Resident 79 was alert and oriented and verbally responsive. Resident 79 had an indwelling foley catheter (a common type of indwelling catheter inserted into the bladder, used to drain urine) with a privacy bag. Resident 79's fingernails were long, and dirty with brownish to blackish dirt built up underneath the nails. Resident 79's left hand was shaking. Resident 79 stated no one cut and cleaned his fingernails. Resident 79 stated he bit his fingernails because they were long. Resident 79 stated he wanted his fingernails to be clean and trimmed. During a concurrent observation and interview on 4/8/26 at 10:56 a.m. with Licensed Vocational Nurse (LVN) 3, in Resident 79's room, LVN 3 checked Resident 79's fingernails and toenails. LVN 3 stated Resident 79's fingernails were long, uneven with sharp edges and dirty with brownish to blackish buildup underneath the nail bed, and toenails were long and thick. LVN 3 asked Resident 79 about biting his fingernails and Resident 79 stated he's been biting his fingernails because they were long. LVN 3 stated Resident 79 required assistance with his ADLs. LVN 3 stated he will inform the Social Services Director (SSD) to schedule a podiatrist (a doctor specializing in diagnosing and treating foot, ankle, and lower leg conditions) to trim his toenails. LVN 3 stated nail care should be provided by nursing staff and podiatrists to prevent infection and skin scratches. During an interview on 4/8/26 at 11:08 a.m. with the SSD, SSD stated Resident 79 had not seen or been evaluated by the podiatrist since admission. The SSD stated Resident 79 should be seen and evaluated by the podiatrist for toenail care. The SSD stated Resident 79 was not on the list for podiatrist visit because she did not receive a communication form from the licensed nurses for Resident 79's need of podiatry services. During an interview on 4/10/26 at 2:20 p.m. with the Director of Staff and Development (DSD), the DSD stated she was responsible for providing training with Certified Nursing Assistants (CNAs). The DSD stated it was her expectation for CNAs to provide nail care every Sunday and as needed if no restrictions. The DSD stated residents' fingernails and toenails should be checked by the CNAs during shower days twice a week. The DSD stated she conducts weekly checks to ensure residents are clean and well groomed. The DSD stated nails that were long and dirty could result in self-inflicted injuries like skin tears and scratches and harbor germs that could cause infection.During an interview on 4/10/26 at 3:09 p.m. with the Interim Director of Nursing (IDON), the IDON stated it was her expectation for staff to follow P&P for nail care by keeping residents' nails clean and trimmed and stated, nice and clean to prevent skin tears and infection. The IDON stated Resident 79 had an increased risk of getting infection related to biting his fingernails. The IDON stated new admit residents should receive necessary care and treatments including podiatrist care and services when needed.During a review of Resident 79's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/10/26, the AR indicated Resident 49 was admitted to the facility on [DATE] with primary diagnosis of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area).During a review of Resident 79's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 3/6/26, the MDS section C indicated Resident 79 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 79 was cognitively intact.During a review of facility's policy and procedures (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 1/2028, the P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .During a review of facility's P&P titled, Fingernails/Toenails, Care of, dated 1/2018, the P&P indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.1. Nail care includes cleaning and regular trimming during showers and/or as needed. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. 6. Stop and report to the nurse supervisor if there is evidence of. or if nails are too hard or too thick to cut with ease. During a review of facility's P&P titled, Foot Care, dated 1/20/28, the P&P indicated, Residents will receive appropriate care and treatment in order to maintain mobility and foot health. 1. Residents will be provided with foot care and treatment in accordance with professional standards of practice. 2. During a concurrent observation and interview 4/7/26 at 12:28 p.m. with Resident 17, in Resident 17's room, Resident 17 was self-propelling his wheelchair. Resident 17 was alert and oriented x 4 (name, time, place, event/situation). Resident 17 had a thick silvery beard. Resident 17 stated he'd been waiting for the staff to shave him and the last time he was shaved was two weeks ago. Resident 17 stated staff were aware that he needed a shave and informed them that he wanted to shave his beard. During a review of Resident 17's MDS, dated [DATE], the MDS section C indicated Resident 17 had a BIMS score of 15. Resident 17 was cognitively intact.During an interview on 4/8/26 at 11:13 a.m. with CNA 7, CNAs should provide shaving during showers and as needed if residents allow. CNA 7 stated shaving was part of providing good hygiene. CNA 7 residents should be shaved to look clean, presentable, and to prevent infection. CNA 7 stated he was not the CNA assigned to Resident 17 and he will look for his CNA.During a concurrent observation and interview on 4/8/26 at 11:16 a.m. with CNA 8, outside Resident 17's room, CNA 8 was talking to Resident 17 about shaving him today (4/8/26). Resident 17 stated he wanted to keep his mustache (a strip of hair left to grow above the upper lip). During an observation and interview on 4/8/26 at 2:55 p.m. with Resident 17, in Resident 17's room, Resident 17 was lying in bed with oxygen via nasal canula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). Resident 17's beard remained thick and long. Resident 17 stated no one shaved him yet. Resident 17 stated he's been waiting to be shaved.During a concurrent observation and interview on 4/8/26 at 3:00 p.m. with CNA 8, in Resident 17's room, CNA 8 was talking to Resident 17 about scheduling his shaving tomorrow (4/9/26) because CNA 8 ran out of time. CNA 8 stated he got busy and could not shave Resident 17 today (4/8/26). CNA 8 stated he had no time to shave Resident 17 because he got busy with other residents. During an interview on 4/8/26 at 3:05 p.m. with Resident 17, in Resident 17's room, Resident 17 stated CNA 8 did not shave him today (4/8/26), and stated, I was puzzled.During an interview on 4/8/26 at 3:10 p.m. with the Infection Preventionist (IP), the IP stated she was working as charge nurse today (4/8/26) and Resident 17 was one of her residents. The IP stated Resident 17 should be shaved today as requested by his CNA and it was not acceptable that he's been waiting for two weeks to be shaved. The IP stated Resident 17 should be shaved by CNA as needed to maintain cleanliness and prevent infection. The IP stated Resident 17 smokes and cigars ashes could potentially transfer to his beard that could cause infection.During an interview on 4/10/26 at 3:09 p.m. with the IDON, the IDON stated it was her expectation for CNAs to provide and maintain proper grooming including shaving to keep residents nice and clean. The IDON stated it was not acceptable for Resident 17 to wait for two weeks to be shaved. The IDON stated when residents requested to be shaved it should be done within the shift. The IDON stated residents should be shaved during shower days.During a review of facility's policy and procedures (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 1/2028, the P&P indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and person and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, interview and record review, the facility failed to follow professional standards of practice to ensure the Care Plan (CP) was reviewed and revised in a timely manner for one of six sampled residents (Resident 6) when the goals for Resident 6 were not reviewed and revised for right and left (bilateral) lower leg edema (swelling) for six months (since October 2025).This failure had the potential for Resident 6 to not receive the appropriate care for his bilateral lower limb edema and put Resident 6 at risk of adverse (harmful) effects from swelling such as skin breakdown, infection, hypertension (when the pressure in the blood vessels is too high), cardiovascular disease (heart disease) and death.Findings:During a concurrent observation and interview on 4/7/2026 at 12:34 p.m. with Resident 6 in Resident 6's room, Resident 6 was observed in bed, wearing a gown. Resident 6 had minimal verbalization and gestured with a thumbs up and nod that he was doing well and had no issues. Resident 6's legs were uncovered and were observed to have swelling in both lower limbs.During a review of Resident 6's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 4/9/26, the AR indicated Resident 6 was admitted to the facility from an acute care hospital on 8/5/24 with diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), hypertension, dysphagia (difficulty swallowing), localized edema, tubule-interstitial nephritis (kidney damage that occurs outside the structures that filter the blood), and pain in leg, unspecified.During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/4/26, the MDS section C indicated Resident 6 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 11 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 6 was moderately impaired. During a concurrent interview and record review on 4/8/2026 at 4:12 p.m. with Registered Nurse (RN) 3, Resident 6's Order Summary Report (OSR), undated, the OSR indicated, monitor +2 edema to the bilateral lower extremities for any signs and symptoms [s/s] of worsening. Notify physician [MD] if noted any. Every shift.order status.active.order date 10/27/2025.start date 10/27/25. RN 3 stated Resident 6 had bilateral leg swelling and staff was monitoring the swelling and would notify the physician if it worsened. RN 3 stated Resident 6 was not taking any medication for his swelling and was not receiving any treatment for his swelling except to elevate his right foot while in bed for foot pain.During a concurrent interview and record review on 4/08/2026 at 4:31 p.m. with RN 1, Resident 6's OSR, undated was reviewed. RN 1 stated Resident 6 was not receiving any medication for edema. RN 1 stated for a resident with any skin condition or any change of condition nurses completed an SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) and monitored the resident for 72 hours. RN 1 stated if there was no improvement, nurses notified the physician. RN 1 stated Resident 6 was being monitored for pain in his right foot, but not for his bilateral leg swelling. RN 1 stated Resident 6's physician should have been notified of his continued leg swelling. RN 1 stated it was important to notify the physician if there was no improvement in Resident 6's swelling, as the swelling could have been from fluid overload and Resident 6 might have needed a diuretic (a medication used to remove excess fluid from the body).During a concurrent interview and record review on 4/08/2026 at 4:31 p.m. with RN 1, Resident 6's Care Plan, undated was reviewed. The CP indicated, .resident has a +2 edema to the bilateral lower extremities.resident will maintain optimal fluid balance [stable weight, minimal edema].assess and document extent of edema.avoid prolonged standing or sitting.elevate affected extremities above heart level several times daily.[furosemide-a medication used to treat edema and hypertension] oral tablet 20milligrams [MG - a unit of measurement] give 1 tablet by mouth two times a day related to localized edema.for 2 weeks. RN 1 stated Resident 6 's CP was initiated on 10/27/25 for edema bilateral legs, and nurses were to assess and document his edema, elevate affected limbs, and monitor Resident 6's weight. RN 1 stated Resident 6 should have had a new assessment with new orders for fluids and medications, and his care plan revised. RN 1 stated Resident 6's continued leg swelling should have been caught by the nurses' weekly assessments.During an interview on 4/10/2026 at 12:30 p.m. with the Minimum Data Set Coordinator (MDS), the MDS stated she reviewed residents CPs, and Change of Condition (COC) assessments, and updated and revised the residents' CPs. The MDS stated the resident's CP should have had a time frame to see if the intervention was working. If the intervention was not working, the nurse should have reassessed the resident and notified the physician for new orders, evaluation and recommendations.During an interview on 4/10/2026 at 3:33 p.m. with the Interim Director of Nursing (IDON), the IDON stated if the resident had a COC, the nurse should have completed an SBAR, notified the physician, family or resident Responsible Party, received new orders and put on 72-hour monitoring. The IDON stated the resident's CP should have been revised with a time frame for the COC and intervention, which was usually seven days or two weeks to reassess the resident and see if the intervention was working. If there was no time frame for the intervention, the nurse should have asked the physician. If the intervention was resolved the residents' CP should have been revised to show the COC was resolved. The IDON stated monitoring Resident 6 for bilateral edema with no change or other intervention since October 2025 was not acceptable. The IDON stated staff should have followed up with Resident 6's physician. The IDON stated nursing, department managers, and the interdisciplinary team, which included the DON and the Director of Staff Development, should have looked at the 24-hour shift reports to see if Resident 6 continued with the COC. The IDON stated the nurses were ultimately responsible for not catching the continued swelling during the weekly assessments. The IDON stated Resident 6's CP should have been revised with an updated physician's order. The IDON stated resident's CPs should have been resident specific, since every resident was different.During a review of the facility's policy and procedure (P&P) titled, Care Planning - Interdisciplinary Team, dated 1/2018, the P&P indicated, .our facility's care planning/Interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident.the care plan is based on the resident's comprehensive assessment.During a review of the facility's P&P titled, Change in a Resident's Condition, dated 1/2018, the P&P indicated, .our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status.a significant change of condition is a major decline or improvement in the resident's status that.will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted.During a review of the facility's P&P titled, Charting and Documentation, dated 1/2018, the P&P indicated, .all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.the following information is to be documented in the resident's medical record.changes in the resident's condition.progress toward or changes in the care plan goals and objectives.

Based on interview and record review the facility failed to designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis when the facility had no full time DON.This failure had the potential to not to meet the critical needs of high acuity residents (individuals requiring intensive, specialized care, constant monitoring, and frequent medical interventions due to severe or complex health conditions) causing serious injury, harm and impairment.During an interview on 3/19/26 at 2:00 p.m. with the Administrator (ADM), the ADM stated he's been the administrator of the facility for eight days. The ADM stated the facility does not have a DON or an interim (in the meantime, temporary or acting) DON. The ADM stated the facility's current census was 71.During an interview on 3/19/26 at 4:28 p.m. with RN 1, RN 1 stated the facility had no DON since the previous DON left two weeks ago. RN 1 stated there was no acting DON. RN 1 stated she called and notified the physician and the administrator for residents' change of condition such as falls.During an interview on 3/19/26 at 3:20 p.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated they do not have a DON and their previous DON resigned. The MDSC stated they have a Corporate RN that they can contact via phone for clinical questions and she visited the facility last Tuesday (3/10/26). The MDSC stated the Corporate RN was not acting DON. The MDSC stated previous DON's last day at the facility was 3/6/26.During an interview on 3/19/26 at 4:45 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated there was no DON in the facility. LVN 3 stated she asked for help from RN on their shift when she needed help for a change of condition like falls.During an interview on 3/19/26 at 4:59 p.m. with RN 2, RN 2 stated they do not have a DON, and she notified the DSD regarding staffing and clinical questions. RN 2 stated the facility's DSD was LVN. During an interview on 3/19/26 at 5:00 p.m. with LVN 4, LVN 4 stated they do not have a DON and their DON left. LVN 4 stated she asked RN in her shift for help when needed. LVN 4 stated the facility was looking for a new DON. LVN 4 stated there were RNs working on a.m. and p.m. shifts, and no RN on night shift. During an interview on 3/20/26 at 1:41 p.m. with the ADM, the ADM stated the facility does not have a DON and, We are actively recruiting. The ADM stated the DON position was posted. The ADM stated it's a regulation to have a full time DON and the DON should be onsite. The ADM stated it was very important to have a DON because DON was in charge of nursing services, staffing and in-services (training that is given to employees during the course of employment). The ADM stated they have qualified RNs in house, but they were not appointed as DON. The ADM stated their corporate asked him if he knew someone, a qualified DON and stated, I don't know of one.During an interview on 3/20/26 at 4:51 p.m. with the MDSC, the MDSC stated the facility does not have a DON or an acting DON. The MDSC stated the facility was actively looking for a potential candidate. The MDSC stated the facility should have full-time DON onsite or an acting DON to direct nursing personnel in ensuring the best quality of care was being delivered to all residents. The MDSC stated if there is no DON there could be a potential risk of medication errors, improper resident assessment, and non-compliance with the facility's policies and procedures (P&Ps). During a review of facility's P&P titled Director of Nursing Services, dated 1/2018, the P&P indicated, The nursing services department is under the direct supervision of a registered nurse. 1. The nursing services department is managed by the director of nursing services. The director is a registered nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing. 2. The director is employed full-time (40-hours per week) and is responsible for, but not necessarily limited to: b. developing standards of nursing practice; c. administer medications as needed; j. overseeing Licensed Nurses schedule;. l. ensuring that all health services notes are informative and descriptive of the supervision and care rendered including the resident's response to his or her care;. p. assuring that nursing care personnel are administering care and services in accordance with the resident's assessment and care plan.During a review of professional reference retrieved from https://www.justice.gov/sites/default/files/nursing_home_staffing_standards_in_state_statutes_and_regulations.pdf titled NURSING HOME STAFFING STANDARDS IN STATE STATUTES AND REGULATIONS, dated 1/2008, the professional reference indicated, .FEDERAL STAFFING: 1 RN 8 consecutive hrs/7days/wk & 1 RN/LVN for 2 remaining shifts. Must have 1 RN who is Full Time DON (5days/wk); if fewer than 60 residents, DON may also be Charge Nurse.During a review of professional reference retrieved from https://canhr.org/nursing-home-care-standards/ titled Nursing Home Standards, dated 6/24/25, the professional reference indicated, .Adequate Staffing.A skilled nursing facility must have a full-time director of nursing who is a registered nurse (RN). 42 CFR S483.35(b), 22 CCR S72327.

Based on interview and record review, the facility failed to ensure professional standards were met when:1) A Licensed Vocational Nurse (LVN 1) failed to accurately complete admission data for one of three sampled residents (Resident 1) when several errors were made when completing Resident 1's new admission assessment.This failure resulted in inaccurate information regarding the fall risks of Resident 1, which had the potential for inaccurate care planning to prevent falls.2) A Licensed Vocational Nurse (LVN 2) failed to wear gloves when applying a cream to the vaginal area of one of three sampled residents (Resident 2).This failure had resulted in loss of dignity and risk of contamination of infectious micro-organisms for Resident 2.1.During a review of Resident 1's admission Record (AR), dated 2/17/26, the AR indicated Resident 1 was a [AGE] year-old female admitted to the facility on [DATE]. The AR indicated Resident 1 had medical diagnoses that included muscle weakness, problems with the muscles and skeletal system, high blood pressure, and Parkinson's Disease (a movement disorder causing tremors, muscle rigidity, slowness of movement and balance issues).During a review of Resident 1's Medication Review Report dated 2/17/26, the MRR indicated she had a physician's order dated 1/9/26 for the medication ropinirole 0.25 milligrams, give 1 tablet by mouth two times a day for stiffness, tremors, muscle spasms, and poor muscle control related to Parkinsonism [Parkinson's Disease].The MRR also indicated Resident 1 had a physician's order dated 1/9/26 for the medication metoprolol tartrate 25 milligrams, give 1 tablet by mouth two times a day related to (Primary) Hypertension [high blood pressure] .During a concurrent interview and record review on 2/24/26, at 3:15 p.m., with Registered Nurse (RN) 1, of Resident 1's Nursing admission Assessment (NAA), dated 1/9/26, was reviewed. The NAA indicated the Resident 1 was assessed to have the following: Fall Risk data [Ambulates, or walks] without any problems and with devices. Balance and gait problem while standing/walking. RN 1 stated these two statements contradict each other and the assessment data entry of [Ambulates, or walks] without any problems and with devices was an error. The NAA also indicated Resident 1 does not take an antihypertensive medication (used to lower blood pressure).RN 1 stated this was an error, as Resident 1 does have a medical diagnosis of hypertension, and is prescribed an antihypertensive medication, beginning on 1/9/26.The NAA also indicated Resident 1 does not have Parkinson's Disease. RN 1 stated this was an error, has Resident 1 does have a medical diagnosis of Parkinson's Disease, and is prescribed a medication for this condition, beginning on 1/9/26.RN 1 stated these three (3) errors contributed to inaccurate assessment data, used to develop the fall risk care plan for Resident 1.During a review of the facility's Policy and Procedure (P&P), titled Falls and Fall Risk Managing, dated 11/17, the P&P indicated, Policy - To identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls.2. During a review of Resident 2's admission Record (AR), dated 2/17/26, the AR indicated she was admitted to the facility on [DATE].During a review of Resident 2's Medication Review Report (MRR), dated 2/17/26, the MRR indicated she had a physician's order dated 1/15/26 for a medicated cream to be applied to her peri-area (the sensitive region of skin and muscle located between the thighs, specifically extending from the anus to the genitals), for MASD (Moisture-Associated Skin Damage, an umbrella term for inflammation and erosion of the skin caused by prolonged or chronic exposure to various sources of moisture). During a review of Resident 2's Progress Notes (PN), dated 1/19/26, at 6:54 a.m., the PN indicated Resident on alert charting for redness to peri area. treatment done to peri-area. The PN was written by Licensed Vocational Nurse (LVN) 2.During an interview on 2/12/26, at 12:15 p.m., with local Police Officer (LPO), LPO stated he interviewed LVN 2 and stated, He admitted to me he was not using gloves while applying the cream on 1/19/26, to Resident 2.During an interview on 2/13/26, at 3:15 p.m., with LVN 2, LVN 2 stated he recalled applying the cream to Resident 2's peri-area on the night of 1/19/26. LVN 2 stated that night, a Certified Nursing Assistant (CNA) 1, came to him and informed him that Resident 2 wanted cream applied to her peri-area. LVN 2 stated he took CNA 1 with him to Resident 2's room and applied the cream on top of her vagina, and then between her thighs and vagina because there was a lot of redness. LVN 2 stated that after the procedure, he went to wash his hands and noticed some cream on his bare fingers. LVN 2 stated the gloves he uses tend to rip. LVN 2 stated that later, an officer from the local police department telephoned him and asked him about this incident. LVN 2 stated I let him know my finger was bare. I told him my finger was exposed.During an interview on 2/18/26, at 8:23 a.m., with CNA 1, CNA 1 stated she recalled going into Resident 2's room with LVN 2 the night of 1/19/26 to apply cream to Resident 2. CNA 1 stated, I was standing right next to him, shoulder to shoulder when he applied the cream to Resident 2's peri-area, over the vaginal area, on upper thighs. He was not wearing gloves.During an interview on 2/19/26, at 10:42 a.m., with the Director of Nursing (DON), the DON stated, Nurses should wear gloves when any contact with the vagina. If a glove breaks, the protocol would be to stop the procedure right there and put on new gloves to protect the skin and stop transmission of micro-organisms. There is a dignity issue as well. He should not have done that.During a review of the facility's Policy and Procedure (P&P) titled, Standards for Clinical Practice, dated 4/05, the P&P indicated, Appropriate Care is taken to ensure the resident's right to privacy and dignity, as well as the resident's health and safety are protected during the performance of any clinical procedure. Prior to the initiation of any clinical procedure: Apply appropriate Personal Protective Equipment (gloves.) as required by the procedure. Maintain the resident's privacy and dignity during the procedure.

Based on interview and record review, the facility failed to ensure residents were free from neglect when Certified Nursing Assistant (CNA) 9 intentionally did not provide incontinent care (provided for those who cannot control their bowels and/or bladder) for three of five residents (Resident 1, Resident 2, and Resident 3) on 12/21/24 between the hours of 11 p.m. and 7:30 a.m. on 12/22/24. CNA 9 expressly limited incontinent care to one change for Resident 1 and Resident 2 and did not provide care for the entire shift for Resident 3. These failures resulted in withholding of required services and neglecting the needs of Residents 1, 2, and 3. These failures resulted in the residents experiencing feelings of anger, frustration, loss of dignity and control, and disrespect by having to remain in their soiled briefs (a type of absorbent underwear worn by those who are incontinent) for three hours, and Resident 3 having to eat breakfast while in a soiled brief, which was against his stated preference that he be changed prior to dining. Findings: During a review of the facility document titled, Verification of Investigation Report (VOI), dated 12/26/24, the VOI indicated that during the night shift beginning at approximately 11:00 p.m., on 12/21/24, through approximately 7:30 a.m., on 12/22/24, Resident 1, Resident 2, and Resident 3 did not receive incontinent care during this shift. The VOI identified the staff person who did not perform the incontinent care as Certified Nursing Assistant (CNA) 9. The VOI indicated a Licensed Vocational Nurse (LVN 3) entered the room shared by Resident 1 and Resident 2, on 12/22/24, at approximately 8:30 a.m., to give them medication. The VOI indicated Resident 1 and Resident 2, informed [LVN 3] that they were upset about the care they received during [night] shift. Per both residents, their [night] shift CNA explained to them that she had 26 residents and would only be doing one brief change during the shift. Both residents explained that this made them feel unimportant and angry. The VOI indicated Resident 1 stated, Around midnight when [CNA 9] came in to change us, she informed us they were only 2 [CNAs on duty] and we would only get one brief change. Resident [1] stated, I felt neglected, and it made me feel angry. The VOI indicated Resident 2 stated, I put my call light on close to twelve midnight to be changed. [CNA 9] came to my room and told me that she has 26 residents and would only be able to do 1 brief change for me this shift. [CNA 9] changed me at this time. I put on my call light again at 4:55 [a.m.] to be changed again. [CNA 9] came to my room at 5:30 [a.m.] through the bathroom door and said, I don ' t know who is on the light but I ' m probably not going to get to you because there was a death and I have to clean him up. [CNA 9] left room and my brief was changed by the day shift CNA at 8:00 a.m. Resident [2] stated, I felt neglected last night. Resident [2] said that she felt dirty and nasty from having to sit in a dirty brief. Resident [2] also expressed feeling helpless and neglected. The VOI indicated Resident 3 stated, On December 22nd, I was not changed from night shift to morning shift. I was not changed the entire shift. The CNA was [CNA 9]. The VOI indicated Resident 1 and Resident 2 voiced that they felt neglected, gross, and angry regarding the incident on 12/22/24. Based on the investigation findings, the alleged neglect claim is substantiated. The VOI was signed by the Administrator on 12/26/24, at 3:30 p.m. During a review of Resident 1 ' s Admission Record (AR), dated 1/13/25, the AR indicated she was a [AGE] year-old female, and had been a resident of the facility for 11 months. During a review of Resident 1 ' s Minimum Data Set (MDS, a comprehensive, standardized assessment tool), dated 11/25/24, the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 1 was cognitively intact (having sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the resident ' s environment). The MDS indicated at Question GG0130 - C, a score of 2, which indicated she required Substantial/maximal assistance - Helper does MORE THAN HALF the effort with Toileting hygiene: The ability to maintain perineal [area between anus and genitals, or ' private parts ' ] hygiene, adjust clothes before and after voiding [urination] or having a bowel movement. During a review of Resident 1 ' s Progress Notes, dated 12/22/24, at 8:56 a.m., the PN indicated, During med[ication] pass at 8:30 [a.m.] resident [1] complain to this charge nurse that she wanted to make a complaint. She stated the CNA made her feel unimportant and frustrated after CNA told her that she would only be able to do one brief change for her for the shift. Resident [1 complained] of feeling neglected by this CNA. Psychiatry to follow up with [Resident 1] related to alleged neglect. During a review of Resident 1 ' s document titled, Behavioral Health (BH), dated 12/25/24, the BH indicated, Follow-up psychiatric visit for evaluation of [signs and symptoms] of emotional distress following a complaint of neglect. [Resident 1] reported an incident that occurred the other night involving a caregiver and expressed frustration and anger due to the caregiver ' s disrespectful behavior and lack of concern for her and her roommate ' s needs. [Resident 1] mentioned that both she and her roommate needed to be changed after having a bowel movement, but the caregiver refused to do so, citing other responsibilities. [Resident 1] felt that the caregiver ' s actions were unprofessional and inappropriate. She reported feeling angry and frustrated during the incident, particularly due to the discomfort of being wet and needing to be changed. [Resident 1] expressed feeling of anger and frustration related to a recent incident of neglect. During a review of Resident 2 ' s Admission Record (AR), dated 1/13/25, the AR indicated she was a [AGE] year-old female and was admitted to the facility in 2020. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 2 was cognitively intact. The MDS indicated at Question GG0130 - C, a score of 2, which indicated she required Substantial/maximal assistance - Helper does MORE THAN HALF the effort with Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. During a review of Resident 2 ' s PN, dated 12/22/24, at 8:54 a.m., the PN indicated, During med[ication] pass at 8:30 [a.m.] resident [2] informed this charge nurse that she would like to make a complaint. Resident states she feels neglected. Per resident her CNA refused to change her brief at 5:30 [a.m.]. Resident states that she was changed by her CNA at midnight after pushing her call light. Resident again pushed her call light at 4:55 [a.m.] to be changed. CNA entered room at 5:30 [a.m.] and informed resident that she was busy . and would not be able to change her at this time. CNA then left without changing the resident. Resident was changed at 8:00 [a.m.] by dayshift CNA during their rounds. Psychiatry to follow up with [Resident 2] related to alleged neglect. During a review of Resident 2 ' s document titled, Behavioral Health (BH), dated 12/25/24, the BH indicated, Follow-up psychiatric visit for evaluation of [signs and symptoms] of emotional distress following a complaint of neglect. [Resident 2] reports an incident where she was left unattended for an extended period of time resulting in her sitting in soiled briefs for over 3 hours. She expressed feelings of embarrassment, loss of dignity, and increased anxiety due to this situation. incidents like the one described have caused her distress. She reported a loss of dignity and control, which contributed to her emotional distress. During an interview on 1/10/25, at 12:05 p.m., with Resident 1, Resident 1 stated that on 12/22/24, I got changed at 12:30 a.m., about the time I got my meds. [CNA 9] came in and answered our call light. She said I have 25 patients and would only be changing us once during the shift. At 5:00 a.m., my roommate [Resident 2] hit the call light because she needed changed, and I did too. [CNA 9] came in and told us she was dealing with a patient death, so she had to clean them up. She shut the door and left without changing either of us. We didn ' t get changed at all. We can ' t get changed during meals, do we didn ' t get changed until 8:30 a.m. This really upset me. It was like she didn ' t care about us as a person. It was depressing. She didn ' t give us a chance to say anything. I felt frustrated and angry. I only got changed once that night, at 12:30 a.m. This was a very depressing thing to happen to me. So disrespectful, like I was nothing to her. [CNA 9] was constantly complaining that she hated her job. I took this to mean she hated me, because I was her job. During an interview on 1/10/25, at 12:21 p.m., with Resident 2, Resident 2 stated that on 12/21/24, I called with my call light, at about 11:30 p.m. [CNA 9] came in . changed us, then said we will only get changed once tonight because we are shorthanded. At 4:55 a.m., I put my call light on. I know what time it was because I as looking at my [smartphone], [CNA 9] came in and told us she would not be changing us because she was too busy. Not getting changed made me feel disgusted. [CNA 1] changed us on day shift at about 8:30 a.m. I felt like my dignity was affected. Resident 2 stated she agreed with [Resident 1] that [CNA 9] was constantly complaining to her and Resident 1 about her job, and by doing so, it felt like she hated both of them. During an interview on 1/10/25, at 12:45 p.m., with CNA 1, CNA 1 stated he recalled caring for Resident 1 and Resident 2 during the morning of 12/22/24. CNA 1 stated, I recall changing them at 8:30 a.m. They both were angry, grumpy, frustrated over this event. [Resident 1] said she ' d not been changed and had to wait. They both said we ' ve been waiting so long, since about 4:30 a.m., to be changed, waiting for someone to come, nobody came. I saw [Resident 1] be tearful, I think it was due to her anger. [Resident 2] was angry, frustrated over the event. During an interview on 1/10/25, at 2:35 p.m., with LVN 2, LVN 2 stated he was CNA 9 ' s supervisor during the night shift beginning at about 11:00 p.m. on 12/21/24, to 7:30 a.m. on 12/22/24. LVN 2 stated he recalled CNA 9 was complaining all the time. LVN 2 stated during their 8-hour shift together, CNA 9 never informed him she had concerns about her workload, not being able to change residents as frequently as needed, or not being able to complete her assigned tasks. LVN 2 stated if CNA 9 had informed him of any issues with her workload, he would have given assistance or assigned more staff to help her. LVN 2 stated he was unaware of Resident 1 and Resident 2 ' s unmet needs until his next shift, the following day. LVN 2 stated he spoke with Resident 1 and Resident 2 about this, and stated, [Resident 2] was upset, [Resident 1] was really upset. LVN 2 stated he could tell Resident 2 was upset because when she gets mad, she moves her hand around, starts to point, with pressured speech. [Resident 1] cried, had tears in her eyes. During a concurrent interview and record review on 1/15/25, at 9:38 a.m., with the Director of Nursing (DON), the VOI was reviewed. DON stated she had spoken to Resident 1 and Resident 2 multiple times regarding the events during the night shift of 12/21/24 - 12/22/24. The DON stated the information indicated on the VOI is correct. The DON stated CNA 9 was terminated for neglect. The DON stated there was a third resident, [Resident 3] also who had complained of not being changed that night. During an interview on 1/15/25, at 10:15 a.m., with Resident 3, Resident 3 stated, Oh yeah, I remember that night. There was a CNA named [CNA 9]. I usually sleep all night, they normally change me at around 8:00 p.m., then again in the morning before breakfast, at about 5:00 a.m. That is my preference. I wear a brief. [CNA 9] didn ' t change me that morning. It ' s not really a big deal, but it would have been nice to be changed before breakfast. I wasn ' t changed until after. That morning, [a nurse] made me fill out a paper about what happened, so I did. During a review of a handwritten, undated document signed by Resident 3, the document indicated, On [DATE] I was not changed from night shift to morning shift[.] I was not changed the entire shift. The CNA was [CNA 9]. During a review of Resident 3 ' s Admission Record (AR), dated 1/17/25, the AR indicated he was a [AGE] year-old male, and had been a resident of the facility for 11 months. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated at Question C0500 a score of 15 out of a possible 15, which indicated Resident 3 was cognitively intact. The MDS indicated at Question GG0130 - C, a score of 1, which indicated he was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity with Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. During a review of the facility email to CNA 9, dated 1/10/25, at 10:48 a.m., the email indicated, This email is to advise you that your employment with [name of facility] is terminated effective January 9, 2025. The company is terminating employment for violation of policy. During a concurrent record review and interview on 1/15/25, at 2:35 p.m., with the Administrator, the VOI was reviewed. The Administrator stated she was the facility ' s Abuse Prevention Coordinator. The Administrator stated the information in the VOI was accurate. The Administrator stated, This was neglect. This should not have happened. During a review of the facility ' s Policy and Procedure (P&P), titled, Abuse Prevention and Neglect Policy, dated 6/22, the P&P indicated, It is the facility ' s policy to prohibit abuse, mistreatment, neglect, involuntary seclusion [confining, isolating or restricting a resident to their room or to a specific area in the facility], and misappropriation of property for all residents through the following: . Prevention of occurrences. Neglect is defined as the failure of the facility to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), resulting in, or may result in, physical harm, pain, mental anguish, or emotional distress. During a review of the undated facility document titled, Here are your residents ' rights: (Rights), the Rights indicated, A dignified and comfortable living environment[.]

Based on 0bservation, interview, and record review the facility failed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections for two of seven residents (Resident 61 and Resident 238) when Certified Nursing Assistant (CNA) 1 did not perform hand hygiene (process of washing or disinfecting hands to prevent the spread of germs) after leaving the shared room of Resident 61 and Resident 238, while carrying a bag of soiled (dirty or contaminated) linen. CNA 1 then moved the linen cart without performing hand hygiene. This failure had the potential to contaminate the surface of the linen cart and cause cross contamination (when germs move from one area to another) of other surfaces. Findings: During an observation on 8/12/24 at 10:47 a.m. outside of Resident 61 and Resident 238's room, CNA 1 exited Resident 61 and Resident 238's room carrying a bag of soiled linen. CNA 1 disposed of the soiled linen bag and did not perform hand hygiene after; CNA 1 then pushed the linen cart forward without performing hand hygiene. During an interview on 8/12/24 at 3:50 p.m. with CNA 1, CNA 1 stated he came out of Resident 61 and Resident 238's room to dispose of the soiled linen and pushed the linen cart forward without performing hand hygiene after. CNA 1 stated he should have performed hand hygiene before moving the linen cart. CNA 1 stated hand hygiene was important to prevent the spread of germs across surfaces. During an interview on 8/14/24 at 2:35 p.m. with CNA 5, CNA 5 stated all staff were supposed to perform hand hygiene anytime they entered or exited a resident room. CNA 5 stated staff were not supposed to touch any surfaces until after they did hand hygiene. CNA 5 stated if a staff member needed to dispose of something they should have disposed of the item and then performed hand hygiene afterwards, before touching any surface. CNA 5 stated it was important to perform hand hygiene because it prevented cross contamination of other surfaces. During an interview on 8/15/23 at 3:45 p.m. with the infection preventionist (IP), the IP stated CNA 1 should have conducted hand hygiene before moving the linen cart after he disposed of the soiled linen from Resident 61 and Resident 238's room. The IP stated all staff members were supposed to do hand hygiene before they touched any surface because it helped keep the equipment and facility clean. During an interview on 8/16/24 at 9:17 a.m. with the director of staff development (DSD), the DSD stated CNA 1 should have conducted hand hygiene before moving the linen cart after he disposed of the soiled linen from Resident 61 and Resident 238's room. The DSD stated performing hand hygiene was important because it helped prevent the spread of infections. During an interview on 8/16/24 at 10:40 a.m. with the director of nursing (DON), the DON stated CNAs were supposed to perform hand hygiene anytime they came out of rooms or came in contact with dirty linens. The DON stated if dirty materials were being disposed of staff should have done hand hygiene after their disposal. The DON stated if staff did not perform hand hygiene, they could have carried infections with them on their hands and they could potentially spread it to others. During a review of the facility's policy and procedure (P&P) titled, Handwashing, undated, the P&P indicated, . All staff members will wash their hands before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of nosocomial (sickness a person receives when the stay in a facility) infections .

Based on observation, interview, and record review, the facility failed to ensure the planned menus were followed for the lunch meal on August 12, 2024 when: 1. Incorrect portion sizes were used on the therapeutic diets: a. 1/2 cup (4 ounces) of sweet potato fries were served instead of 1/4 cup (2 ounces) to 20 residents (Resident 42, 5, 16, 6, 26, 9, 23, 60, 12, 74, 34, 4, 37, 24, 77, 25, 22, 29, 78, and 13) who were on a Consistent Carbohydrate (CCHO) diet (a diet that provides a consistent amount of carbohydrates at each meal and from day to day to help keep blood sugar levels stable); and b. #16 scoop (2 ounces) of roast beef was served instead of #10 scoop (3.2 ounces) to eight residents (Resident 21, 57, 61, 54, 3, 55, 66, and 28) who were on a mechanical soft diet (a diet of soft-textured foods that are easy to chew and swallow); and c. #12 scoop (2.67 ounces) of pureed roast beef was served instead of #8 scoop (4 ounces) to seven residents (Resident 27, 1, 69, 2, 15, 49, and 44) on a puree diet (designed for residents who have difficulty chewing and/or swallowing and the texture of the food should be of a smooth, moist consistency and able to hold its shape); and d. Double portions of all food items were given to three residents (Resident 227, 20, and 44) on a large portion diet; and e. 4 ounces of sweet potato fries were given to two residents (Resident 13 and 45) on a renal diet (diet with lower amounts of sodium, protein, potassium, and phosphorus provided for residents with limited kidney function) and did not receive the food stated on the menu. 2. Pureed coleslaw was not measured when placed into bowls; and 3. Cappuccino mousse was not served, and chocolate pudding was not filled up consistently in the scoop when portioned as the dessert; and 4. Corn coleslaw was not served. These failures had the potential to result in residents on therapeutic diets to not meet their physician's prescribed diet order and their nutrition needs to not be met which can result in over or under nutrition. Findings: 1. During a review of the facility's Summer Menus for the lunch meal for August 12, 2024, showed the regular diet with regular portions to receive: 3 ounces (oz.) french dip - roast beef, 1 soft sandwich roll, 2 ounces Au Jus juice/sauce, 1/2 cup sweet potato fries, #8 scoop (1/2 cup) corn coleslaw; #12 cappuccino mousse (cap mousse). The large portion showed: 3 ounces roast beef, 1 soft sandwich roll, 3/4 cup sweet potato fries, #8 scoop corn coleslaw, #12 scoop cap mousse. Mechanical Soft diet showed: Ground roast beef #10 scoop, 1/2 cup sweet potato fries, #8 scoop corn coleslaw, #12 scoop cap mousse. Puree diet showed: #8 scoop roast beef moisten with broth, #12 scoop puree roll, #8 scoop puree sweet potato fries, #12 scoop corn coleslaw, #12 scoop cap mousse. CCHO, regular texture diet showed: 3 ounces roast beef with 1 roll, 1/4 cup sweet potato fries, #8 scoop corn coleslaw, #12 scoop cap mousse. Renal diet showed: 3 ounces roast beef, 1 roll, 2 ounces Au Jus, pineapple ring (no fries), #8 scoop corn coleslaw, Sugar cookies - 2 small. During an observation of the lunch meal service on 8/12/24 starting at 12:31 p.m. in the kitchen, the steam table had scoops for the following: #12 scoop for the regular texture roast beef, #16 scoop for the mechanical soft roast beef, #12 scoop for the pureed roast beef, and four-ounce (oz - unit of measurement) scoop (1/2 cup) for the regular texture sweet potato fries. Cross Reference F802. a. During a review of the facility's Summer Menus (SM), dated 8/12/24, the SM indicated residents on regular texture, CCHO, regular portions diet, to receive 1/4 cup of sweet potato fries. The SM indicated 1/2 cup of sweet potato fries is large portions for residents on regular texture, CCHO diet. During an observation on 8/12/24 at 12:32 p.m. in the kitchen, Dietary Aide (DA) 1 was not calling out CCHO from the meal tickets when telling the cook what to put on the plate. During an observation of the lunch meal service on 8/12/24, starting at 12:32 p.m. in the kitchen, [NAME] 1 used a four oz. scoop to serve regular texture sweet potato fries to 20 residents (Resident 42, 5, 16, 6, 26, 9, 23, 60, 12, 74, 34, 4, 37, 24, 77, 25, 22, 29, 78, 13) on regular texture, CCHO, regular portions diet. During a review of the facility's Diet Type Report (DTR), dated 8/12/24, the DTR indicated the following residents are on regular texture, CCHO, regular portions diet: Resident 42, 5, 16, 6, 26, 9, 23, 60, 12, 74, 34, 4, 37, 24, 77, 25, 22, 29, 78, 13). b. During a review of the facility's SM, dated 8/12/24, the SM indicated residents on mechanical soft regular portions diet get #10 scoop (3.2 ounces) of ground roast beef. The SM indicated #16 scoop (2 ounces) of ground roast beef is small portions for residents on mechanical soft diet. During an observation of the lunch meal service on 8/12/24 starting at 12:31 p.m. in the kitchen, [NAME] 1 used #16 scoop (small portions) to serve ground roast beef to eight residents (Resident 21, 57, 61, 54, 3, 55, 66, 28) on mechanical soft regular portions diet. During a review of the facility's DTR, dated 8/12/24, the DTR indicated the following residents are on mechanical soft regular portions diet: Resident 21, 57, 61, 54, 3, 55, 66, 28). c. During a review of the facility's SM, dated 8/12/24, the SM indicated residents on pureed regular portions diet get #8 scoop (4 ounces) of pureed roast beef. The SM indicated #12 scoop of pureed roast beef is small portions for residents on pureed diet. During an observation of the lunch meal service on 8/12/24 starting at 12:31 p.m. in the kitchen, [NAME] 1 used #12 scoop (small portions) to serve pureed roast beef to seven residents (Resident 27, 1, 69, 2, 15, 49, 44) on pureed regular portions diet. During a review of the facility's DTR, dated 8/12/24, the DTR indicated the following residents are on pureed, regular portions diet: Resident 27, 1, 69, 2, 15, 49, 44). d. During a review of the facility's SM, dated 8/12/24, the SM indicated residents on regular texture, large portions diet get three oz of roast beef and 3/4 cup of sweet potato fries. During an observation of the lunch meal service on 8/12/24 starting at 12:31 p.m., in the kitchen, [NAME] 1 served two #12 (5.34 oz) scoops of roast beef and two 4 oz scoop (one cup) of sweet potato fries to Resident 227 and Resident 20. During a review of the facility's DTR, dated 8/12/24, the DTR indicated Resident 227 and Resident 20 are on regular texture, large portions diet. During a review of the facility's policy and procedure (P&P) titled, Portion Sizes, dated 2023, the P&P indicated, The small and large portion servings will be served as printed on the cook's spreadsheets for every meal Double portions are used for residents with high caloric needs who are eating well and for whom large portions are inadequate.: e. During an observation on 8/12/24 at 12:40 p.m. in the kitchen, DA 1 was not calling out Renal from the meal tickets when telling the cook what to put on the plate. During an observation of the lunch meal service on 8/12/24 at starting at 12:31 p.m. in the kitchen, [NAME] 1 served roast beef and sweet potato fries to Resident 13 and Resident 45. During a review of the facility's DTR, dated 8/12/24, the DTR indicated Resident 13 and Resident 45 are on renal diet. During a review of the facility's SM, dated 8/12/24, the SM indicated. Renal diets. French Dip: Roast Beef Roll with Au Jus, Pineapple Ring ** No Fries. During an interview on 8/12/24 at 1:20 p.m. with [NAME] 1, [NAME] 1 stated residents on renal diet should get pineapple rings and not sweet potato fries. [NAME] 1 stated DA 2 should call out if residents are on renal diet. [NAME] 1 confirmed while reading the menu that the portion sizes were incorrect for CCHO, mechanical soft, large portions and puree diets. During an interview on 8/14/24 at 2:43 p.m. with Registered Dietitian (RD), RD stated she expects the kitchen staff to follow the portion sizes on the menu spreadsheet and follow what menu shows for all the different therapeutic diets. RD stated large portions is not double portions. 2. During an observation and concurrent interview on 8/12/24 at 12:21 p.m., with [NAME] 1, blended coleslaw in a blender. [NAME] 1 stated she had 12 servings portioned in the blender. During an observation on 8/12/24 at 12:22 p.m. with DA 3, DA 3 poured a pitcher of pureed coleslaw into seven disposable bowls unmeasured. During a review of the facility's SM, dated 8/12/24, the SM indicated residents on pureed diet get #12 scoop of pureed coleslaw. During a review of the facility's DTR, dated 8/12/24, the DTR indicated the following residents are on pureed diet: Resident 27, 1, 69, 2, 15, 49, 44. During an interview on 8/14/24 at 2:43 p.m. with RD, RD stated she expects the kitchen staff to follow the portion sizes on the menu spreadsheet and not to guess what the portion sizes are. 3. During an observation on 8/12/24 at 10:52 a.m. in the kitchen, DA 2 was preparing chocolate pudding for the residents' dessert for lunch. During a concurrent interview and observation on 8/12/24 at 10:53 a.m. with DA 2 in the kitchen, DA 2 was using a #12 scoop when scooping chocolate pudding into approximately 20 bowls on a tray. There were approximately 10 bowls that were not full. DA 2 stated some bowls had less pudding that the other bowls since she did not fill up the scoop as much. DA 2 then put the lids on the bowls and started a new tray of bowls. During an interview on 8/13/24 at 10:03 a.m. with DA 2, DA 2 stated, I don't think we had the ingredients for that [cappuccino mousse]. During an interview on 8/14/24 at 2:43 p.m. with RD, RD stated she expects the kitchen staff to follow the portion sizes on the menu spreadsheet and to fill up the scoops when portioning food items. 4. During an observation on 8/12/24 at 10:33 a.m. in the kitchen, [NAME] 1 was preparing coleslaw for the residents' side for lunch. The coleslaw did not have corn. During a review of the facility's SM, dated 8/12/24, the SM indicated, French Dip-Roast Beef on a Soft Sandwich Roll, Au Jus, Sweet Potato Fries, Ketchup, Corn Coleslaw, Cappuccino Mousse, Milk for lunch. During an interview on 8/13/24 at 10:01 a.m. with [NAME] 1, [NAME] 1 stated she did not put corn in the corn coleslaw. [NAME] 1 stated some ingredients were not in house for the recipes. During a review of the facility's Resident Council Minutes (RCM), RCM, dated 5/29/24, the RCM indicated, Old business: Portion size, food preference. During a review of the facility's RCM, dated 6/24/24, the RCM indicated, Old business: Portion size, food preferences. Dietary: Food continuously coming out late. During a review of the facility's P&P titled, Menu Planning dated 2023, showed menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders, and to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus provide a variety of foods in adequate amounts each meal. 50409

Based on observation, interview and record review, the facility failed to meet professional standards of practice for four of eight sampled residents (Resident 8, 38, 2 and 57) when: 1. Registered Nurse (RN) 2 did not follow medication administration direction when she gave medication to Resident 8 without giving food. This failure had the potential to put Resident 8 at risk for stomach upset. 2. A small medication cup with one tablet was left on top of Resident 38's bedside table accessible to other residents. This failure had the potential for Resident 38 to not receive a prescribed medication and for other residents to have access to the medication. 3. Resident 2 and Resident 57's physician order for bed rails was not followed. This failure had the potential to put Resident 2 and Resident 57 at risk for injury which could lead to more serious health condition. Findings: 1. During a concurrent observation and interview on 8/14/24 at 7:28 a.m. in Station 1 (one)outside of room [ROOM NUMBER]. RN 2 prepared Resident 8's medication which included Metformin (brand name-used to treat high blood sugar) Oral Tablet to be given with food. RN 2 administered medication to Resident 8 with water and did not give food as indicated in the medication direction. RN 2 stated she administered the medication to Resident 8 without food as indicated in the medication direction. RN 2 stated the medication could irritate Resident 8's stomach and cause upset stomach which could lead to serious health condition if done repeatedly. During a review of Resident 8's Admission Record, dated 8/16/24, the admission record indicated, Resident 8 was admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs) and diabetes (high blood sugar in the blood). During a review or Resident 8's Order Summary Report [OSR], dated 8/16/24, the OSR indicated, . metFORMIN HCl [hydrochloride] Tablet 1000 MG[milligram-unit of measurement] . Give with food . During an interview on 8/16/24 at 10:15 a.m. with the Director of Staff Development (DSD), the DSD stated it was important to follow medication direction. DSD stated the medication should have been given with meals, snacks or any food. The DSD stated not giving medication with food to Resident 8 could cause nausea and stomach upset. During an interview on 8/16/24 at 1:47 p.m. with the Director of Nursing (DON), the DON stated Resident 8's metformin medication should have been given with meal to prevent stomach upset or nausea or RN 2 should have made sure Resident 8 was assisted to eat immediately after she administered the medication. The DON stated she could have given Resident 8 apple sauce to make sure Resident 8's stomach was not empty when medication was administered. According to Lexicomp, a nationally recognized drug reference, . All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away: Stomach pain or heartburn. Gas. Diarrhea, upset stomach, or throwing up. Feeling tired or weak. Headache . Use this drug as ordered by your doctor. Read all information given to you. Follow all instructions closely . Take with meals . 2. During an observation on 8/12/24 at 9:20 a.m. in Resident 38's room, Resident 38 was lying in bed with eyes closed. There was a 30 ml (milliliter-unit of measurement) medicine cup with one round yellowish tablet on top of the bedside. The medication cup was available and accessible for other residents to take. During a review of Resident 38's Admission Record, dated 8/16/24, the Admission Record indicated, Resident 38 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing) and muscle weakness. During an interview on 8/12/24 at 9:25 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated he was the CNA for Resident 38. CNA 1 stated the medication cup with one tablet was for Resident 38 but he did not know why it was left on top of the bedside table. CNA 1 stated other residents goes in and out of other residents room and they could take the medicine and drink it themselves. During an interview on 8/12/24 at 9:40 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated he was the night nurse of Resident 38. LVN 2 stated the medication was a multivitamin for Resident 38. LVN 2 stated Resident 38 was awake when he left the medication cup on top of the bedside table. LVN 2 stated he should have went back to make sure Resident 38 took the medication. LVN 2 stated it was never a nursing practice to leave any type of medications at bedside table unattended. LVN 2 stated other residents could have gone in Resident 38's room and took the medication. LVN 2 stated if taken by other residents, it could potentially cause allergic reaction. During an interview on 8/16/24 at 2:05 p.m. with the Director of Nursing (DON), the DON stated it was never acceptable to leave medication on top of bedside table because other residents can go in the room, grab the medication cup with the medication and take it themselves which could potentially cause allergic reactions. The DON stated the practice was for licensed nurses to make sure resident swallowed medications before leaving resident's bedside and moved to another resident. During a review of facility's policy and procedure (P&P) titled, Medication Administration-General Guideline, undated, the P&P indicated, . Medications are administered only by licensed nursing . Medications are administered at the time they are prepared . The resident is always observed after administration to ensure that the dose was completely ingested . 3. During initial tour and observation on 8/12/24 at 9:08 a.m. in Resident 2's room, Resident 2 was lying in bed eating breakfast from food laid on top of the overbed table across the bed. Resident 2's bed had one half bed rails on both sides of bed and bed rails did not have any padding. During a review of Resident 2's Admission Record, dated 8/16/24, the Admission Record indicated Resident 2 was readmitted to the facility on [DATE] with diagnoses which included convulsions (a medical condition that causes a person's muscles to contract and relax rapidly and repeatedly, resulting in uncontrolled shaking), anemia (blood does not have enough healthy red blood) and falls. During a review of Resident 2's Order Summary Report, dated 8/16/24, the Order Summary Report indicated, . Half side rails with padding [protective cushion] X2 (times) for bed mobility and seizure . order date 1/17/21 . During a concurrent observation and interview on 8/12/24 at 9:05 a.m. with certified Nursing Assistant (CNA) 8, CNA 8 stated Resident 2 did not have padded bed rails. CNA 8 stated Resident 2 used to have padded bed rails but recently did not have the padding on her bed rails and was using pillows to pad Resident 2's bed rails. CNA 8 stated she was not sure when Resident 2's bed rails padding was no longer used. During a concurrent observation, interview and record review on 8/2/24 with Licensed Vocational Nurse (LVN) 1, LVN 1 reviewed Resident 2's bed rails order and stated Resident 2's bed rails order was 1/2 (one half) rails on both side of bed with padding. LVN 1 Observed Resident 2's bed rails at bed side and stated Resident 2's bed rails did not have padding. LVN 1 stated Resident 2 needed her bed rails padded because of safety issues. LVN 1 stated Resident 2 could potentially injure herself like hitting her head against the bed rails or put her arms and legs through the bed rails when having seizure episodes. During an interview on 8/16/24 at 2:20 p.m. with the Director of Nursing (DON), the DON stated her expectation was for the bed rails order was followed. DON stated the staff should have made sure Resident 2's bed rails were padded because Resident 2 was diagnosed with seizure. DON stated Resident 2 could potentially sustain injuries hitting her head on the bed rails when having seizure episodes. During initial tour and observation on 8/12/24 at 9:50 a.m. in Resident 57's room, Resident 57 was observed lying in bed with eyes closed and did not answer any questions asked. Resident 57's bed was observed with whole bed rails on both sides of the bed and one bed rail had padding applied. During a review of Resident 57's Admission Record, dated 8/15/24, the Admission Record indicated, Resident 57 was admitted to the facility on [DATE] with diagnoses which included Transient Ischemic Attack (TIA- stroke), hypertension (high blood pressure) and history of falling. During a review of Resident 57's Order Summary Report, dated 8/15/24, the Order Summary Report indicated, . Half side rails X2 (times) when in bed for bed mobility per RP (responsible party) request . During an interview on 8/14/24 at 10:05 a.m. with Certified Nursing Assistant (CNA) 11, CNA 11 stated he was familiar with Resident 65's care. CNA 11 stated he was aware Resident 65's bed had full bed rails on with padding on one side. CNA 11 stated he did not know Resident 65 supposed to have 1/2 (one half) bed rails on each side of bed only. CNA 11 stated he did not remember any of the licensed nurses mentioned Resident 65 to have 1/2 rails only. During a concurrent observation, interview and record review on 8/15/24 at 9:45 a.m. with LVN 3, LVN 3 reviewed Resident 65's order for bed rails. LVN 3 stated Resident 65 has an order for 1/2 rails and no padding. LVN 3 observed Resident 65's bed at bedside and stated, . Resident's bed with full bed rails, her order is only for 1/2 rails . LVN 3 stated the Physician order was not being followed. LVN 3 stated it was a safety issue and did not want to answer any more questions because she was not familiar with Resident 65. During a concurrent interview and record review on 8/16/24 at 2:30p.m. with DON, the DON stated Resident 65 was under hospice care (specialized care that provides physical comfort and emotional, social, and spiritual support for people nearing the end of life). DON stated hospice company provided Resident 65 her bed including the bedrails. DON reviewed Resident 65's bed rails order and stated the physician order for bed rails was not followed. During a review of facility's policy and procedure (P&P) titled, Proper use of Side Rails, dated 1/18, the &P indicated, . The purpose of these guidelines are to ensure the safe use of side rails as restraints unless necessary to treat a resident's medical condition . Review of professional reference https://www.fda.gov/medical-devices/hospital-beds/guide-bed-safety-bed-rails-hospitals-nursing-homes-and-home-health-care-facts . Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient ' s health care team will help to determine how best to keep the patient safe .

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that meets resident preferences for one of seven residents (Resident 66) when Resident 66's preference to be cared for by female staff was not care planned. This failure had the potential to cause male staff members to unknowingly enter Resident 66's room to provide care. Findings: During a review of Resident 66's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/15/24, the AR indicated Resident 66 was admitted on [DATE] with the following diagnoses: heart failure (condition which makes it difficult for the heart to pump blood to the rest of the body), atrial fibrillation (heart condition characterized by an irregular and often times fast heart beat) and major depressive disorder (mental condition characterized by long bouts of sadness). During an interview on 8/15/23 at 9:55 a.m. with certified nursing assistant (CNA) 2, CNA 2 stated Resident 66 only wanted female staff taking care of her. CNA 2 stated Resident 66 did not like any male staff members entering her room or providing care to her. CNA 2 stated nurses gave verbal communication to male staff to not enter the room, but there was not any written documentation stating her preference. CNA 2 stated Resident 66 should have had her preferences documented in her care plan because nurses may forget to communicate to new male staff members here preferences. CNA 2 stated if a new male staff member entered Resident 66's room, it would have made her upset. During an interview on 8/15/24 at 10:33 a.m. with CNA 3, CNA 3 stated Resident 66 did not like male staff members taking care of her. CNA 3 stated nurses have been the ones communicating to staff about Resident 66's preference for female staff. CNA 3 stated Resident 66's preference was not documented anywhere. CNA 3 stated Resident66's preference for female staff should have been in her care plan to better communicate the information to all staff. CNA 3 stated it was important to follow Resident 66's preference to ensure she felt comfortable and safe. During an interview on 8/15/24 at 1:24 p.m. with CNA 11, CNA 11 stated care plans were important in order for all staff to know what a resident's specific preferences were. CNA 11 stated a resident's preference for female staff should have been included in the care, so all staff were made aware. During a concurrent interview and record review on 8/15/24 at 2:35 p.m. with registered nurse (RN) 1, Resident 66's care plan, undated, was reviewed. The care plan did not have Resident 66's preference to be cared for by female staff included. RN 2 stated Resident 66 did not have a care plan implemented for her preference and there were no interventions included anywhere to provide female only staff for her care. RN 2 stated it was important to appropriately care plan Resident 66's preferences because it helped ensure all staff were aware of who can and can't enter her room. During a concurrent interview and record review on 8/15/24 at 2:35 p.m. with the minimum data set coordinator (MDSC), Resident 66's care plan, undated, was reviewed. The care plan did not have Resident 66's preference to be cared for by female staff included. The MDSC stated Resident 66's preferences should have been developed and implemented in a care plan. The MDSC stated it was important to develop a care plan for Resident 66's preference so she could have felt safe and comfortable. During an interview on 8/16/24 at 10:40 a.m. with the director of nursing (DON) the DON stated Resident 66 did not like male staff members giving her showers or doing brief changes. The DON stated Resident 66 should have had a care plan developed for her preferences so all staff members could have been made aware of her preference and what interventions to take. During a review of the facility's Licensed Vocational Nurse (LVN) job description, dated 10/19/15, the job description indicated, The LVN contributes to nursing assessment and care planning . Responsibilities/Accountabilities . care planning: 2.1 contributes to establishing individualized patient goals; 2.2 Assists in developing interventions to achieve goals; 2.3. Implements the plan of care . During a review of the facility's Registered Nurse job description, dated 10/23/15, the job description indicated, . Responsibilities/Accountabilities . 2) Writing and initiating plan of care . 3) Reguarly re-evaluating patient . needs .4) Participating in revising the plan of care as necessary .2. Develops a care plan that establishes goals, based on nursing diagnosis . During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 1/18, indicated . A comprehensive, person -centered care plan that includes measurable objectives . is developed and implemented for each resident. 7. The care planning process will: . c. incorporate the resident's personal and cultural preferences in developing the goals of care. 8. The comprehensive, person-centered care plan will: . f. include the resident's stated preference J. reflect the resident's expressed wishes regarding care and treatment goals .

Based on interview, and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status of four of nine sampled residents (Residents' 14, 29, 34 and 38) when Resident 14, Resident 29, Resident 34 and Resident 38's smoking habits was inaccurately coded on the MDS assessment. This failure had the potential to result in Residents' 14, 29, 34 and 38's care needs not met. Findings: During a review of Resident 14's Admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information) dated 8/16/24, the AR indicated, Resident 14 was admitted to the facility on [DATE] with diagnoses which included pain, diabetes (high blood sugar in the blood) and abnormalities of gait and mobility. During a review of Resident 14's Smoking - Safety Screen dated 7/19/24, the Smoking-Safety Screen indicated, Resident 14 smoked 2-5 cigarettes per day. During a concurrent interview and record review on 8/16/24 at 8:50 a.m. with Minimum Data Set Nurse (MDSN), MDSN stated Resident 14 was a smoker. MDSN reviewed Resident 14's smoking assessment dated [DATE], which indicated Resident 14 was safe to smoke with supervision. MDSN reviewed Resident14's annual MDS assessment dated [DATE], section J. Resident 14's tobacco use was not coded on the annual MDS assessment. MDSN stated Resident 14 should have been coded as a smoker. During a review of Resident 29's AR dated 8/16/24, the AR indicated, Resident 29 was admitted to the facility on [DATE] with diagnoses which included hyperlipidemia (high cholesterol-excess fats in the blood) and diabetes (high sugar level in the blood). During a review of Resident 29's Smoking - Safety Screen dated 5/15/24, the Smoking-Safety Screen indicated, Resident 29 smoked 2-5 cigarettes per day. During a concurrent interview and record review on 8/16/24 at 9 a.m. with Minimum Data Set Nurse (MDSN), MDSN stated Resident 29 was a smoker. MDSN reviewed Resident 9's smoking assessment dated [DATE], which indicated Resident 29 was safe to smoke with supervision. MDSN reviewed Resident 14's annual MDS assessment dated [DATE], section J. Resident 29's tobacco use was not coded on the annual MDS assessment. MDSN stated Resident 29 should have been coded as a smoker. During an interview on 8/12/24 at 11:50 a.m. in Resident 34's room, Resident 34 stated she smoked and they have a smoking schedule they follow. Resident 34 stated she goes out in the patio to smoke with other resident who smokes. Resident 34 stated there is always a staff outside to supervised. During a review of Resident 34's AR dated 8/16/24, the AR indicated, Resident 34 was admitted to the facility on [DATE] with diagnoses which included muscle weakness and asthma (a chronic (long-term) condition that affects the airways in the lungs). During a review of Resident 34's Smoking - Safety Screen dated 7/17/24, the Smoking-Safety Screen indicated, Resident 34 smoked 2-5 cigarettes per day. During a concurrent interview and record review on 8/16/24 at 8:42 a.m. with Minimum Data Set Nurse (MDSN), MDSN stated Resident 34 was a smoker. MDSN reviewed Resident 34's smoking assessment dated [DATE], which indicated Resident 34 was safe to smoke with supervision. MDSN reviewed Resident 34's annual MDS assessment dated [DATE], section J. Resident 34's tobacco use was not coded on the annual MDS assessment. MDSN stated Resident 34 should have been coded as a smoker. During an interview on 8/12/24 at 11:05 a.m. in Resident 38's room, Resident 38 stated he smokes and had been smoking since admitted to the facility. Resident 38 stated there was always a staff outside with the group during scheduled smoking. During a review of Resident 38's AR dated 8/16/24, the AR indicated, Resident 38 was admitted to the facility on [DATE] with diagnoses which included hyperlipidemia (high cholesterol-excess fats in the blood) and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body). During a review of Resident 38's Smoking - Safety Screen dated 7/15/24, the Smoking-Safety Screen indicated, Resident 38 smoked 2-5 cigarettes per day. During a concurrent interview and record review on 8/16/24 at 8:45 a.m. with Minimum Data Set Nurse (MDSN), MDSN stated Resident 38 was a smoker. MDSN reviewed Resident 38's smoking assessment dated [DATE], which indicated Resident 38 needs to be supervised to smoke. MDSN reviewed Resident 38's annual MDS assessment dated [DATE], section J. Resident 38's tobacco use was not coded on the annual MDS assessment. MDSN stated Resident 38 should have been coded as a smoker. The MDSN stated she followed RAI manual to complete her assessment. During an interview on 8/16/24 at 11:29 a.m. with the Activity Assistant (AA), the AA stated she takes residents out in the patio daily to smoke on the scheduled times. The AA stated she did not keep a log of who goes out to smoke. The AA stated all nine smokers on the list goes out everyday to smoke. The AA stated she supervised the whole time residents are out in the patio smoking. During an interview on 8/16/24 at 2:42 p.m. with the Director of Nursing (DON), the DON stated her expectation was accurate assessment on all MDS assessment. The DON stated inaccurate assssment is considered falsification of records. During an interview on 8/16/24 at 3:20 p.m with the Administrator (ADM), the ADM stated, . my expectation was to not make any mistakes, but in reality it is not possible . The ADM stated it was important for MDS assessment to be accurately captured. During a review of facility's policy and procedure (P&P) titled, Certifying Accuracy of the Resident Assessment, dated 1/18, the P&P indicated, . Any person who completes any portion of the MDS assessment, tracking form, or correction request for is required to sign the assessment certifying the accuracy of that portion of that assessment During a review of professional reference titled, Resident Assessment Instrument version #.0 Manual, dated 10/23, indicated, . Tobacco use includes tobacco used in any form . If the resident states he or she used tobacco in some form during the 7-day look back period code 1, yes . If the resident is unable to answer or indicates that he or she did not use tobacco of any kind during the look back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look back period .

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for three of nine sampled residents (Resident 20, Resident 24 and Resident 40) when: 1. Registered Nurse (RN) 2 administered medication to Resident 20 in the hallway. 2. RN 1 administered medication to Resident 24 and did not provide privacy. 3. Licensed Vocational Nurse (LVN) 1 administered medications to Resident 40 and did not provide privacy. These failures resulted in Resident 20, Resident 24 and Resident 40 not being provided with respect and dignity while taking their medications. Findings: During a observation on 8/14/24 at 8:35 a.m. in Station one hallway during medication pass, Resident 20 was sitting up in his wheelchair. RN 2 prepared Resident 20's medications. RN 2 administered Resident 20's medications in the hallway with other residents, staff and visitors walking by. During a review of Resident 20's Admission Record, dated 8/16/24, the Admission Record indicated, Resident 20 was readmitted to the facility on [DATE] with diagnoses which included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), lack of coordination and history of traumatic brain injury. During a review of Resident 20's Minimum Data Set (MDS- an assessment tool used to identify resident cognitive[pertaining to reasoning, memory and judgement] and physical functional level), assessment dated [DATE], indicated Resident 20's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 5 had no cognitive deficit. During a concurrent observation and interview on 14/24 at 2:50 p.m. with RN 2, RN 2 stated she administered Resident 20's medications in the hallway. RN 2 stated she should not have administered Resident 20's medications in the hallway. RN 2 stated, . I should have explained to Resident 20 the importance of providing privacy and to go back in his room . RN 2 stated it was important to provided privacy because it was one of their rights. During an interview on 8/15/24, at 9:35 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the practice was to provide privacy when administering medications to residents. LVN 3 stated residents are not to be given their medications in the hallway unless it was an emergency situation. LVN 3 stated other residents, staff and visitors passing by did not need to know what was going on, providing privacy is one of resident rights. 2. During a concurrent observation and interview on 8/14/24 at 11:47 a.m. in Station one hallway, RN 1 prepared Resident 24's medication. RN 1 administered Resident 24's aspart (brand name- medication used to treat high blood sugar in the blood) injection to Resident 24's abdominal area. RN 1 did not provide privacy by closing the door or closing the privacy curtain to Resident 24 while she exposed Resident 24's abdominal area. RN 1 stated she should have provided privacy to Resident 24 but she did not. RN 1 stated residents have rights to have their privacy. During a review of Resident 24's Admission Record, dated 8/16/24, the Admission Record indicated, Resident 24 was readmitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar in the blood) and hemiplegia (complete paralysis) and hemiparesis (partial weakness). During a review of Resident 24's MDS assessment dated [DATE], indicated Resident 24's BIMS assessment score was 13 out of 15 indicating Resident 24 had no cognitive deficit. During an interview on 8/15/24 at 9: 37 a.m. with LVN 3, LVN 3 stated it was important to provide privacy to residents when administering medications. LVN 3 stated, . Residents should always be given privacy when taking their medications . 3. During a concurrent observation and interview on 8/14/24 at 4:05 p.m. in Station 2 hallway, LVN 1 prepared Resident 40's medications. LVN 1 administered Resident 40's medication in Resident 40's room but did not provide privacy by closing the privacy curtain or the door. LVN 1 stated she did not closed the privacy curtain between bed A and bed B. LVN 1 stated she did not closed the door to the hallway and exposed Resident 40 for other residents, staff and visitors walking by. LVN 1 stated she administered medication to Resident 40 without privacy. During a review of Resident 40's Admission Record, dated 8/16/24, the Admission Record indicated, Resident 40 was readmitted to the facility on [DATE] with diagnoses which included heart failure, hyperlipidemia (high cholesterol) and hearing loss. During a review of Resident 40's MDS assessment dated [DATE], indicated Resident 40's BIMS assessment score was 13 out of 15 indicating Resident 40 had no cognitive deficit. During an interview on 8/16/24 at 2:13 p.m. with the Director of Nursing (DON), the DON stated her expectations from licensed nurses during medication administration was to give respect and privacy to residents by closing the privacy curtain and offer to take residents in their room to administer medications. The DON stated there were other residents, staff and visitors walking by in the hallway and could see residents taking their medications. The DON stated, . Residents have rights and one of them was to ensure privacy was provided at all times . During a review of facility's policy and procedure (P&P) titled, Resident Rights, dated 1/18, the P&P indicated, .be treated with respect, kindness, and dignity . be supported by the facility in exercising his or her rights . During a review of facility's P&P titled, Specific procedures for all medications, undated, the P&P indicated, . To administer medications in a safe and effective manner . Provide privacy for residents if appropriate .

Based observation, interview, and record review the facility failed to ensure four of fourteen residents (Residents 8, 30, 57 and 65) were provided their right to be treated with respect and dignity when: 1. Resident 30's back was not covered after being transported out of the shower room. This failure resulted in Resident 30 having his back exposed while being transported out of the shower room, down the hall, and into his room. 2. Certified Nursing Assistant (CNA) 11 stood over Resident 8 while spoon feeding him breakfast while lying in bed. This failure resulted in Resident 8 not being provided a respectful and dignified dining experience which could further enhance resident's quality of life. 3. Resident 57 was lying flat in bed eating lunch but unable to see food placed on top of the overbed table positioned in front of her. This failure placed Resident 57 at risk for aspiration and choking which could lead to more serious health condition. 4. Resident 65's urinary catheter (flexible tube inserted into bladderto drain urine) bag was not covered and was visible to residents and visitors to see. This failure had the potential to violate Resident 65's privacy and dignity. Findings: 1. During a review of Resident 30's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/15/24, the AR indicated Resident 30 was admitted with the following diagnoses: cerebrovascular disorder (term used to describe a group of conditions which affect blood flow to the brain) , dysphagia (difficulty swallowing), and anxiety disorder (condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 30's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 5/26/24, the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of nine (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 10 had moderate cognitive impairment. During an observation on 8/12/24 at 9:18 a.m. next to the shower room, Resident 30's back was not covered after being transported out of the shower room by certified nursing assistant (CNA) 4. During an interview on 8/12/24 at 4:15 p.m. with CNA 4, CNA 4 stated CNAs were responsible for ensuring all areas of a resident's body were covered after coming out of the shower room. CNA 4 stated Resident 30 should not have had his back exposed, he should have been fully covered. CNA 4 stated it was important to cover a resident's whole body because it provided privacy. During an interview on 8/15/24 at 10:03 a.m. with CNA 2, CNA 2 stated staff were supposed to cover the body of any resident who comes out of the shower. CNA 2 stated the shower blanket should have covered the whole body because they provided privacy and dignity to the resident. During an interview on 8/15/24 at 1:59 p.m. with registered nurse (RN) 1, RN 1 stated CNAs were responsible for doing resident showers. RN 1 stated CNA 1 should have covered Resident 30 with a shower blanket. RN 1 stated if the shower blanket was too small, the CNA could have also used a second blanket or a gown to cover Resident 30's back. RN 1 stated Resident 30 should have been fully covered because he had a right to be provided privacy and dignity. During an interview on 8/16/24 at 9:12 a.m. with the director of staff development (DSD), the DSD stated CNAs needed to fully cover residents after coming out of the shower. The DSD stated if one blanket wasn't enough to fully cover the resident, then an additional blanket could have been used. The DSD stated it was important to fully cover residents after they exited the showers because residents have the right to be provided privacy. During an interview on 8/16/24 at 10:40 a.m. with the director of nursing (DON), the DON stated residents needed to be covered after staff took them out of the shower room. The DON stated ensuring proper coverage of the body after the shower was important because it provided dignity to residents. During a review of the facility's policy and procedure (P&P) titled, Quality of Life-Dignity, dated 1/18, indicated, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . 1. Residents shall be treated with dignity and respect at all times. 2. 'Treated with dignity' means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . During a review of the facility's (P&P) titled, Resident Rights, dated 1/18, indicated, .Employees shall treat residents with kindness, respect, and dignity . federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents rights to: a. a dignified existence b. be treated with respect, kindness, and dignity . 40641 2. During an observation on 8/14/24 at 8:42 a.m. in Resident 8's room, Resident 8 was lying in bed with head of the bed elevated and bed in highest position. Resident 8's bedside table on the side of the bed and CNA 11 was standing on the side of Resident 8's bed while spoon feeding him breakfast. During a review of Resident 8's Admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information) dated 8/16/24, the AR, indicated, Resident 8 was admitted to the facility with diagnoses which included quadriplegia (complete or severe loss of motor function in all four limbs) and dysphagia (difficulty swallowing). During an interview on 8/14/25 at 10:05 a.m. with CNA 11, he stated he assisted Resident 8 during breakfast. CNA 11 stated he was standing on the side of the bed while he was spoon- feeding Resident 8 because Resident 8's bed was high. CNA 11 stated, . I should have been sitting and lowered his [Resident 8] bed so we would have been face to face while I was spoon-feeding him [Resident 8] because it was a dignity issue . During an interview on 8/16/24 at 10 a.m. with the Director of Staff Development (DSD), she stated she was not sure whether staff should be sitting on a chair or standing next to resident's bed when assisting residents during meals. DSD stated she had seen staff pull a chair next to resident's bed and some staff preferred standing while spoon-feeding residents. During an interview on 8/16/24 at 10:45 a.m. with CNA 7, she stated the practice was to lower resident's bed, elevate the head of the bed and sit next to the resident. CNA 7 stated the bed should be positioned at eye level with resident when assisting residents with meals in bed. CNA 7 stated it was a dignity issue standing over residents while assisting during meals. During review of facility's policy and procedure (P&P) titled, Quality of Life- Dignity, dated 1/18, the P&P indicated, . Residents shall be treate with dignity and respect at all times . resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . 3. During a concurrent observation and interview on 8/12/24 at 1:10 p.m. in Resident 57's room, Resident 57 was lying flat in bed touching and picking on food from the food tray she could not see. Resident 57's food tray was placed on the overhead bed table higher than Resident 57's visual field. Resident 57 stated she did not need help. During a review of Resident 57's AR, dated 8/15/24 the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses which included Transient Cerebral Ischemic Attack (TIA-stroke) and dementia (loss of mental skills that affects daily life). During an interview on 8/12/24 at 1:12 p.m. with CNA 6 in Resident 57's room, CNA 6 stated she tried to straightened Resident 57 to sit up during meals and tried to assist her but Resident 57 refused. CNA 6 stated Resident 57 was at risk for aspiration (inhaling food or liquid through the vocal cords into the airway) and choking because she was lying flat in bed and it was also a dignity issue. During interview on 8/15/24 at 9:20 a.m. with CNA 2, she stated she was familiar with Resident 57's care. CNA 2 stated she tried to help Resident 57 during meals and sometimes Resident 57 refused assistance. CNA 2 stated she made sure Resident 57's head of the bed was elevated. CNA 2 stated Resident 57 lying flat in bed when eating puts her at high risk for aspiration and choking. During an interview on 8/16/24 at 10:05 a.m. with the DSD, she stated when residents are eating in bed, residents are to be pulled all the way to the head of the bed and elevated to preventthe resident from sliding. The DSD stated residents lying flat in bed while eating puts them at risk for aspiration and choking. During an interview on 8/16/24 at 2:10 p.m. with the Director of Nursing (DON), she stated her expectation was for residents to be sitting up and positioned at 90 degree angle to prevent aspiration and choking. The DON stated the staff should have checked Resident 57 constantly when she refused assistance to make sure she was not lying flat in bed. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 1/18, the P&P indicated, .Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include . a. a dignified existence; b. be treated with respect, kindness, and dignity . 4. During an observation on 8/14/24 at 8:40 a.m. in Resident 65's room, Resident 65 was lying in bed with head of bed slightly elevated. Resident 65's urinary catheter bag hanging on the side of the bed uncovered. During a review of Resident 65's AR, dated 8/16/24, the AR indicated, Resident 65 was admitted to the facility on [DATE] with diagnoses which included contracture and muscle wasting and atrophy (decreased in size or wasting away of a body part). During an interview on 8/14/24 at 8:45 a.m. with Rehabilitative Nursing Assistant (RNA) and CNA 2, they both stated the urinary catheter bag should have been covered with privacy bag but it was not. RNA and CNA 2 stated it was a dignity issue, other residents and visitors walking by could see the urinary catheter bag. During an interview on 8/14/24 at 8:50 a.m. with Registered Nurse (RN) 2, she stated she did not noticed the urinary catheter bag was not covered with a privacy bag. RN 2 stated urinary catheter bag should be covered with privacy bag at all times because it was a dignity issue. RN 2 stated, . We do not want other residents and visitors walking by to see what was draining out of resident . RN 2 stated residents needs their privacy respected. During an interview on 8/16/24 at 9:25 a.m. with the Infection Preventionist (IP), the IP stated, . Urinary catheter bags should be covered at all times with privacy bag because it was a dignity issue . The IP stated nursing staff should have been checking residents with foley catheter to ensure urinary catheter bags was covered with privacy bag. The IP stated it was also her responsibility to ensure all foley catheter bags are covered with privacy bag. During an interview on 8/16/24 at 2:15 p.m. with the DON, the DON stated her expectation was for all urinary catheter bags to be fully covered with privacy bag whether resident were lying in bed or up in their wheelchair. DON stated it was a dignity issue and visitors and other resident could see the exposed bag while walking by. During a review of facility document titled, Inservice Lesson Plan (ILP) undated, the ILP indicated, . All the catheter bags should be covered with the blue privacy bags all the time, inform charge nurse immediately .` During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 1/18, the P&P indicated, .Federal and state laws guarantee certain basic rights to all residents of the facility. These rights include . a. a dignified existence; b. be treated with respect, kindness, and dignity . privacy and confidentiality . During a review of the facility's P&P titled, Quality of Life - Dignity, dated 1/18, the P&P indicated , . Staff shall promote dignity and assist residents as needed by: a. Helping the rsident to keep urinary catheter bags covered .

Based on observation, interview and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1) when Resident 1 who was at risk for elopement (define) left the facility. Staff disarmed the door alarm and Resident 1 left the facility before the door alarm was reactivated on 9/12/19. As a result of this failure Resident 1 was not found for 4 days until 9/15/19. Resident 1 during this time wandered about outdoors in temperatures ranging from 82 -101 degrees Fahrenheit. Resident 1 was found outside near a homeless encampment and his physical appearance was visibly dirty and his clothes soiled in his own urine and feces. he was diagnosed with [REDACTED]. Resident 1 was admitted to the GACH for higher level of care. As of 11/19/19, Resident 1 remained in the hospital as an inpatient. Findings: During a review of the clinical record for Resident 1, the Admission Record (record containing resident personal information) undated, indicated Resident 1 was a [AGE] year-old admitted to the SNF on 8/2/19, with [DIAGNOSES REDACTED]. Resident 1's Brief Interview of Mental status assessment (BIMS - screening tool used in nursing home to assess cognition) dated 8/30/19 indicated Resident 1 scored 10 of 15 points which indicated Resident 1 was moderately impaired with cognitive skills for daily decision making. During an interview with the Director of Nursing (DON), on 9/13/19, at 10:01 a.m., the DON stated she learned Resident 1 was missing at approximately 8 a.m. on 9/12/19. The DON stated staff immediately started searching for Resident 1 in all rooms, bathrooms and the outside premises of the facility. The DON stated staff was not able to locate Resident 1 in or out of the facility. The DON stated the Social Service Director (SSD) went to a local nearby homeless shelter and Resident 1 was not there. The Administrator (ADM) on 9/12/19 searched the neighborhood near the facility and could not locate Resident 1. The DON stated the search for Resident 1 lasted until 10:30 a.m., on 9/12/19 without success. The DON stated the Director of Staff Development (DSD) reported to the local police department on 9/12/19 of Resident 1's elopement and the unsuccessful search. The DON stated she viewed the facility video surveillance footage in the Administrator's office that showed Resident 1 had exited from the exit door by the Kitchen on 9/12/19. During an interview with the DON, on 9/13/19, at 10:01 a.m., the DON explained how Resident 1 left the building. The DON stated the exit door to the outside near the kitchen was equipped with an alarm that does not respond to the wander guard (a tracking application designed to prevent person at risk from leaving a facility unaccompanied) alarm placed on Resident 1. The alarm on the exit door to the outside requires staff to set the alarm to an on position. Once the exit door has been set to arm the door has a delay of 15 seconds before the alarm was armed. The DON stated the dietary aide (DA) 1 who was working in the kitchen on 9/12/19 had disarmed the exit door to take out trash and saw Resident in the kitchen hallway near the exit door. Once the DA 1 had completed the task of taking out the trash, DA 1 armed the exit door and returned to the kitchen. The DON stated Resident 1 remained in the kitchen hallway near the exit door and left the building prior to the 15-second alarm delay was completed to re-arm the exit door. The DON stated the facility video surveillance recording of the hallway and exit door used by DA 1 and Resident 1 showed DA 1 speaking to Resident 1 and DA 1 going back into the kitchen behind closed doors. The DA 1 did not see Resident 1 leave the building. During a concurrent interview and record review with the DON, on 9/13/19, at 10:15 a.m., the DON stated they had an elopement binder in each nurses' station. The DON reviewed the elopement binder which contained the photos of each resident who was in the facility. The elopement binder contained resident face sheet, and the elopement policy and procedure which indicated, .Process 1. Staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .and Missing Resident Procedure Form and Mechanical Alarm System policy . During a review of the clinical record for Resident 1, the physician's orders [REDACTED]. During a review of the clinical record for Resident 1, the nurses note titled Weekly Summary dated 8/19/19, at 7:07 a.m., indicated, (Resident 1) . At risk for elopement .apply wander guard due to resident (1) at risk for elopement . During a concurrent record review, interview with the DON, and on a speaker phone, a telephone interview with Licensed Nurse (LN) 1, on 9/13/19, at 4:30 p.m., LN 1 stated she received the physician order [REDACTED]. LN 1 stated she applied the wander guard bracelet alarm on Resident 1's ankle on the same day the physician's orders [REDACTED]. LN 1 stated she forgot to perform the elopement risk assessment after obtaining the wander guard bracelet physician's orders [REDACTED]. The LN 1 stated she should had performed the elopement assessment after she had witnessed Resident 1's exit seeking behavior on 8/17/19. During a concurrent interview and record review, on 9/13/19, at 5 p.m., with the DON, the DON reviewed Resident 1's Elopement Risk Assessment, dated 8/24/19 which indicated Resident 1's elopement risk score was 6 which meant Resident 1 was identified as having a moderate risk for elopement. During a concurrent interview and record review, on 9/13/19, at 5 p.m., with the DON, the DON reviewed Resident's 1's elopement care plan, dated 8/18/19 which indicated, (Resident 1) . At risk for Elopement . (Resident 1 was) Disoriented to place. Resident (1) wanders aimlessly . Interventions .Redirect resident . During a concurrent interview and record review, on 9/13/19, at 5:20 p.m., with the DON, the DON reviewed Resident 1's elopement care plan, dated 8/27/19 which indicated, Focus: Resident (1) exhibits the following behavior excessive pacing without any reason .Interventions: Document resident (1's) behavior on the monitoring in Medication Administration Record [REDACTED]. Redirect (Resident 1's wandering behavior) . Remove resident (1) from stimulus . During an interview with Certified Nursing Assistant (CNA) 1, on 9/13/19, at 12 p.m., CNA 1 stated she was assigned to care for Resident 1 on 9/12/19 prior to his elopement. CNA 1 stated on 9/12/19 at approximately 7 a.m., she assisted Resident 1 with his dressing needs before she left him in his room and went out to other areas of the facility to distribute breakfast trays to other residents. She stated at approximately 7:30 a.m., she went and checked on Resident 1 and he was not in his room. CNA 1 went searching for him throughout the facility and was unable to find him. CNA 1 reported to Resident 1's nurse that he was missing. CNA 1 stated after reporting to the nurse, she then called a code 10 (code for missing resident). She stated all staff except the charge nurse and 1 to 2 CNAs conducted a search of the facility for Resident 1. CNA 1 stated she was told Resident 1 was seen on the surveillance video leaving out the exit door by the kitchen at approximately 7:30 a.m., on 9/12/19. During an interview with the DSD, on 9/13/19, at 12:13 p.m., the DSD stated she was the nurse for Resident 1 on 9/12/19. The DSD stated she was at Station 2 at around 7:45 a.m., receiving exchange of shift report from the night shift charge nurse. The DSD stated she heard the announcement of Code 10 and directed staff to start searching for Resident 1. The DSD stated staff searched the front and back parking lot and immediate neighborhood surrounding the facility and were unable find Resident 1. The DSD stated she called the police department and reported Resident 1 was missing. The DSD stated the last time she saw Resident 1 was around 7 a.m. and he was wearing a hospital gown and holding his water pitcher in the hallway. The DSD stated another LN asked him to go back to his room to change into his clothes and the LN assisted him to his room. During a concurrent observation and interview with DA 1, on 9/13/19, at 1:56 p.m., DA 1 explained his work assignment at the time of Resident 1's elopement. DA 1 demonstrated turning off the alarm from the exit door near the kitchen and then taking boxes outside and re-entering the facility and turning on the alarm. DA 1 stated he remembered Resident 1 came near him by the exit door the day Resident 1 went missing 9/12/19. The DA stated he re-directed Resident 1 to leave the area but Resident 1 remained in the kitchen hallway near the exit door. DA 1 stated he was not aware Resident 1 had exited from the un-armed exit door. DA 1 stated he was not aware Resident 1 was a risk for elopement. DA 1 stated he was not aware the facility had a binder with a list of residents that were identified as risk for elopement. During an interview with the ADM, on 9/13/19, at 2:53 p.m., the ADM stated she was not aware DA 1 and dietary staff did not know Resident 1 was a risk for elopement. During a concurrent observation and interview with Maintenance Supervisor (MS), on 9/13/19, at 2:40 p.m., the MS tested the wander guard alarms on exit doors and found the alarms were functional and working except for the kitchen hallway exit door. The MS stated all exit doors had wander guard alarms except the Northwest side of the building exit door next to the kitchen where Resident 1 exited. The MS stated the exit door next to the kitchen had a different alarm that staff could disarm and when staff would re-arm the alarm had a 15 seconds delay to where the door can be opened, and the alarm would not go off. During a concurrent observation, interview and review of the video surveillance recording (no audio) with the ADM, on 9/13/19 at 3:30 p.m., Resident 1 was observed coming into view and was standing in the kitchen hallway watching DA 1 carrying boxes toward the Northwest side exit door. The video showed DA 1 disarming the alarm to the exit door near the kitchen, open the door and placed the kitchen boxes outside the door. DA 1 walked back into the facility and reset the alarm, turned and looked at Resident (1) standing in the hallway. DA 1 appeared to tell Resident 1 to go over there pointing away from the door. The video surveillance showed that as soon as DA 1 walked into the kitchen, Resident 1 exited the door at 7:36 a.m., before the 15-second delay of the alarm was reactivated. During telephone interview with the ADM, on 9/16/19, at 12:56 p.m., the ADM stated a local hospital called the facility informing them that Resident 1 had been found and was in their hospital. During a review of Resident 1's hospital clinical record titled, Emergency Department Reports dated 9/19/19, indicated. (Resident 1 was admitted with) severe Altered Mental Status (AMS- confused and disoriented), Acute Kidney injury (AKI- condition in which the kidney suddenly can't filter waste from the blood) Uremia, [MEDICAL CONDITION] and dehydration (significant loss of body fluid that impairs normal body functions). Resident 1 noted to have hematemesis (vomiting of stomach contents mixed with blood) with coffee ground emesis (the presence of clotted blood within the vomit). The hospital Clinical Record indicated, Patient (Resident 1) dirty, feces and urine on clothes .right hip area with redness .Buttocks area with redness .Bedside glucose (blood sugar) 280 mg (milligrams)/dl (deciliter) (unit of measurement) .patient vomited approx. 100 ml (milliliter - unit of measurement) coffee ground/reddish emesis (vomit). The hospital Clinical Record indicated, Staff member from ( name) nursing home called and stating they were looking for this patient which went missing from their facility two days . ( prior on 9/12/19) . During a review of Resident 1's hospital clinical record titled, Discharge Summary dated 12/3/19, indicated .admitted [DATE], (through) 12/3/19 ( a total of 79 days' hospitalization ) .Patient . found by other homeless people, confused, soiled (with) urine and feces. The hospital Clinical Record indicated Resident 1 was admitted into CPCU (Cardiac (heart) Progressive Care Unit- unit that provides specialized care to patients requiring heart monitoring for various cardiovascular (heart) disorders) . During a review of the facility's policy and procedure titled, Elopement/Wandering Resident, dated 6/2017, indicated, Policy - the facility will strive to prevent unsafe wandering . for residents who are at risk for wandering .1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) . 2. The staff will assess at risk individuals for potentially correctible risk factors related to unsafe wandering . During a review of the facility's policy and procedure titled, Mechanical Alarm System, dated 6/2017, indicated, Policy- To provide an environment that is hazard free .control and supervision and assistive device are used to ensure that avoidable incident of accidents as a result of elopement .

Based on observation, interview, and record review, the facility failed to ensure freedom from neglect for one of three sampled residents, Resident 1, when Resident 1 was not provided with a bed, wheelchair, shower chair or sling (a hammock like cloth device to hold the resident during transfer using a mechanical lift) able to safely and comfortably accommodate her size. As a result of these failures, Resident 1 suffered emotional distress due to isolation from group dining and activities and was placed at risk for injury from improperly sized equipment. Findings: Review of Resident 1's clinical record titled, Admission Record (a record which contains resident personal information) indicated Resident 1 was [AGE] years old and was admitted to the Skilled Nursing Facility (SNF) on 10/5/17 from the General Acute Care Hospital (GACH) with [DIAGNOSES REDACTED]. high blood sugar levels), muscle weakness, and history of falling. Review of Resident 1's clinical record titled, Minimum Data Set (MDS, a resident assessment tool that is used to develop a plan of care), assessment Section F Preferences For Customary Routine and Activities (a guide to create an individualized plan of care based on the resident's activity preferences) dated 10/12/17, indicated the following activities were Very Important to Resident 1; listening to music, keeping up with the news, doing favorite activities, going outside to get fresh air when the weather is good, and participating in religious services and practices. The MDS assessment for activities indicated it was Somewhat important to Resident 1 to be around animals such as pets, and to do things with groups of people. Review of Resident 1's MDS assessment dated [DATE], indicated a Brief Interview for Mental Status (BIMS, a test for memory and recall) score of 15 points out of 15 possible points, which indicated Resident 1 was cognitively (pertaining to memory, judgement and reasoning ability) intact. Review of Resident 1's GACH clinical record titled, PT (Physical Therapy) Assessment - Inpatient dated 10/3/17, indicated, Pt (patient) with massive obesity and is now with PT (physical therapy) order for eval (evaluation) and tx (treatment) per (physician) .Patient will benefit from having appropriate equipment to properly care for her by nsg (nursing) staff including bariatric mech (mechanical) lift (provided to bedside with sling) and bariatric chair as patient is willing to be oob (out of bed) with lift .Equipment Recommendations: Mechanical lift and bariatric chair needed . On 5/18/18 at 12:30 p.m., during a concurrent observation and interview, Resident 1 was wearing a nasal cannula (tube into the nose) which supplied oxygen and sat on her bed with her legs spread out across both sides of the bed. Resident 1's body was larger and wider that the width of the bed could accommodate. Resident 1 stated she had been in the SNF since (MONTH) (YEAR) and had been in the same bed since admission. Resident 1 stated the bed was too small. Resident 1 stated, No, I am not comfortable in this bed. Resident 1 stated she was told by the facility Administrator (Adm) in (MONTH) (YEAR) that a bariatric bed (a large bed that can comfortably and safely accommodate an obese resident) would be ordered for her, but the bed never arrived. Resident 1 stated the facility did not provide a wheelchair that could accommodate her size and she would like to have one to attend activities and go outside. Resident 1 stated she felt deprived of activities because she had no wheelchair to get up and and attend the activities. Resident 1 stated, I have never been to the activities room and dining room. Resident 1 stated she did not have a shower chair that would accommodate her size upon admission to the SNF. Resident 1 stated her Family Member (FM) brought a shower chair from home on 5/7/18 so that she would be able to shower. Resident 1 stated the SNF used a sling and a mechanical lift to transfer her and to obtain her weight but there was no sling available to accommodate her size and weight. Resident 1 stated she did not want the staff to weigh her because she was fearful the sling was not big enough to safely accommodate her. On 5/18/18 at 1:35 p.m., during an interview, the facility Social Service Director (SSD) stated, There was a wheelchair in the facility but it was not the right size (for Resident 1) and it was returned to the General Acute Care Hospital (GACH) where it was borrowed from. (Resident 1) does not have a wheelchair to use while at the facility (SNF). The SSD stated, We are unable to find the right wheelchair to accommodate her (Resident 1). It was too expensive. that's why (Adm) did not buy it. On 5/18/18 at 1:43 p.m., during a concurrent interview and document review, Resident 1 stated the Adm asked her to go social media and solicit donations to purchase a wheelchair. Resident 1 provided a copy of wheelchair specifications printed from the Internet with a date of 4/6/18 and stated the printed specifications were provided to her by the Adm. Review of the the printed wheelchair specifications at HTTPS:www.used-wheelchairs-usa.com/chairdetails dated 4/6/18, indicated, Used (brand name of wheelchair). Price including insurance and shipping to (location): $3465 - fully assembled and ready to ride! General Specifications . Maximum capacity 600.0 lbs., Length: 38.25 (inches), Width: 29.25 . On 5/18/18 at 1:48 p.m., during an interview, the SSD stated, The resident (Resident 1) should not be going to social media to solicit money to purchase a wheelchair. The resident needs were not accommodated for her to come out of her room as she desired. On 5/18/18 at 2:10 p.m., during an interview, Resident 1 stated she wanted a wheelchair. Resident 1 stated, I'll be able to go to activities, enjoy meals in the dining room, go to the store. These activities did not occur due to lack of equipment (a wheelchair). It makes me feel bad that I'm not able to get around, to get out and go to the doctor, the dentist, go to the store, or get a sunlight outside the building. I feel that I am getting depressed. I'm trying to do other things in order for me not to cry and feel depressed. Resident 1 was tearful while talking and started to cry. Resident 1 stated, It's just upsetting that I cannot do the things I like to do. I try not to think about my situation. It makes me sad. I get lonely. My family can't visit me because it is so far for them to visit me. On 6/20/18 at 2:07 p.m., during an interview, the facility Activities Director (AD) stated, As far as I can remember she (Resident 1) has not attended group activities because she does not have a proper wheelchair .(Resident 1) prefers to go outside for fresh air. Without proper equipment or a wheelchair the resident cannot be taken outside .I have asked during the IDT (Interdisciplinary Team, a team of healthcare providers including nurses, social services, activities staff, dietary staff and physician who meet to plan care) meeting, but so far there were no ideas on how to get a proper chair for the resident to go to activities and go outside of the building. The only equipment she has is the shower chair and it is not appropriate for her to go around. The shower chair is to be used from bedroom to shower room and back to her room. Her need to go outside was not met because she doesn't have proper equipment or a wheelchair. On 6/20/18 at 3:14 p.m., during a concurrent interview and record review the MDS Coordinator (MDSC) reviewed Resident 1's, Care Plan titled The resident has limited physical mobility r/t (related to) [MEDICAL CONDITION] (obesity so severe as to interfere with normal activities including breathing) dated 10/14/17. The Care Plan indicated Interventions: Ambulation: The resident uses wheelchair for walking. Locomotion: The resident uses wheelchair for locomotion. The MDSC stated, The care plan is not accurate because there is no wheelchair. An intervention should not be written unless there is proper equipment like a wheelchair to use. On 6/20/18 at 3:15 p.m., during an interview, Licensed Nurse (LN) 1 stated Resident 1 did not have a proper wheelchair. LN 1 stated, (Resident 1) loves social activities like watching movies in the activity room, playing cards, monopoly, and crossword puzzles. Yesterday residents in the facility went to a picnic. (Resident 1) was not invited. Staff told her that she doesn't have a wheelchair and can't go. On 6/20/18 at 3:58 p.m., during an interview, the facility Occupational Therapist (OT) stated (Resident 1) was maximum dependent on admission and was unable to stand. Rehab (rehabilitation) goal was to sit up on a bariatric wheelchair (wheelchair that can comfortably and safely accommodate an obese resident). She (Resident 1) was able to sit up on the edge of the bed (at the completion of therapy). The OT stated the resident needed a bariatric wheelchair. The OT stated he requested a bariatric wheelchair from the Durable Medical Equipment (DME) Company, But no wheelchair was delivered. I'm not quite sure what happened from there. When the DME representative came to the facility, it was between the DME Company and the Adm. No wheelchair was delivered. On 7/25/18 at 9:07 a.m., during an interview, Resident 1 stated, I have not gotten a wheelchair yet. The Adm has not updated me yet on the status of the wheelchair. On 6/19/18 there was an outing to the zoo and I was not invited, maybe because I don't have a wheelchair. I would like to go since I have not been there. It turned out it was a picnic at the park. On 7/25/18 at 9:17 a.m., during an interview, Resident 1 stated, on (MONTH) 20, (YEAR) she was given a shower and the sling used to transfer her from the shower chair back to bed began to rip. Resident 1 stated, I was up on the air and I noticed a ripping sound and I looked; it was not the strap ripping but it was the actual sling ripping toward my left shoulder. The CNAs (Certified Nursing Assistants) put me to bed right away. Resident 1 stated, I am supposed to have a shower today after lunch if there is a sling. On 7/25/18 at 10:06 a.m., during an interview, Certified Nursing Assistant (CNA) 3 stated, We are waiting for a sling to come in (delivered to the facility). Today, I cannot give her a shower because there is no sling. On 7/25/18 at 10:40 a.m., during an interview, CNA 1 stated, I have been providing care for (Resident 1) since (MONTH) (YEAR). When she was admitted , a bed bath was given as she was uncomfortable, she didn't fit with the largest shower chair the facility had. When she received her shower chair from her family she started having showers. For eight months she was just receiving bed baths. CNA 1 stated Resident 1 had no wheelchair since she was admitted to the SNF. On 7/25/18 at 10:45 a.m., during an interview, CNA 2 stated, I assisted (Resident 1) out of the shower room to her room approximately Thursday or Friday last week (7/19/18 or 7/20/18). I waited for (CNA 1). We used the (mechanical lift) to put her back to bed. We used a sling. During the transfer from the shower chair to her bed (with the use of a sling) a tearing noise was heard. We put her to bed as fast as we could. CNA 2 stated, the sling was torn on the left side close to Resident 1's shoulder. CNA 2 stated falling out of sling would be harmful to Resident 1 because The resident could fall and break something like her bones. On 7/25/18 at 11:17 a.m., during an interview, CNA 1 stated Resident 1 preferred a particular sling to transfer from her bed to the shower chair but that sling was not available for use on 7/20/18. CNA 1 stated on 7/20/18 Resident 1 was given a shower. CNA 1 stated the sling used during transfer on that day was not the sling Resident 1 preferred and during the transfer of Resident 1 from the shower chair back to her bed the sling started to rip. CNA 1 stated, We (CNA 1, CNA 2, and Resident 1) heard the sling ripping . I held her close over the bed and another CNA (CNA 2) pushed the button (a control button connected to the mechanical lift) down to lower her into the bed. CNA 1 stated the ripped area of the sling was on the left side above Resident 1's left shoulder. CNA 1 stated, The sling was the largest we have. I am not sure if that was the largest size. That was the sling provided by the facility for us to use. The resident could get hurt very badly (if sling was ripped completely). CNA 1 stated she gave the ripped sling to the Adm on 7/20/18. On 7/25/18 at 12 p.m , during a concurrent observation and interview with CNA 1 and the Adm, CNA 1 showed two slings that were located in the Adm's office. CNA 1 took the slings out of a clear plastic bag. The manufacture's labels on the slings were wrinkled, faded and unreadable. CNA 1 stated the first sling was the sling Resident 1 preferred, was gray in color, and the four corners of the sling where the straps were sewn were damaged and the sling was unusable. The second sling was blue in color with a ripped area on the left side of the sling below the strap. The Adm stated, There is no sling that she (Resident 1) can use at this time. On 7/25/18 at 12:55 p.m., during an interview, the Directory of Nursing (DON) stated she was aware that Resident 1 had not taken a shower because there was no sling available that would fit her. The DON stated a sling ripped during a transfer of Resident 1 and Resident 1 was fearful that she would fall if the sling was not the right size. The DON stated she did not know the weight limit of the sling that ripped during the transfer of Resident 1. The DON stated, (Resident 1) does not have a specific bariatric sling. The DON stated The resident does not have a wheelchair yet. I don't know why. That decision is dependent on (Adm). The DON was asked of the risks to Resident 1 due to not having necessary equipment such as a bariatric wheelchair and sling. The DON stated Resident 1 was not able to receive showers, get out of bed, or get out of her room. The DON stated being bedbound increased Resident 1's risk of developing blood clots. The DON stated Resident 1 was provided a different bed in (MONTH) (YEAR). The DON stated, I don't know if it is a bariatric bed. The DON stated Resident 1 told her the bed was taken from another room in the facility. The DON stated, I don't know her (Resident 1's) weight. I don't know the weight limit of the bed. The DON stated the Restorative Nursing Assistant (RNA) told her Resident 1 was not weighed because there was no sling available to use with the mechanical lift that would accommodate Resident 1's size. The DON stated she was not aware of Resident 1's special equipment needs when she was transferred from the GACH to the SNF in (MONTH) (YEAR). The DON stated, 99 percent of the time I am not involved with approving inquires (requests for placement of residents). I am just being told that the resident is coming for admission. There was no discussion of her needs with me prior to admission. On 7/25/18 at 1:47 p.m., during an interview with the facility Marketing and Business Development staff member (MBD), the MBD stated, I sent an email to the department heads about the clinical information of the resident (Resident 1) prior to admission. The MBD provided a printed copy of an email sent to the department heads dated 10/4/17. The email indicated, This lady is 370 lbs.(pounds) coming from (name of town). ETA (expected time of arrival) 8:30 p (p.m.)) .I am sure we could work with her. Discharge orders to follow. On 7/25/18 at 1:51 p.m., during an interview, the Adm stated, Yes, I was aware of her needs when she was admitted . On 7/25/18 at 2:15 p.m., during an interview, the MBD stated the preadmission information supplied from the GACH regarding Resident 1's condition included Resident 1 had a BMI (Body Mass Index, a measure to determine weight status) greater than 100 (BMI of 30 or greater is considered obese). The MBD stated, I did not focus on the BMI greater than 100. I don't know if I asked about BMI greater than 100. I don't know what it means. The MBD stated there was no response to his email regarding Resident 1 from the department heads and he informed the GACH to transfer the patient (Resident 1) to the SNF on 10/5/17. On 7/25/18 at 2:43 p.m., during an interview, RNA 1 stated, I did not take her (Resident 1's) weight when she was admitted (readmitted on [DATE] after a short hospital stay). RNA 1 stated, on 7/21/18 Resident 1 refused to be weighed because there was no sling. On 7/25/18 at 3:25 p.m., during an interview with the facility Business Office Manager (BOM), the BOM stated (Resident 1) was on Medicare Part A (a government payer source for residents in a SNF requiring skilled care and other services including but not limited to medical supplies and equipment used in the facility) from 10/5/17 to 12/1/17. The BOM stated Resident 1 was on Medi-Cal (a government payer source for residents in a SNF) from 12/1/17 to present. The BOM stated, If the resident (Resident 1) needed equipment, like a specialized wheelchair then the facility will provide the equipment needed during her or his stay at the facility. We borrowed a bariatric wheelchair from (name of GACH) unfortunately it did not fit her. It was returned back to (name of GACH) in (MONTH) (YEAR). Since that time we did not find a wheelchair for her . The wheelchair has to be customized with estimated cost at $15,000.00 for a non-motorized wheelchair. For motorized wheelchair is twice the cost of non-motorized. (Resident 1) does not have a wheelchair at this time. On 7/25/18 at 4:07 p.m. during an observation and interview, Resident 1 sat on her bed fanning herself with a cardboard fan. Resident 1 stated, I didn't get a shower today because there was no sling to use. When I was admitted to the facility there was no shower chair large enough to fit me. I tried to take showers using the largest shower chair that the facility had. After four or five showers I stopped taking showers because of lack of proper equipment .I prefer a shower over a bedbath. I took the bedbath because that was the only means I can cleanse myself. I prefer a shower because it lowers my body temperature. I feel hot all the time. Resident 1 stated her FM brought in a shower chair that fit her in (MONTH) (YEAR) so that she could receive showers again. Resident 1 stated, The problem is there is no sling that is appropriate that I can fit and feel safe. I am scared to get up on the mechanical lift after the incident last week when we heard the sling tearing apart . Resident 1 stated she had not received showers because there was no sling large enough to accommodate her size. On 7/25/18 at 4:10 p.m., during a concurrent interview and document review with the Adm in her office, the Adm stated, I could not determine if the slings (the two damaged slings) that were used for the resident (Resident 1) last week when she took a shower were bariatric slings. The Adm produced copies of invoices dated 12/16/16 and 10/26/17 which indicated a total of ten slings had been ordered on the invoices. The maximum weight capacity for all slings ordered was 450 pounds. On 7/31/18 at 4:10 p.m., during a concurrent interview and record review, the Registered Dietician (RD) stated she started working at the SNF in (MONTH) (YEAR). The RD stated residents' weight were taken on admission, weekly for four weeks, then monthly. Review of Resident 1's weight record indicated missing weight documentation for the monthly weight for Resident 1 for February, March, April, and (MONTH) (YEAR). The RD stated the weights for those months were not taken because there was no sling available to weigh Resident 1. The RD added Resident 1 went to the GACH from 7/13/18 to 7/19/18 and weekly weights were not done after readmission to the SNF because the sling that was used to lift Resident 1 was ripped and there was no available sling to measure Resident 1's weight. Review of Resident 1's clinical record titled, Weights and Vitals dated 7/25/18, indicated the following weights were taken using a mechanical lift and a sling: 10/20/17, 470 (initial admission weight recorded) pounds (lbs.), 10/22/17, 470 lbs., 11/11/17, 495 lbs., 1/4/18, 501 lbs., and 6/5/18, 495 lbs. Review of facility policy and procedure titled, Safe Lifting Movement dated 07/06, indicated Policy: In order to protect the safety and well-being of staff and patients and to promote quality care, this facility uses appropriate techniques and devices to lift and move patients. Process .3. Staff will document paitent transferring and lifting needs in the care plan. Such assessment shall include: Patient's preferences for assistance .Patient's size .9. Enough slings, in the sizes required by patients in need will be available at all times . Review of the facility document titled, California Standard Admission Agreement For Skilled Nursing Facilities and Intermediate Care Facilities dated 05/11, indicated .Attachment D-1, Supplies and Services Covered By the Medicare Program for Medicare Residents .Medicare Part A covered services include .durable medical equipment . Review of facility policy and procedure titled, Weight Assessment and Intervention dated 1/18, indicated Weight Assessment 1. The nursing staff will measure weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns at this point, weights will be measured monthly thereafter .5. The Dietician will review the unit Weight Record by the 15th of the month to follow individual weight overtime. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. Review of facility policy and procedure titled, Comprehensive Plan of Care dated 4/05, indicated Policy: Each resident must have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental, and psychological needs .Fundamental Information: The comprehensive care plan must describe the services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. The comprehensive plan of care must: Address the resident's individual needs, strengths, and preferences . Review of Internet resource: HTTPS://downloads.cms.gov/files/mds-30-rai-manual-v115-october-2017.pdf , indicated Section F: PREFERENCES FOR CUSTOMARY ROUTINE AND ACTIVITIES Intent: The intent of items in this section is to obtain information regarding the resident's preferences for his or her daily routine and activities .Nursing homes should use this as a guide to create an individualized plan based on the resident's preferences .Health-related Quality of Life .Obtaining information about preferences directly from the resident .is the most reliable and most accurate way of identifying preferences .Planning for Care: Quality of life can be greatly enhanced when care respects the resident's choice regarding anything that is important to the resident .Information about preferences that comes directly from the resident provides specific information for individualized daily care and activity planning . Internet source: Skilled Nursing Facility (SNF)| www.Medicare.gov dated 8/6/18, indicated Medicare Part A (Hospital Insurance) covers skilled nursing care provided in skilled nursing facility .Medicare-covered services include, but aren't limited to: .Medical supplies and equipment used in the facility .

Based on observation, staff and resident interview and administrative document review, the facility failed to maintain an Infection Control Program designed to provide a safe, sanitary environment to help prevent transmission of disease and infection when flies were observed in the biohazard waste (a biological agent that constitutes a hazard to humans or the environment) closet, in the residents' juice and drinking water pitchers, and the residents' living area when the biohazard waste closet was filled with biohazard waste infested with flies. This placed all residents at potential risk for infectious disease transmission and potential contamination of drinks that were to be consumed by the residents on Station 1 who were given medications. The survey team identified an Immediate Jeopardy (IJ) situation on 8/17/12 at 7:20 p.m., as a result of the facility's failure to provide a safe, sanitary environment to help prevent transmission of disease and infection when the biohazard closet inside the facility was filled with biohazard waste infested with flies. The IJ was called with the Social Service Director (SSD) and the Maintenance Supervisor (MS). The Administrator and Director of Nursing Services (DNS) was not present or available for onsite. Findings: A review of "Guidelines for Environmental Infection Control in Health-Care Facilities Recommendations of CDC (Center for Disease Control) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) contained information: Cockroaches, flies and maggots, ants, mosquitoes, spiders, mites, midges, and mice are among the typical arthropod and vertebrate pest populations found in health-care facilities. Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector." The CDC Guidelines for Environmental Infection Control in Health-Care Facilities dated 2003 indicated " ...Outbreaks of infection attributed to microorganisms carried by insects may occur because of infestation coupled with breaks in standard infection-control practices ..." and "Health-care facilities are instructed to dispose medical wastes regularly to avoid accumulation. Medical wastes requiring storage should be kept in labeled, leak-proof, puncture-resistant containers under conditions that minimize or prevent foul odors. The storage area should be well ventilated and be inaccessible to pests ..." On 8/17/12 at 4:45 p.m.., during an interview Licensed Nurse 1 (LN 1) stated she had noticed there were a lot of gnat looking flies on Station 1. At 5:00 p.m., Certified Nurse Assistant 1 (CNA 1) stated there had been a lot of gnat looking flies on Station 1 for about 2 months and she had observed flies in the resident water pitchers. At 5:55 p.m., Registered Nurse 1 (RN 1) stated she had seen the flies on Station 1. At 5:55 p.m., CNA 2 stated she had seen a lot of gnat looking flies around Station 1 for three weeks especially around the biohazard closet located near Nurses Station 1 closet and resident rooms [ROOM NUMBERS]. At 6:04 p.m.., the Administrator (Admin) stated he thought the biohazard waste had been picked up last by the biohazard company three weeks ago. On 8/17/12 at 6:05 p.m. during observation the door to the biohazard waste room was opened by housekeeping (Hsk 1). The room was four feet by four feet in width and eight feet in height. The room contained two visible barrels full to the brim of red bags that were completely filled. Numerous red bags sat on top of the barrels, to the sides and the back of the closet stacked high bulging with biohazardous waste. Numerous red bags were unsealed and seeping liquid. There was a stench emanating from the closet to the corridor. A mass exodus of flies (a swarm) flew out of the closet into the corridor when the door was opened by Hsk 1. On 8/17/12 at 6:10 p.m., Resident 1 stated he had seen small flies in his room over the last few weeks. On 8/17/12 at 6:15 p.m., during a observation there was a fly floating in Resident 2's water pitcher at Resident 2's bedside. Registered Nurse (RN 1) witnessed the fly floating in Resident 2's water pitcher located on her bedside table. On 8/17/12 at 6:17 p.m., Resident 3 stated she had noticed flies in her room for one and half weeks and needed to cover her food to protect it from flies. Resident 3 stated she had to protect her meal tray from flies and stated, "It's been terrible because the flies get into your hair." On 8/17/12 at 6:20 p.m., Resident 4 stated flies had been driving her crazy for about 4 days. During this interview, a fly was observed floating in her water pitcher. On 8/17/12 at 6:25 p.m., Resident 5 stated flies had been around "badly" for about two weeks. During this interview, a fly was observed floating in his water pitcher. RN 1 witnessed the fly floating in Resident 5's water pitcher located on his bedside table. RN 1's response was "yuk." On 8/17/12 at 6:30 p.m., the MS stated he sent an e-mail on 8/6/12 at 12:13 p.m. to a corporate staff member. The MS stated in his e-mail to the corporation: "we are on credit hold because we are over 90 days past due at the sum of 3150.54. Our total amount due is 4238.32. their corporate number is 1-800------. can you please help with this matter it will soon be a infection control issue." The MS stated the biohazard company had not been paid from April 2012 through July 2012. The MS stated biohazard red bags contained adult briefs with urine and feces, sharps (needles, safety razors), and bandages (wound dressings). The "Accounts Payable Batch Report" dated 7/20/12, indicated the biohazard company total due was $4238.32. On 8/17/12 at 7:15 p.m.., during an observation on Nurses Station 1 four flies landed on the arm of the evaluator and more were soaring around his head. Station 1 was next to four resident rooms. There were residents present near the nurses station during this time. On 8/17/12 at 7:18 p.m., during observation, there were two flies floating in a juice container on medication cart 1. RN 1 observed at this time, the flies in the juice container which was used to pour juice for multiple residents. RN 1 stated juice containers on medication cart 1 would be used to administer medications for residents from Rooms 22 A through 34 B (32 residents). On 8/17/12 at 7:20 p.m., the MS stated he would not be able to get the biohazard waste picked up prior to Monday (three days later). On 8/17/12 at 10:30 p.m., the team accepted a plan of action for the IJ which included: Sealed the biohazard closet door shut with tape, Pest Control company sprayed with "Demand CS" (an insecticide) underneath the door, signs were placed on the biohazard waste door warning staff not to open the door. Three residents were removed from rooms [ROOM NUMBERS] and placed in alternate rooms. On 8/18/12 at 12:05 p.m., during observation flies were seen around Nurses Station 1 and had landed on the countertop of Nurses Station 1 and on the surveyor. Residents were present in the same vicinity. On 8/18/12 at 12:33 p.m., LN 2 stated the biohazard waste was being stored in a separate building outside where the generator was located for the weekend. On 8/18/12 at 7:15 p.m., during a concurrent observation and interview, LN 3 stated the biohazardous waste was being stored in the area where the generator was located. The surveyor observed one red bag stored on the floor next to the generator. LN 3 observed the red bag in the generator room. The building where the generator was located did not have a sprinkler system in the event of fire. The biohazards material was combustible. On 8/20/12 at 8:10 a.m., the DON stated all residents who resided on Station 1 which included Rooms 22 to room [ROOM NUMBER] were removed from the area to protect the residents from a possible swarm of flies when the biohazardous waste closet was opened for decontamination. On 8/20/12 at 9:35 a.m., observation of the biohazardous waste closet revealed approximately 50 dead flies on the back wall of the closet. The biohazardous waste was removed by the pest control company who sprayed insecticide. Five 55 gallon drums were filled with biohazardous waste and removed along with 70 containers and 40 bags. The pest company sprayed insecticide into the emptied closet and shut the door. On 8/20/12 at 10:37 a.m., the Admin stated he had the "all clear" to return residents to their rooms on Station 1 once the insecticide had dried. On 8/20/12 at 10:55 a.m., during observation and concurrent interview, the MS stated the biohazardous waste would now be stored in a standing freezer in the utility room to be used only for biohazard waste. On 8/20/12 at 1:41 p.m., the California Department of Public Health (CDPH) received an e-mail from the biohazardous waste company: "Per our conversation concerning (Facility)..., they have not had a pick up since 6/29/12 and are on a credit hold due to non payment." On 8/21/12 at 9 a.m., the Account Representative from the biohazardous waste company contracted with the facility stated the facility had renegotiated the contract and there would be a pick up of the biohazardous waste on 8/22/12 and every two weeks following. The IJ was abated on 8/21/12 at 5:43 p.m. based on implementation of an acceptable plan of correction.

Based on staff and resident interview and administrative document review, the facility failed to ensure 1 of 15 sampled residents (Resident 10) was free of sexual and verbal abuse when Licensed Nurse (LN) 6 made sexual gestures and used foul language to speak to a resident. Resident 10 felt ashamed, dirty, anxious, and used. Resident 10 requested counseling. Findings: Resident 10's clinical record indicated that on 2/29/12, Resident 10 was admitted to the facility. Resident 10's Minimum Data Set ((MDS) dated [DATE] indicated the resident was alert, oriented, and able to answer questions appropriately. Resident 10 was his own responsible party. On 3/27/12 at 2 p.m., during an interview, Resident 10 stated LN 6 made "Sexual suggestions" to him while the LN passed medications. Resident 10 stated LN 6 yelled at him and said "F...(expletive) you! Resident 10 stated LN 6 went into (an empty) resident's room and she began touching her breast. Resident 10 stated the incident made him ashamed, dirty, anxious and used. Resident 10's Declaration dated 3/14/12 indicated he "asked for his medication she was busy, and then became upset. I asked her again about 5 min (minutes) later. She had her cart in the door, was making gestures as she wanted to give me a bl... job, she keep (sic) gesturing me to go into my room, and she keep (sic) sticking her fingers in her mouth sucking on them and grabbing her breast..." On 3/27/12 at 2:20 p.m., during an interview, the Social Service Director (SSD) stated upon resident interview on 3/14/12, Resident 10 appeared hesitant to talk about the incident but confirmed what occurred (sexual gestures and foul language incident) . On 3/30/12 at 2:10 p.m., during an interview, the Administrator (ADM) stated LN 6's "inappropriate behavior" was reported by Resident 10's girlfriend. The ADM stated the incident was confirmed by CNA 2 as indicated in the CNA's written declaration. On 3/30/12 at 3:05 p.m., during an interview, Certified Nurse Assistant (CNA) 2 stated on 3/13/12, LN 6 was "Sitting on a resident's bed, sucking on her finger, and touched her breast..." CNA 2 stated LN 6 was "Seductively touching herself..." and immediately jumped off the bed when CNA 2 walked by. CNA 2 stated Resident 10 "Appeared shocked ..." CNA 2 stated Resident 10 was alert and oriented. Review of CNA 2's written declaration dated 3/15/12 indicated, "... I witness LN 6 using foul language and yelling at a resident... Resident came to her outside room [ROOM NUMBER] and started to ask again and started to cuzz him out again (sic)..." Review of CNA 1's written declaration dated 3/13/12 indicated, "... P.M. shift, March 13, 2012... I observed (LN 6) with the medication cart in front of room [ROOM NUMBER] and (Resident 10) was asking her for something, she then literally started yelling at the resident 'shut up, shut your F...ing (expletive) mouth!' The resident started to say something she yelled at him again "No I'm not playing, shut the f...(expletive) up!'..." On 4/2/12 at 3 p.m., during an interview, CNA 1 stated she saw Resident 10 sitting up by a medication cart in the hallway asking for a medication. CNA 1 stated she heard LN 6 yell at the resident "Shut up! Shut up! Shut the F...(expletive) up!..." CNA 1 stated she heard this as she walked along the hallway. CNA 1 stated she "Thought it was odd... thought the resident may have said something... but she (referring to LN 6) shouldn't have said those (words)..." CNA 1 stated LN 6's words "Could be considered verbal abuse."

Based on staff and resident interview and administrative document review, the facility failed to implement their "Abuse" Policy and Procedure in 1 of 15 sampled residents (Resident 10) to prevent mistreatment of [REDACTED]. This failure allowed CNA 8 to take advantage of Resident 10 who she was entrusted to care for. Findings: Resident 10's clinical record indicated that on 2/29/12, Resident 10 was admitted to the facility. Resident 10's Minimum Data Set ((MDS) dated [DATE] indicated the resident was alert, oriented, and able to answer questions appropriately. Resident 10 was his own responsible party. On 3/29/12 at 3:35 p.m., Resident 10 stated he was on his way out to a store (resident unable to recall date) when CNA 8 gave him a ride in her personal car. Resident 10 stated on their way back, CNA 8 received a "text from (Director of Staff Development (DSD))" indicating, "It was inappropriate that he was in her car." Resident 10 stated he exchanged phone numbers with CNA 8 and they continued to text and talk with each other. Resident 10 stated the next day, CNA 8 picked him up at a grocery store and they went to a park. Resident 10 stated they kissed and had sex in the park. On 3/29/12 at 3:42 p.m., during an interview, the DSD stated Resident 10's girlfriend complained on 3/28/12 that a staff had "inappropriate" sexual relations with Resident 10. On 3/29/12 at 4:05 p.m., during an interview, the Administrator (ADM) stated CNA 8 had "Crossed the line of patient-employee relations." The ADM stated it was an inappropriate behavior. On 4/2/12 at 3:15 p.m., during a phone interview, CNA 8 stated she gave Resident 10 a ride to the store on Sunday (3/25/12). CNA 8 stated she exchanged phone numbers with Resident 10 and they texted and called each other. CNA 8 stated she picked Resident 10 up at a store the next day and brought him to a park. CNA 8 stated, "(I) did something I should not have done." CNA 8 clarified this to mean she had sex with Resident 10. Review of the administrative document titled, "NURSE ASSISTANT CODE OF ETHICS" signed by CNA 8 on 1/16/12 indicated, "The Nurse Assistant shall practice his/her profession with integrity..." Review of the administrative document titled, "... EMPLOYEE HANDBOOK" signed by CNA 8 on 1/16/12, indicated, "... INVOLVEMENT IN THE PERSONAL AFFAIRS OF THE RESIDENTS At no time shall you become involved in the personal affairs of any resident in the facility..."