Every finding on record at Gold Country Health Center

Based on observation, interview, and record review, the facility failed to ensure required transfer and discharge notifications were provided for three of three sampled residents (Resident 2, Resident 3, and Resident 4), when the facility notified Resident 3 and Resident 4 of their discharges on 7/13/26, the same day they were discharged , without any documented exception permitting shorter notice; the facility did not notify the Office of the State Long-Term Care Ombudsman (OMB, an independent advocate for residents of long-term care facilities) before the transfer/discharge of Resident 3; and the facility issued no written notice while attempting to discharge Resident 2.These failures removed Resident 3 and Resident 4 from the facility with same day notice, denying their right to exercise appeal rights, and denied Resident 2 the required notice and opportunity to appeal a facility initiated discharge and had the potential to affect residents' mental and psychosocial well being.Findings:A review of Resident 3's admission record (AR) showed Resident 3 was admitted in spring 2026 with diagnoses including weakness, back bone fracture, foot ulcer, depression, and diabetes mellitus (DM, disorder with difficulty in blood sugar control). A review of Resident 3's Physician Visit Note, dated 4/2026, indicated Resident 3's memory was intact.A review of Resident 4's AR indicated Resident 4 was admitted in early spring 2026 with diagnoses including DM with foot ulcer, liver cirrhosis (late-stage liver disease with scar tissues blocking normal blood flow), and anxiety.A review of Resident 3's Notice of Proposed Transfer/Discharge (NTD), dated 7/13/26 indicated the facility notified Resident 3 on 7/13/26 and discharged Resident 3 on 7/13/26. No exception to the 30 day notice requirement was documented.A review of Resident 3's Nurse Progress Note (NPN), dated 7/13/26 at 1:36 p.m., indicated Resident 3 was discharged to another skilled nursing facility (SNF 2), departing at 1:10 p.m.A review of Resident 3's NTD and NPN both dated 7/13/26 indicated Resident 3 was notified and discharged on 7/13/26. There was no evidence the facility notified the Ombudsman Program (OMB) before Resident 3's discharge.A review of Resident 4's NTD, dated 7/13/26, indicated Resident 4 was notified and discharged on the same day, with no documented exception.A review of both residents' Discharge Summaries (DS), dated 7/13/26, indicated both were discharged to SNF 2 for long term care.During a telephone interview on 7/16/26 at 1:01 p.m., Resident 4's Family Member 1 (FM 1) stated Resident 4 felt like he did not have any other choice and felt pushed out.staff told him his days were running out.if he transferred to another facility his days would extend, and if not, he would have to pay a shared cost.he expressed he did not want to go.During a telephone interview on 7/16/26 at 1:28 p.m., Resident 4 stated, It was [SS 1 Social Services] who had me sign the paper, but I did not get an orientation of what I was signing, and I signed something and I did not feel like it was explained. Resident 4 stated a copy was supposed to be returned to him but was not provided, and stated, I didn't know they were supposed to give me a grace period. During a telephone interview on 7/16/26 at 3:09 p.m., Resident 3 stated the notice he received was two days before discharge.During an interview on 7/16/26 at 3:26 p.m. with the Director of Nursing (DON), the DON stated residents were notified 72 [hours] prior for all insurance discharges and were given the NOMNC (Notice of Medicare Non-Coverage, a notification of the date Medicare coverage will end and how to appeal the coverage decision) form to sign. The DON's description of the transfer and discharge process did not include a 30-day written notice. The DON described the transfer/discharge steps but did not include OMB notification.During an interview on 7/16/26 at 4:39 p.m. with the Administrator (ADM), the ADM stated, I've never given a 30-day notice to any residents in 30 years. Never needed to.During an interview on 7/16/26 at 4:43 p.m. with the DON, the DON stated, The only time you get a 30-day is if the facility is asking you to leave, and stated a 30-day notice had never been given.During a review on 8/6/26 of email from the OMB program, dated 7/27/26 at 11:08 a.m., the email indicated the OMB received Resident 3's NTD on 7/14/26, one day after the discharge. The OMB reported no NTD was received for Resident 4.A review of Resident 2's AR indicated Resident 2 was admitted in late spring 2025 with diagnoses including degenerative disease of the nervous system (disease that can cause difficulty walking and talking), anxiety, and depression. A review of Resident 2's Physician's Progress Notes (PPN, 4/26) showed Resident 2 had no memory impairment.A review of Resident 2's clinical record showed no written notice of transfer/discharge.During a concurrent interview and record review on 8/6/26 of email from the OMB program dated 7/27/26 the email indicated no notice was received for Resident 2, and the OMB first learned of Resident 2's discharge situation when the OMB met with Resident 2 at the facility on 7/21/26, at which time Resident 2 reported being urged to be discharged by the facility. Resident 2 indicated she did not want to leave the facility and did not want to make a lateral transfer.During an interview on 7/16/26 at 10:30 a.m., Resident 2 stated, Monday or Friday, I started hearing I was moving. I didn't even know. It wasn't even discussed until Tuesday. We had a meeting. I was not provided with 30 day notice. Resident 2 stated she was told she had until the 31st of this month to go. Resident 2 indicated she did not speak with the OMB, and stated she was told they are moving away from being long term skilled nursing here.During an interview on 7/16/26 at 3:50 p.m., the Assistant Director of Nursing (ADON) stated Resident 2 was notified during a care conference the day before (7/15/26) but could not provide a copy of any written notice.A review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan, revised 3/25, the P&P indicated, A member of the IDT reviews the final discharge plan with the resident and family at least twenty-four (24) hours before the discharge is to take place. A review of the facility's P&P titled, Transfer or Discharge, revised 3/25, indicated, Once admitted to the facility, residents have the right to remain in the facility. Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record.Residents have the right to appeal a transfer or discharge through the state agency that handles appeals.The facility will assist the resident in filing the appeal, if such assistance is requested.

Based on observation, interview, and record review, the facility failed to ensure residents were only transferred or discharged for valid, allowable reasons, when the facility discharged two of five sampled residents (Resident 3 and Resident 4) from skilled nursing facility (SNF) 1 to SNF 2 without documented medical justification, even though both facilities provided the same level of care. The required physician documentation supporting improvement or unmet needs was absent or contradictory, and the residents were not given a choice.This failure violated Resident 3 and Resident 4's discharge rights to remain in the facility and placed them at risk for transfer trauma and disruption of care.Findings:A review of SNF 1 and SNF 2's licensing and certification information showed both facilities were licensed as SNFs providing the same level of care and certified for skilled nursing and long term care services.A review of Resident 3's admission record (AR) showed Resident 3 was admitted in spring 2026 with diagnoses including weakness, back bone fracture, foot ulcer, depression, and diabetes mellitus (DM, disorder with difficulty in blood sugar control which could contribute to poor wound healing).A review of Resident 3's Physician Visit Note (4/2026) showed Resident 3's memory was intact.A review of Resident 3's Notice of Proposed Transfer/Discharge (NTD, 7/13/26) showed the stated reason: The transfer/discharge is appropriate because your health has improved sufficiently so that you no longer require services of this facility.A review of Resident 3's Discharge Summary (DS), dated7/13/26, showed Resident 3 discharged in stable condition to a nursing facility for long term care and still had wounds present to feet. The DS contradicted NTD by showing active wounds and ongoing long term care needs.A review of Resident 3's Notice of Medicare Non Coverage (NOMNC), dated 7/9/26 showed Medicare services would end on 7/11/26. Resident 3 was discharged on 7/13/26.A review of Resident 3's Physician Discharge Note (PDN), dated 7/13/26 showed no physician documentation supporting that Resident 3 had improved sufficiently to no longer require SNF 1's services.A review of Resident 4's AR showed Resident 4 was admitted in early spring 2026 with DM with foot ulcer, liver cirrhosis (late-stage liver disease with scar tissues blocking normal blood flow), and anxiety.A review of Resident 4's NTD dated 7/13/26 showed two conflicting discharge reasons: (1) needs could not be met at the facility, and (2) health had improved sufficiently so services were no longer required.A review of Resident 4's PDN dated 7/13/26 showed discharge to SNF 2 for long term care with active diagnoses including wound to primary foot, DM with ulcer (when high blood sugar damages blood vessels causing difficulty in healing), nonalcoholic steatohepatitis with cirrhosis (liver damage), chronic heart failure (a weak heart), and Chronic Obstructive Pulmonary Disease (COPD, long-term lung disease causing difficulty breathing). The PDN contained no documentation identifying specific needs that SNF 1 could not meet and indicated, The facility attempts to meet those needs, or services available at the receiving facility (SNF 2).During a concurrent interview and record review on 7/16/26 at 12:26 p.m., Social Service 1 (SS 1) stated [SNF 2] is skilled nursing and provides long term skilled nursing care, and confirmed both residents were discharged to SNF 2.During a telephone interview on 7/16/26, at 1:01 p.m., Resident 4's Family Member 1 (FM 1) stated Resident 4 felt pushed out, was told his days were running out, and if he transferred his days would extend, and if not, he would have to pay a shared cost. FM 1 stated Resident 4 did not want to go.During a telephone interview on 7/16/26, at 1:28 p.m., Resident 4 stated his insurance did not cover any more, staff talked to him about moving, he felt pressured, was told he Must go, was offered only [SNF 2], was promised a private room and television, and did not want to leave [SNF 1]. Resident 4 stated, Since the move, I now wake up confused and wondering where I am.I am having bad dreams.During a telephone interview on 7/16/26, at 3:09 p.m., Resident 3 stated he was told two days prior he was being discharged , staff told him his insurance was ending, and [SNF 2] was his only option. Resident 3 stated he would have stayed if given a choice and felt sad about being discharged .During an interview on 7/16/26, at 3:50 p.m., the Assistant Director of Nursing (ADON) stated Resident 4 wanted and agreed to go, and stated, When it's insurance driven, we let them know.During an interview on 7/16/26, at 4:39 p.m., the Director of Nursing (DON) stated SNF 2 was suggested to renew care for 30 days more.During a review of the facility policy and procedure (P&P) titled Transfer or Discharge, March 2025, the P&P indicated, Once admitted to the facility, residents have the right to remain in the facility. If the resident continues to need long-term care services, the facility will offer the resident the ability to remain.documents information about the resident condition and the appropriateness of the discharge.

Based on observation, interview, and record review, the facility failed to:1. Ensure nursing staff accurately documented the removal of controlled medications (those with high potential for abuse or addiction) during medication pass;2. Ensure accurate accountability and effective storage of controlled medication when random controlled medication audits for two out of two residents (Resident 14 and Resident 17) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps a record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents; and,3. Demonstrate adequate safeguards were implemented to ensure chain of custody of controlled substances and limit their potential for diversion prior to final destruction. These failures resulted in the facility not having accurate accountability of controlled medications and increased potential for diversion, abuse or misuse of these medications.Findings: 1.During a concurrent interview and record review on 9/7/25 at 8:12 a.m. with Assistant Director of Nursing (ADON), Resident 82's physician's order for pain relief was reviewed. Resident 82's medical record indicated the following physician's order for pain management: -Oxycontin (a medication used for pain relief) oral tablet ER (extended release). Give 10 milligrams (mg, a unit of measurement) by mouth two times a day for pain management. Hold for sedation or respiratory rates (RR per minute) less than 12. Do not crush/chew, ordered on 9/8/25. During a medication pass observation on 9/7/25 at 8:12 a.m., ADON administered Oxycontin ER 10 mg tablet to Resident 82 but did not document the removal of the medication on the CDR prior to administration. During a concurrent observation and interview on 9/7/25 at 8:12 a.m. with ADON, ADON confirmed she did not document the removal of the medication on the CDR prior to the administration of the medication to Resident 82. ADON confirmed the process should be to sign on CDR prior to administration when she stated, We get it out, and we sign it when we pop it out. A review of the facility's policy and procedure (P&P) titled, Controlled Medications, dated 3/2018, indicated, . The licensed nurse administering the medication immediately enters the following information on the accountability record (CDR) and Medication Administration Record (MAR): date and time of administration, amount administered, signature of the nurse administering the dose. 2a. A review of Resident 14's medical records indicated the following physician's orders: -Valium (a highly potent medication usually prescribed for anxiety and muscle spasms) oral tablet five mg. Give 0.5 tablet by mouth two times a day for neuromuscular degenerative (progressive muscle weakness and loss of function) AEB (as evidenced by) repetitive physical movements (fidgeting and pacing), ordered on 4/21/25. -Valium oral tablet five mg. Give one tablet by mouth at bedtime for neuromuscular degenerative AEB repetitive physical movements (fidgeting and pacing), ordered on 4/21/25. A review of Resident 14's CDR and MAR, dated August 2025, indicated Valium five mg was removed from the medication cart on 8/31/25 at 8:02 p.m., but the respective administration was not documented on the MAR. During a concurrent interview and record review on 9/8/25 at 4:31 p.m. with Director of Nursing (DON), Resident 14's CDR and MAR for Valium were reviewed. DON confirmed the identified discrepancy and stated the withdrawal on 8/31/25 at 8:02 p.m. might have been accidentally documented on the incorrect CDR as the timing of the withdrawal coincided with the bedtime dose. 2b. A review of Resident 17's medical record indicated a physician's order for morphine sulfate (a highly potent pain relief medication) tablet 15 mg. Give 7.5 mg every four hours as needed for moderate to severe pain 4-10 (a scale used to measure intensity of pain), dated 6/8/25. A review of Resident 17's CDR and MAR, dated July 2025, indicated morphine sulfate 15 mg was removed from the medication cart on 7/21/25 at 6:10 a.m. but the respective administration was not documented on the MAR. During a concurrent interview and record review on 9/8/25 at 4:31 p.m. with DON, Resident 17's CDR and MAR for morphine sulfate were reviewed. DON confirmed the above identified discrepancy. A review of the facility's P&P titled, Controlled Medications, dated 3/2018, indicated, . The licensed nurse administering the medication immediately enters the following information on the accountability record (CDR) and Medication Administration Record (MAR): date and time of administration, amount administered, signature of the nurse administering the dose, completed after the medication is administered. A review of the facility's P&P titled, Controlled Substances, dated 4/2019, indicated, Upon administration: The nurse administering the medication is responsible for recording: name of the resident receiving the medication; name, strength and dose of the medication; time of administration; method of administration . Signature of nurse administering medication. 3. During an interview on 9/8/25 at 4:31 p.m. with DON, DON stated the steps of drug destruction included: nurse on the floor would bring the CDR and controlled medication into her office upon discontinuation of orders or discharge of resident, nurse and DON both signed off on CDR after counting the controlled medication, DON put the controlled medication into a locked drawer in her office to which only she would have access to, Consultant Pharmacist (CP) would come into the facility once a month and both DON and CP counted the controlled medication and CP would note it in a notebook the DON kept in the office, the controlled medication would be locked back up into storage in incineration box (a form of disposal of controlled medication), and the medication would be kept there until final pick up. DON agreed there were not adequate safeguards in place to ensure the chain of custody of controlled substances limited the potential for diversion. During an interview on 9/8/25 at 10:56 a.m. with CP, CP stated he would try to come to facility monthly or every other month for the destruction of controlled medication. CP stated when controlled medication was removed from cart, the medication and CDR both went to the DON and were locked into storage in her office. CP further stated if there was an entire bubble pack of controlled medication and the CDR missing from the storage prior to his arrival, the only way it would be detected by him was if the DON would detect it and share that information. CP confirmed there was no system in place that allowed him to identify if controlled substances were diverted from the time they were locked in the DON's cabinet to the time he arrived at the facility for destruction. CP acknowledged and confirmed the process did not limit the potential for diversion because of lack of accountability and documentation for processing controlled medications for destruction. A review of the facility's P&P titled, Medication Destruction, dated 3/2018, indicated, Controlled medication destruction is done in the presence of a pharmacist and a registered nurse employed by the facility. The destruction is documented on a mediation disposal form or a controlled medication disposition log . Controlled medications remaining in the facility after the order has been discontinued are retained in the facility in a securely locked area with restricted access until destroyed by the facility's RN and consultant pharmacist; or as otherwise directed by state law.

Based on observation, interview, and record review, the facility had a 14.81 percent (%, a unit of measure) error rate when four medication errors out of 27 opportunities were observed during a medication pass for two of three Residents (Resident 82 and Resident 85). This failure resulted in medications not given in accordance with the prescriber's orders and increased potential to affect the residents' clinical conditions.Findings: 1. During a medication pass observation on 9/7/25 at 8:12 a.m., the Assistant Director of Nursing (ADON) was observed preparing and administering seven medications for Resident 82 which included: oxycontin (a medication given to treat pain) ER (extended release, a long acting formulation) 10 milligrams (mg, a unit of measurement), Nephro vitamins (Vitamin B-Complex with Vitamin C and Folic Acid, a collection of vitamins and minerals), Senokot 8.6 mg (a medication to relieve constipation), Lidoderm 5% patch (a topical patch applied to the skin that relieves pain), Clear lax (a powder mixed with water that helps relieve constipation and helps irregular bowel movements), calcium carbonate (helps neutralize excess stomach acid) 500 mg, ertapenem (an antibiotic; a medication that kills or inhibits the growth of bacteria, used to treat urinary infections). A review of Resident 82's medical record indicated physician's orders for: -Senna Plus oral tablet 8.6-50 mg (a dual action medication comprised of sennosides [derived from the senna plant, this ingredient irritates the lining of the bowel to stimulate muscle contractions and promote a bowel movement] and docusate sodium [an ingredient that increases the amount of water the stool absorbs, making it softer and easier to pass]). Give two tablets by mouth one time a day for bowel management and hold for loose stool, ordered on 9/7/25. During a concurrent interview and record review on 9/7/25 at 12:15 p.m. with ADON, Resident 82's physician's orders were reviewed. ADON confirmed the order was for Senna Plus oral tablet 8.6-50 mg ordered but she administered Senokot 8.6 mg. 2. During a medication pass observation on 9/7/25 at 9:26 a.m., Licensed Nurse 4 (LN 4) was observed preparing and administering medications for Resident 85 which included: carvedilol (a medication used to treat high blood pressure) 3.125 mg, Jardiance (a medication used to help kidney function) 10 mg, budesonide/formoterol (brand name Symbicort, a medication that is inhaled that helps with reducing inflammation in airway) inhaler. A review of Resident 85's medical record indicated the following physician's orders: -Carvedilol 3.125 mg one tablet to be given orally two times a day with meal, ordered on 9/3/25;-Jardiance 10 mg to be taken with meal. Give 10 mg orally one time a day for diabetes mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), ordered on 9/3/25; and -Budesonide/formoterol (brand name Symbicort) 160-4.5 micrograms (mcg, a unit of measurement) actuation inhaler two puffs to be inhaled orally two times a day for chronic obstructive pulmonary disease (COPD, a group of lung diseases that cause long term breathing problems) and to rinse mouth after use, ordered on 9/3/25. During a medication pass observation on 9/7/25 at 9:26 a.m., LN 4 was observed administering carvedilol 3.125 mg to Resident 85 without food. LN 4 was also observed administering Jardiance 10 mg to Resident 85 without food. During a concurrent interview and record review on 9/7/25 at 9:26 a.m. with LN 4, LN 4 stated she did not know when Resident 85 last ate food and did not verify with Resident 85 prior to administration. LN 4 confirmed that the physician's orders for carvedilol 3.125 mg and Jardiance 10 mg both stated to give these medications with a meal. LN 4 confirmed that giving medication without meals as ordered could have potentially affected the efficacy of the medication and caused side effects. During an interview on 9/7/25 at 12:15 p.m. with ADON, ADON stated Resident 85 last ate approximately around 7:15 a.m. to 7:30 a.m. During an interview on 9/8/25 at 1:20 p.m. with Consultant Pharmacist (CP), CP stated administration of medication two hours after mealtime was not considered administration with food. CP stated medications ordered with a meal should be administered within 30 to 45 minutes of the mealtime. CP stated the potential outcome for administering medications ordered with a meal but given on an empty stomach could lead to stomach upset. CP further stated the absorption of some medications could be better with a meal. During a concurrent medication pass observation and interview on 9/7/25 at 9:26 a.m. with LN 4, LN 4 was observed administering one puff of Symbicort inhaler to Resident 85. LN 4 confirmed the physician's orders for Symbicort indicated to administer two puffs and stated she only administered one. A review of the facility's policy and procedure (P&P) titled, Administering Medications, dated April 2019, indicated, Medications are administered in accordance with prescriber orders, including any time frame. The P&P further indicated, The individual administering the medication checks the label three times . Before administering the medication.

Based on observation, interview, and record review, the facility failed to:1. Ensure multi-dose medications with shortened expiration dates were labeled correctly after use with an open date;2. Ensure medications were securely stored within manufacturer's specifications; and3. Ensure safe storage and monitoring of over the counter (OTC) medications. These failures had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date, incorrect medications from inadequate labeling, and unsafe or ineffective medications or biologicals from inadequate storage that was left unsupervised and open to anyone in the facility.Findings: 1. During a medication pass observation on 9/7/25 at 9:26 a.m. with Licensed Nurse 4 (LN 4), Resident 85's inhalers Budesonide/Formoterol or Symbicort (a prescription inhalation medication used to treat chronic lung diseases) and Tiotropium or Spiriva Respimat (a prescription medicine used as a long-term once-daily maintenance treatment) were found to be unlabeled with an open date. During a concurrent medication cart audit of Cart 2 and interview on 9/7/25 at 12:49 p.m. with LN 2, three out of five Refresh Tears eye drops (OTC liquid eye medicine meant to provide moisture to eyes) did not have resident specific labeling. LN 2 confirmed that labeling was missing. A review of the facility's policy and procedure (P&P) titled, Medication Labels, dated 3/2018, indicated, Labels are permanently affixed to the outside of the prescription container. The P&P further indicated, If a label does not fit directly onto the product, for example eye drops, the label may be affixed to an outside container or carton, but the resident's name must be maintained directly on the actual product container . Nonprescription medications not labeled by the pharmacy are kept in the manufacturer's original container and identified with the resident's name. 2. During a concurrent medication cart audit of Cart 2 and interview on 9/7/25 at 12:49 p.m. with LN 2, budesonide inhalation suspension ampules (a liquid medication contained in small individual containers used to reduce inflammation and swelling in airways) 0.5 milligrams per milliliter (mg/ml; units of measurement) were not stored inside foil packaging. LN 2 reviewed the manufacturer's labeling and confirmed it indicated, Once the foil envelope is opened, use the vials within 2 weeks . LN 2 confirmed the ampules were not stored in foil packaging in accordance with the manufacturer's specifications. During a concurrent medication cart audit of Cart 2 and interview on 9/7/25 at 12:49 p.m. with LN 2, fluticasone furoate/vilanterol (a prescription dry powder inhaler used long-term to help with symptoms of various lung diseases) 100-25 micrograms (mcg, a unit of measurement) was identified without an opened date. LN 2 confirmed the inhaler did not have an opened date and stated it should have. A review of the facility's P&P titled, Medication Labels, dated 3/2018, indicated, Contents are not transferred from one container to another. The P&P further indicated, Each prescription medication label includes date dispensed . Expiration date of medication. A review of the manufacturer's labeling for budesonide ampules indicated, After opening the aluminum foil envelope, the unused ampules should be returned to the aluminum foil envelope to protect them from light. 3. During an observation on 9/8/25 at 9:25 a.m., the central supply room (a space where facility stored items such as medical equipment, and supplies in a secure locked area) was left with the door wide open and the room unattended. OTC medications were observed on the shelves unattended in the open room which was located next to resident rooms. During an interview on 9/8/25 at 9:35 a.m. with Staffing Coordinator (SC), SC confirmed the door to the central supply room where OTC medications were stored should not have been left unlocked and unattended. During an interview on 9/8/25 at 11:48 a.m. with the Administrator (ADM) and Director of Nursing (DON), ADM and DON confirmed the door to the central supply room should have been locked and secured. A review of the facility's P&P titled, Storage of Medications, dated 11/2020, indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner . Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls . Compartments containing drugs and biologicals are locked when not in use.

Based on observation, interview, and record review, the facility failed to follow the recipe for three residents of a census of 67 (Resident 16, Resident 24, and Resident 85), when an unmeasured amount of milk was added to pureed (a very smooth, lump-free, and moist consistency similar to pudding, requiring no chewing and able to be swallowed easily) rice.This failure had the potential to add extra liquids to the rice serving and decrease the intake of nutrients.Findings:A review of Resident 16's admission Record, indicated she was admitted to the facility in 2023.A review of Resident 16's Order Summary Report, dated 8/25/25, indicated a fortified diet (added calories) order with a pureed texture and nectar thick consistency.A review of Resident 24's admission Record, indicated he was admitted to the facility in 2024 with a diagnosis of dysphagia (difficulty swallowing). A review of Resident 24's Order Summary Report, dated 9/8/25, indicated an order for a regular large portions diet with a pureed texture and thin liquids consistency. A review of Resident 85's admission Record, indicated she was admitted to the facility on [DATE] with a diagnosis of dysphagia.A review of Resident 85's Order Summary Report, dated 9/4/25, indicated a diet order with no added salt, consistent carbohydrate/controlled carbohydrate (CCHO - a diet for managing blood sugar), a pureed texture and nectar thick consistency.A review of the facility's lunch menu, dated 9/9/25, indicated the lunch menu consisted of curry lemon chicken, garlic rice, peas with onions, wheat roll, and ice cream.A review of the facility's recipe titled, Pureed (IDDSI Level 4 [International Dysphagia Diet Standardization Initiative-Level 4 consists of pureed foods and extremely thick drinks]) Starch (Rice .), dated 2024, indicated six to 12 ounces [(a unit of measure) 0.75 to 1.5 cups] of warm milk to be added to six servings of rice.During a concurrent observation and interview on 9/9/25 at 10 a.m. with [NAME] 2 (C2) and the Dietary Services Supervisor (DSS), lunch preparation for pureed food items was observed. C2 stated she was making six servings of rice, then measured six servings of cooked rice and put it in a blender. Heated milk was to be added in increments using a 1/3 cup scoop to obtain the desired pureed consistency. C2 added three unmeasured scoops of milk and stated she should have followed the recipe and measured the amount of added milk. DSS took the recipe binder from behind C2 and showed her the pureed recipe for rice.During an interview on 9/9/25 at 10:40 a.m. with the Registered Dietician (RD), RD stated C2 did not measure three of the scoops of milk added to the rice. RD further stated it was uncertain what the partial scoops added up to in total.A review of the facility's policy titled, Diet Orders, dated 2023, indicated, Diet orders as prescribed by the Physician will be provided by the Food and Nutrition Services Department.

Based on observation, interview, and record review, the facility failed to properly prepare and store food for a census of 67 residents, when:1. Stored food was found expired and unlabeled; and 2. The cool down procedure was not followed for cooked meat.This failure decreased the facility's potential to prevent foodborne illnesses among vulnerable residents.Findings:1. During a concurrent observation and interview on 9/7/25 at 8:32 a.m. with the Assistant Dietary Manager (AsstDM), the following items were found:-In the dry storage: One unopened package of hamburger rolls, removed from freezer on 8/27/25, with a 'use by' date of 9/3/25; one opened package of wheat bread, unlabeled and undated; two opened packages of pasta, opened on 9/1/24, with a 'use by' date of 9/1/25. AsstDM stated the items were past their expiration dates and needed to be discarded.-In the walk-in refrigerator: 20 heads of celery with wilted leaves, with an expiration date of 9/4/25. AsstDM confirmed the celery was past the expiration date and should not be served to residents.During an interview on 9/7/25 at 8:44 a.m. with the Dietary Services Supervisor (DSS), DSS confirmed the food items in the dry storage and walk-in refrigerator were expired and stated it should not be served to residents. DSS further stated serving expired food could potentially cause foodborne illness among residents.A review of a facility document titled, Dry Goods Storage Guidelines, dated 2023, indicated opened and unopened bread should be stored on the shelf 5-7 days before discarding, and opened pasta could be stored safely for one year. A review of the facility's policy and procedure (P&P) titled, Storage of Food and Supplies, dated 2023, indicated, All food will be dated - month, day, year. All food products will be used per the times specified in the Dry Food Storage Guidelines . Dry food items which have been opened . will be tightly closed, labeled and dated . Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents, or swells shall not be retained or used.A review of a facility document titled, Produce Storage Guidelines, dated 2023, indicated celery was to be stored one week in the refrigerator before discarding.A review of a facility document titled, Storing Produce, dated 2023, indicated, Check boxes of fruit and vegetables for rotten, spoiled items . Throw away all spoiled items . Remove the wilted or spoiled portions of lettuce, celery, and other fresh vegetables in the refrigerator often so they don't cause the rest of the vegetable to spoil.2. During an observation on 9/7/25 at 9:25 a.m., [NAME] 1 (C1) was cutting turkey roasts on the meat slicer for the residents' lunch entree. During a concurrent interview and record review on 9/7/25 at 9:25 a.m. with C1 and DSS, the facility's document titled, Cool Down Log, dated 9/25, was reviewed. The log indicated the temperature at two hours in the cooling process of cooked meats should be 70 degrees Fahrenheit ( F - a temperature scale where water freezes at 32 F and boils at 212 F) or below. If the meat temperature was higher than 70 F, the meat was to be discarded. The log further indicated on 9/6/25 at the two-hour cool down time, [NAME] 1 (C1) documented the temperature of the turkey roasts was 80 F, and continued the cool down process. Both C1 and DSS stated 80 F was too high as a cool down temperature for the meat at the two-hour mark, and the turkey needed to be discarded. A review of the facility's P&P titled, Cooling and Reheating of Potentially Hazardous Food (PHF), dated 2023, indicated, Cooked PHF. shall be cooled and reheated in a method to ensure food safety. PHF food includes food of animal origin that is raw or heat-treated . [which] includes . meat, fish, poultry. The P&P further indicated, When cooked PHF food will not be served right away, it must be cooled as quickly as possible. The P&P specified the two-stage cool down method: Cool cooked food from 140 F to 70 F within two hours. Then cool from 70 F to 41 F or less in an additional four hours for a total cooling time of six hours . Corrective Action is to be taken when the cool down process is not done correctly: discard cooked, hot food immediately when the food is above 70 F and more than 2 hours into the cooling process.

Based on observation, interview, and record review, the facility failed to properly dispose garbage for a census of 67 residents, when a kitchen garbage dumpster was found to have two gaping, warped lids. This failure had the potential to produce unsanitary conditions for residents due to easy access for rodents and other pests.Findings:During a concurrent observation and interview on 9/7/25 at 9:46 a.m. with the Registered Dietician (RD) and the Maintenance Plant Director (PD), the kitchen dumpsters were observed. One garbage dumpster's lids were rounded and bowed, leaving a lengthy 3-inch (a unit of measure) gap between the lids and the top rim. RD stated it was a pest problem because rodents and insects had access inside the dumpster. PD stated he ordered a new dumpster but had no documentation of the order with the disposal company.A review of the facility's document titled, Garbage and Trash, dated 2023, indicated, Adequate, clean, vermin-proof areas must be provided for the storage of garbage . and that the lids are closed.

Based on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented for a census of 67 residents, when:1.Multiple surfaces in the laundry room's clean area were found with an accumulation of a gray powdery substance;2.Resident 73's nebulizer (machine that turns liquid medicine into a mist that can be easily inhaled) mask was found on top of the nightstand without a bag;3.Resident 34's bathroom toilet contained a large, thick soiled dressing;4.Licensed Nurse (LN) 3 and LN 4 did not maintain fingernails in accordance with the facility's policy;5.Multi-resident medical equipment was not sanitized and disinfected in accordance with professional standards; and6.Single use Styrofoam tray used during med pass was not disposed after use.These failures had the potential to spread infection among residents, staff, and visitors.Findings: 1.During an observation on 9/8/25 at 11:06 a.m. in the laundry room's clean area, an accumulation of gray powdery substance was found on a cart containing clean linens covered with pink mesh material, on a portable fan on the table where staff would fold clean laundry, and in the area behind the three dryers. During a concurrent observation and interview on 9/8/25 at 11:20 a.m. with Environmental Services Supervisor (EVS), the cart containing clean linens covered with pink mesh material, the portable fan on the table, and the area behind the three dryers were observed. EVS confirmed the accumulation of the gray powdery substance and stated it was neither clean nor good for residents and staff. EVS further stated they did not pay much attention to the accumulation of the gray powdery substance. A review of the facility's policy titled, Departmental (Environmental Services) – Laundry and Linen, dated January 2014, indicated, Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination . A review of the facility's policy titled, Cleaning and Disinfection of Environmental services, dated August 2019, indicated, Environmental surfaces will be cleaned and disinfected . 2. A review of Resident 73's admission Record, indicated Resident 73 was admitted to the facility in September 2025 with diagnoses including chronic obstructive pulmonary disease (a lung condition that causes long-term damage to the airways and lungs, making it difficult to breathe) and pulmonary embolism (a condition where a blood clot blocks a lung artery but does not immediately cause acute right heart strain or failure). A review of Resident 73's Order Summary Report, dated 9/10/25, indicated Resident 73 had an order for ipratropium-albuterol solution (a combination of two medications, both which help to relax the muscles in the airways and increase airflow to the lungs) to be inhaled via nebulizer every six hours. During an observation on 9/7/25 at 10:06 a.m. in Resident 73's room, a nebulizer mask was found on top of Resident 73's nightstand without a bag. During a concurrent observation and interview on 9/7/25 at 10:14 a.m. with Infection Preventionist (IP) in Resident 73's room, Resident 73's nebulizer mask was observed. IP confirmed the nebulizer mask was not in a bag and stated the nebulizer mask should always be inside a bag to prevent infection. A review of the facility's policy titled, Respiratory Therapy – Prevention of Infection, dated November 2011, indicated, Infection Control Considerations related to Medication Nebulizers . Store the circuit [complete nebulizer setup] in plastic bag . between uses. 3. A review of Resident 34's admission Record, indicated he was admitted to the facility in August 2025 with diagnoses including neutropenia (an abnormally low count of neutrophils, a type of white blood cell that is crucial for immunity), lung transplant, squamous cell carcinoma on the scalp (a cancer on the outer skin layer), and a pressure sore (an injury to the skin and underlying tissue resulting from prolonged pressure) of the sacral region (tailbone). A review of Resident 34's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 8/22/25, indicated his Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 11 out of 15 with moderate memory impairment. A review of Resident 34's Treatment Administration Record, dated September 2025, indicated Resident 34 had daily orders for dressing changes to his scalp cancer surgical site and tailbone pressure sore. A review of Resident 34's Order Summary Report, dated 9/10/25, indicated he was receiving mycophenolate mofetil to maintain immunosuppression (a medical treatment that represses the immune system, often prescribed to prevent rejection of transplanted organs) for his lung transplant. During a concurrent observation and interview on 9/7/25 at 10:10 a.m. with Resident 34, Resident 34 stated he was continent of bowel and bladder, and staff always assisted him to the toilet. The toilet in Resident 34's room had a large rectangular skin bandage, dated 9/5/25. The dressing had absorbed a large amount of toilet water and appeared cube-shaped, measuring approximately 4 x 3 x 3 inches (a unit of measure). During a concurrent observation and interview on 9/7/25 at 10:27 a.m. with LN 5, LN 5 stated it was unacceptable for a staff member to leave the soiled bandage in the toilet after assisting Resident 34. LN 5 further stated the nursing aide who cared for Resident 34 should have discarded it in a safe biohazard receptacle and this was an infection control issue. A biohazard waste bin was in Resident 34's room for such items. During an interview on 9/9/25 at 7:50 a.m. with IP, IP stated dressings should never be discarded in the toilet and the assistant caring for Resident 34 should have disposed of the soiled dressing in the biohazard disposal bin in the resident's room, not the toilet. IP further stated flushing the dressing down the toilet would clog the pipes and cause contaminated water to overflow, exposing Resident 34 to infectious microorganisms, knowing that Resident 34 was undergoing immunosuppressive therapy following a lung transplant, and any exposure to infectious organisms could be fatal. A review of a facility document titled, Infections-Clinical Protocol, revised in 3/18, indicated, The physician . and staff will identify infection transmission risks and (in conjunction with the Infection Preventionist) will implement relevant precautions. A review of the facility's policy titled, Infection Prevention and Control Program, revised in 10/18, indicated the infection prevention program provides . a safe, sanitary . environment and to help prevent the development and transmission of communicable diseases and infections. The policy further indicated to prevent infection, the facility should ensure staff are adhering to . proper techniques and procedures . following established general guidelines such as those of the Centers for Disease Control (CDC). 4. During a medication pass observation on 9/7/25 at 9:26 a.m., LN 4 was observed preparing and administering medication with approximately one-inch-long acrylic fingernails on both hands. During a concurrent observation and interview on 9/8/25 at 8:42 a.m. with LN 3, LN 3 was observed preparing and administering medication with approximately one-inch-long acrylic fingernails on both hands. LN 3 stated she knew she was not supposed to have them. LN 3 further stated long fingernails could grow pathogens (a virus or other microorganism that can cause disease). During an interview on 9/8/25 at 9:56 a.m. with IP, IP stated artificial nails were not allowed. IP further stated she had an in-service for her staff and informed staff nails should not exceed tip of finger because of patient care, because it had the potential to scratch the residents. IP also stated short nails helped prevent the spread of infection. During an interview on 9/8/25 at 4:31 p.m. with Director of Nursing (DON), DON stated long nails were an infection control issue and no one should have had them, especially nurses and Certified Nursing Assistants (CNAs) because they performed direct patient care. A review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 9/2022, indicated, Personnel with direct-care resident responsibility should maintain short, natural fingernails . Wearing artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities and is prohibited among those caring for severely ill or immunocompromised residents. A review of an undated article published by the CDC titled, Clinical Safety: Hand Hygiene for Healthcare Workers, indicated, Know when to clean your hands: Immediately before touching a patient . Immediately after glove removal . Maintain fingernail and jewelry safety: Natural nails should not extend past the fingertip. Do not wear artificial nails or extensions when having direct contact with high-risk patients . Germs could live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing. 5. During a medication pass observation on 9/7/25 at 8:52 a.m., LN 4 was observed using Micro Kill 2 Germicidal wipes (used in healthcare settings to clean and disinfect hard, non-porous surfaces and equipment) to disinfect the blood pressure (BP) cuff and stethoscope (medical devices used to measure BP) without gloves after checking a resident's BP. During an interview on 9/7/25 at 1:27 p.m. with LN 4, LN 4 stated she was expected to wear gloves when using Micro Kill 2 Germicidal wipes to disinfect medical equipment after use on a resident, but she had not. During an interview on 9/8/25 at 9:56 a.m. with IP, IP stated staff were expected to wear gloves when cleaning medical equipment to protect their skin from harmful chemicals and also for infection control. During an interview on 9/8/25 at 4:31 p.m. with DON, DON stated staff were expected to wear gloves when they touched a chemical wipe and the BP cuff was dirty after use and staff's hands were dirty after touching it. DON further stated gloves were to help prevent cross contamination between the BF cuff and soiled hands. A review of an article published by the CDC titled, Cleaning and Disinfecting your Facility, dated 4/5/21, indicated, Use chemical disinfectants safely! Always read and follow the directions on the level of cleaning and disinfection products to ensure safe and effective use . Wear gloves for all tasks in the cleaning process. 6. During a medication pass observation on 9/7/25 at 9:26 a.m., LN 4 was observed using a single use Styrofoam tray on her medication cart to prepare medication for Resident 85. LN 4 was then observed taking the medication on the tray into Resident 85's room and placing it on her bedside table. After administration of medication to Resident 85, LN 4 was observed putting the same single use Styrofoam tray back onto her cart instead of discarding it after use. During an interview on 9/8/25 at 9:56 a.m. with IP, IP stated the Styrofoam trays were not multi use and should have been thrown away immediately after its first use because of the possibility of spreading infection. IP then stated if a resident had C. Diff (clostridium difficile a bacterium that could cause inflammation of the colon and could be spread through contact of contaminated surfaces) then staff would have introduced that to the medication cart and that's how infection spreads. During an interview on 9/8/25 at 4:31 p.m. with DON, DON stated not discarding the single use Styrofoam tray immediately after use would have created an infection control issue. A review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 9/2022, indicated, Single-use items are disposed of after a single use.

Based on observation, interview, and record review, the facility failed to protect and keep secure when not in use confidential resident health data and records for a census of 67 residents. This failure had the potential to expose and disclose personal and confidential residents' health information to unauthorized individuals.Findings:During a medication pass observation on 9/7/25 at 9 a.m., Licensed Nurse (LN) 4's computer screen was observed unlocked and accessible to residents and staff passing by when she left to clarify an order. During a medication pass observation on 9/7/25 at 9:08 a.m., LN 4's computer screen was again observed unlocked and accessible to residents and staff passing by when she left to enter a resident's room. During an interview on 9/7/25 at 1:21 p.m. with LN 4, LN 4 confirmed she left the computer unlocked and unattended when she went to clarify an order and again when she entered a resident's room. During an interview on 9/8/25 at 4:31 p.m. with Director of Nursing (DON), DON stated nursing staff were expected to lock the cart and screen to hide residents' information so personal health information would not be exposed. A review of the facility's policy and procedure titled, Electronic Medical Records, revised in 3/14, indicated, Policy Interpretation and Implementation . 3. Only authorized persons who have been issued a password and user ID code will be permitted access to the electronic medical records system. 4. The facility will make reasonable efforts to limit the use or disclosure of protected health information .

Based on observation, interview, and record review, the facility failed to ensure professional standards were followed for three of 26 sampled residents (Resident 7, Resident 82 and Resident 85), when:1. A lidocaine (anesthetic used to treat pain) five percent (%, a unit of measurement) patch was applied to Resident 82's lower back without date, time and initials of the nurse applying it;2. Licensed Nurse 4 (LN 4) did not identify Resident 85 prior to medication administration;3. LN 4 did not wear gloves during preparation and administration of hazardous medication; and4. Nursing staff did not clarify overlapping PRN (as needed) pain medication orders. These failures had the potential to result in inappropriate medication administration, preventable medication errors, increased risk of adverse drug events, oversedation, and resident harm or death. Findings:1.During a medication pass observation on 9/7/25 at 8:12 a.m., the Assistant Director of Nursing (ADON) was observed applying a topical lidocaine patch to Resident 82's lower back. ADON applied the patch without signing and dating it.During an interview on 9/7/25 at 12:15 p.m. with ADON, ADON confirmed she was supposed to sign and date the lidocaine patch after applying it but did not do so because she did not have a marker.During an interview on 9/8/25 at 4:31 p.m. with the Director of Nursing (DON), DON stated nurses were expected to date and sign patches upon administration to ensure the patch was changed correctly and to prevent medication errors.A review of the facility's policy and procedure (P&P) titled, Transdermal Drug Delivery System (Patch) Application, dated 3/18, indicated, Procedures: Label patch with date and nurse's initials.2.During a medication pass observation on 9/7/25 at 9:26 a.m., LN 4 was observed entering the room of Resident 85 and beginning medication administration without properly identifying the resident.During an interview on 9/7/25 at 9:36 a.m. with LN 4, LN 4 stated she missed identifying the resident prior to medication administration and normally she would ask their name and date of birth prior to giving medication.During an interview on 9/8/25 at 4:31 p.m. with DON, DON stated nurses were expected to verify the identity of the residents prior to medication pass, and some ways to do that were to use the picture on the Medication Administration Record (MAR) and look at the name on the wall by resident's door.A review of the facility's P&P titled, Administering Medications, dated April 2019, indicated, The individual administering medication verifies the resident's identity before giving the resident his/her medications. The P&P further indicated, The individual administering medication checks the label three times to verify the right resident . Before giving the medication.3.During a medication pass observation on 9/7/25 at 9:26 a.m., LN 4 was observed preparing and administering Resident 85's spironolactone (medication used to treat conditions such as high blood pressure, heart failure, fluid retention), a hazardous medication, without gloves.During a concurrent interview and record review on 9/7/25 at 9:26 a.m. with LN 4, the labeling on the bubble packet of Resident 85's medical record and spironolactone was reviewed. LN 4 confirmed Resident 85's medical record did not have any indication to alert staff that spironolactone was a hazardous drug. LN 4 confirmed the label on the bubble packet contained the word HAZAR to indicate it was hazardous.During an interview on 9/7/25 at 1:21 p.m. with LN 4, LN 4 stated she did not know spironolactone was a hazardous medication and required gloves when it was prepared and administered.During an interview on 9/8/25 at 1:09 p.m. with Consultant Pharmacist (CP), CP stated for spironolactone, gloves would be required for handling especially for staff that could be pregnant. CP also stated staff were made aware a drug was hazardous by the labels on the bottles and by his recommendation to have it added into charts.During an interview on 9/8/25 at 4:31 p.m. with DON, DON stated she informed her staff on several occasions to never touch any medication. DON added she did not know spironolactone was hazardous, but she told staff to always have gloves on because you never know. DON further stated no one had told her spironolactone should be stored separately.A review of the facility's P&P titled, Storage of Medications, dated 11/20, indicated, Hazardous drugs are clearly marked and stored separately from other medications.4.During a concurrent interview and record review on 9/9/25 at 11:32 a.m. with DON, Resident 7's physician's orders were reviewed. Resident 7's medical record indicated the following physician's orders for pain management:-Acetaminophen (a mild pain medication) oral tablet 500 milligrams (mg, a unit of measurement). Give 500 mg by mouth every six hours as needed for pain not to exceed (NTE) three grams (g, a unit of measurement) of Acetaminophen (APAP) within a 24-hour period, ordered on 6/1/25, and-Hydrocodone-Acetaminophen (a more potent pain medication) tablet 5-325 mg. Give one tablet by mouth every six hours as needed for pain NTE 3 g of APAP within a 24-hour period, ordered on 6/22/25.DON confirmed Resident 7's physician's orders for Acetaminophen and Hydrocodone/APAP were both ordered as needed and stated nursing staff should have clarified the order with the physician to know when it was appropriate to administer each medication. DON further stated nursing staff should have clarified the order with the physician to include parameters (a pain scale) to know when to administer each medication.A review of the facility's P&P titled, Administering Medications, dated 4/19, indicated, If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.

Based on interview and record review, the facility failed to ensure two of 26 sampled residents (Resident 16 and Resident 11) and their responsible parties (RP- a person responsible for health care decisions) were informed of the residents' change of condition and medical appointments.This failure had the potential for the residents' RP not to be able to make an informed decision about the residents' healthcare.FindingsA review of Resident 16's admission Record, indicated she was admitted to the facility in 2023 with diagnoses including dementia (a progressive state of decline in mental abilities) and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities). The record also indicated Resident 16's son was the RP.During an interview on 9/8/25 at 12:19 p.m. with Resident 16's RP, RP stated Resident 16 was to be seen by an Ear, Nose and Throat specialist (ENT- a doctor specializing in conditions affecting the ears, nose, throat, sinuses, and parts of the head and neck.) for a follow up about her ear infections and had not been seen.A review of Resident 16's medical record indicated two ENT follow-up appointments were completed on 7/24/25 and 8/13/25. The medical record did not indicate the RP was notified of the follow-up ENT appointments or the treatment plan.A review of Resident 11's admission Record, indicated she was admitted to the facility in August 2025 with diagnoses including cerebral infarction (blood flow is interrupted to the brain, causing damage) and vascular dementia (cognitive decline caused by damage to the blood vessels in the brain).A review of Resident 11's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/15/25, indicated Resident 11's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was three out of 15 with severe memory impairment.During an interview on 9/9/25 at 9:36 a.m. with Resident 11's RP, RP stated she was concerned about the lack of notification after Resident 11's fall on 8/23/25 which led to a right foot injury.A review of Resident 11's medical record indicated Resident 11's RP was not notified after a change of condition (COC- a document that indicates a change in resident health condition) on 8/25/25. The COC form indicated a call to the RP without a response. The medical record did not indicate a follow-up call to the RP or a contact with another family member.During a concurrent interview and record review on 9/9/25 at 2:15 p.m. with the Assistant Director of Nursing (ADON), Resident 16 and Resident 11's medical records were reviewed. ADON confirmed there were no RP notifications in the medical records regarding Resident 16's follow-up ENT appointments and Resident 11's COC. ADON stated her expectations were staff should have notified the RPs of appointments, treatment plans and changes in conditions in any resident.A review of the facility's policy titled, Informing Resident of Health, Medical Condition and Treatment Options, dated 2/2021, indicated, Every resident is informed of his or her total health status, medical condition and options for treatment and/or care. The policy further indicated, Each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance of treatment and on an on-going basis. If a resident has an appointed representative, the representative is also informed.

Based on observation, interview, and record review, the facility failed to ensure proper care of respiratory equipment was consistent with the facility's policy and professional standards of practice for one of 26 sampled residents (Resident 10), when Resident 10's nebulizer tubing and nasal cannula (a thin, flexible tube that goes around your head and into the nose and gives additional oxygen through the nose) were not changed after seven days.This failure decreased the facility's potential to provide safe respiratory care for Resident 10.Findings:A review of an admission record indicated Resident 10 was admitted to the facility in February 2024 with a diagnosis of respiratory failure with hypoxia (insufficient amount of oxygen in the body's tissues).A review of Resident 10's Order Summary Report, dated 7/30/25, indicated an order for oxygen via nasal cannula to keep oxygen saturation at 92 percent.During a concurrent observation and interview on 9/7/25 at 9:32 a.m. with Licensed Nurse 1 (LN 1) in Resident 10's room, a nebulizer machine with tubing/mouthpiece (a machine that turns liquid medicine into a fine mist) and a nasal cannula were observed by Resident 10's bedside table. LN 1 confirmed both tubings were last replaced on 8/28/25 as indicated by the label attached to it. LN 1 stated the tubings were not changed in seven days.During an interview on 9/10/25 at 10 a.m. with the Director of Nursing (DON), DON stated her expectation for staff was to adhere to the facility's policy regarding the proper use and maintenance of respiratory equipment for residents.A review of the facility's policy titled, Departmental Respiratory Therapy, revised in 11/2011, indicated, The purpose of this procedure is to guide . with respiratory therapy tasks and equipment including . medication nebulizers/Continuous Aerosol . Discard the administration set-up every seven (7) days.

Based on interview and record review, the facility failed to accommodate the needs of one of 26 sampled residents (Resident 76), when Resident 76 was not given a shower as scheduled.This failure decreased the facility's potential to provide comfort to residents.Findings:A review of an admission record indicated Resident 76 was admitted to the facility in September 2025 with a diagnosis of right femur (thigh bone) and vertebra (backbone) fracture.During an interview on 9/7/25 at 9:24 a.m. with Resident 76, Resident 76 stated she felt uncomfortable because she had not taken a shower since her admission to the facility.A review of the facility's Skilled Nursing Shower Assignment, updated on 8/18/25, indicated Resident 76 was scheduled to have morning showers on Monday, Wednesday and Friday.During an interview on 9/10/25 at 9:45 a.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated residents were assisted with showers in the morning per their schedule. CNA 2 further stated CNAs must complete a shower tracking sheet and document it in the computer to let the Licensed Nurse (LN) know if the shower was given or refused by the resident.During a concurrent interview and record review on 9/10/25 at 10 a.m. with LN 1, Resident 76's shower schedule and the facility's shower tracking sheet binder were reviewed. LN 1 confirmed there was no documented shower sheet for Resident 76.During a concurrent interview and record review on 9/10/25 at 11:10 a.m. with the Director of Staff Development (DSD), Resident 76's progress notes and bathing task documentation were reviewed. DSD stated based on the notes Resident 76 did not refuse to take a shower the week before. DSD further stated the assigned CNA did not provide Resident 76 a shower.During an interview on 9/10/25 at 1:30 p.m. with the Administrator (ADM), ADM stated he expected CNAs to provide showers to residents as scheduled unless they refused. ADM further stated staff should prioritize the residents' physical needs to provide comfort and dignity.A review of the facility's policy titled, Bath, Shower/Tub, revised in 2/18, indicated, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.

Based on observation, interview, and record review, the facility failed to accurately assess one of 26 sampled residents (Resident 5), when the Minimum Data Set (MDS, a federally mandated assessment tool) inaccurately indicated Resident 5 had no pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).This failure had the potential to incorrectly recognize Resident 5's care needs.Findings:A review of an admission record indicated Resident 5 was admitted to the facility in November 2023 with a diagnosis of pressure ulcers. During an observation on 9/7/25 at 9:44 a.m. inside Resident 5's room, a wound vacuum assisted closure device (wound VAC, a negative pressure wound treatment that uses suction to help hard to heal wounds heal faster) was observed at the side of Resident 5's bed in continuous operation.A review of Resident 5's Order Summary Report, dated 7/10/25, indicated Resident 5 had treatment orders for two stage four pressure ulcers (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone at the base of the spine), one located on the sacrum (a triangular bone in the lower back) and the other one located on the left gluteal crease (horizontal line at the bottom of the left buttock cheek) and had the wound VAC.A review of Resident 5's MDS, dated [DATE], indicated no documented pressure ulcers in the skin condition MDS assessment.During a concurrent interview and record review on 9/9/25 at 1:44 p.m. with the MDS Coordinator (MDSC), Resident 5's MDS assessments, physician orders, treatment notes and Treatment Administration Record (TAR) were reviewed. MDSC confirmed Resident 5 had pressure ulcers since admission and stated the MDS assessment, dated 6/2/25, was inaccurately coded based on the TAR and treatment notes. During a concurrent interview and record review on 9/9/25 at 2:10 p.m. with the Nurse Consultant (NC), Resident 5's MDS assessments were reviewed. NC stated MDSC should have made sure assessments were documented accurately to ensure proper delivery of care to residents.A review of the facility's policy titled, Certifying the Accuracy of Resident Assessment, revised in 12/19, indicated, Any person . completing the MDS must . certify the accuracy of that portion of the assessment.

Based on observation, interview, and record review, the facility failed to maintain privacy for one of 26 sampled residents (Resident 82), when Resident 82's urinary catheter (a tube left in the bladder to continuously drain urine into a collection bag) collection bag had no privacy cover. This failure decreased the facility's potential to maintain Resident 82's dignity.Findings:A review of Resident 82's admission Record, indicated she was admitted to the facility in August 2025 with diagnoses including acute cystitis (bladder infection) and neuromuscular dysfunction of the bladder (a condition in which the nerves controlling the bladder and urinary sphincter are damaged, leading to problems with urine storage and emptying).A review of Resident 82's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/3/25, indicated her Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) was 12 out of 15 with moderate memory impairment.A review of Resident 82's Treatment Administration Record, dated 9/25, indicated an order to monitor Resident 82's urinary catheter.During a concurrent observation and interview on 9/7/25 at 1:20 p.m. with Resident 82 in her room, Resident 82 was sitting in her wheelchair at her bedside table eating lunch. Resident 82's urinary catheter bag was attached beneath the seat. Resident 82 stated she never had a private cover for the urine collection bag since she was admitted and wanted to have one.During a concurrent observation and interview on 9/7/25 at 1:40 p.m. with Certified Nursing Assistant 1 (CNA 1) in Resident 82's room, CNA 1 confirmed Resident 82 did not have a privacy cover for her urinary collection bag and stated she should have one.During an interview on 9/9/25 at 7:50 a.m. with the Infection Prevention Nurse (IP), IP stated urinary catheter bags should always be covered to maintain residents' privacy.A review of the facility's policy titled, Dignity, revised in 2/21, indicated, Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered .

Based on observation, interview, and record review, the facility failed to promote dignity for one of three sampled residents (Resident 2), when the resident was not provided shower for five days. This failure had the potential to result in Resident 2 ' s not attaining her feelings of self-worth and self-esteem. Findings: Resident 2 was admitted to the facility in spring 2025 with diagnoses which included spinal stenosis (narrowing of the spine), weakness, gait (walking) and mobility (moving) abnormalities, and lower back pain. During a review of Resident 2 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 6/6/25 , the MDS indicated Resident 2 required assistance with activities of daily living (ADLs), including bathing. During a concurrent observation and interview on 6/12/25 at 9:40 a.m. with Resident 2 in Resident 2 ' s room, Resident 2 was awake, alert and verbally responsive, and stated, I voiced my concern about not getting a shower quite a bit to the CNA ' s (Certified Nursing Assistant). My hair was so matted and dirty it didn ' t make me feel good at all. During a concurrent interview and record review on 6/12/25 at 10a.m. with CNA 1, the Skilled Nursing Shower Schedule, dated April 2025 was reviewed. The Skilled Nursing Shower Schedule indicated, Resident 2 ' s regular scheduled shower days were Monday and Thursday. CNA 1 indicated residents were scheduled on certain days for showers and CNA 1 would have expected residents to have a shower on their regular scheduled day unless documented as refusal. During a concurrent interview and record review on 6/12/25 at 10:14 a.m. with Director of Staffing Development (DSD), the undated Shower Tracking Sheet was reviewed. The Shower Tracking Sheet indicated, Resident 2 received a bed bath on 6/4/25 and a shower on 6/11/25. DSD confirmed Resident 2 did not receive her scheduled bath. During an interview on 6/12/25 at 1 p.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 stated completed and refused resident baths were documented on the shower tracking sheet. RNA 1 stated residents not having showers could put a resident at risk for infections and made them feel unclean. During a concurrent interview and record review on 6/12/25 at 2 p.m. with the Director of Staff Development (DSD), the Follow Up Question Report: Bathing Performed: Shower, Tub Bath, or Bed Bath, dated June 2025, indicated, there were no bathing services provided for Resident 2 for 5 days. The DSD stated, she expected Resident 2 ' s Saturday schedule shower to be in the log. The DSD stated the adverse outcome of not having a shower for a long period of time could lead to skin breakdown. During an interview on 6/12/25 at 1 p.m. with Director of Nursing (DON), the DON stated, she expected staff to follow the shower schedule and document completions and refusals. The DON stated the adverse outcome of missing shower could cause skin breakdown, could cause disinterest, and effect the resident ' s dignity. During a review of Resident 2 ' s Care Plan Report, dated 5/31/25, the Care Plan Report indicated, Resident 2 was dependent on staff for ADLs (bathing). During a review of the facility ' s policy and procedure (P&P) titled, Quality of Care- Dignity, dated 1/22, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on observation and interview, the facility was unable to provide a clean environment for the residents and visitors when three of three garbage dumpsters, located outside the facility, was not closed securely due to deformed dumpster lids. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: During a concurrent observation and interview with Dietary Supervisor (DS) on 9/23/24 at 8:38 a.m outside, three out of three dumpsters were covered with bent and deformed lids with bags of trash inside the bins. There were gaps between the deformed lids and the bins because the lids lacked integrity to securely cover the bins. DS confirmed the condition of the dumpster lids and agreed that the facility needed to order new trash bins. The DS further acknowledged that the lids needed to be closed tightly to prevent pest issues. During a review of facility policy and procedure titled, Miscellaneous Areas, last revised 2023, indicated, 1. All food waste must be placed in sealed leak proof, non absorbent, tightly closed containers .the trash collection area is a potential feeding ground for vermin and rodents and must be kept clean . According to the Food and Drug Administration (FDA) Food Code 2022, Section 5-501.15 Outside Receptacle, referenced 7/23/24, (A) Receptacles and waste handling units for refuse .used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors, or covers.

Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. The microwave in the kitchen was not clean; 2. Several various sizes of metal sheet pans were stacked wet stored at the clean and ready-to-use storage areas; 3. Produce items were not fresh and not discarded; and, 4. One dishwasher was not able to verbalize the procedure for the manual dishwashing with 3-compartment sinks correctly. These failures had potential to cause food-borne illness in a highly susceptible population of 59 out of 59 residents who received food from the kitchen. 1.During a concurrent observation and interview with Dietary Supervisor (DS) on 9/23/24 at 8:48 a.m. at the kitchen's initial tour, the microwave was observed to have dry liquid splashes on the interior top of the microwave. The DS confirmed the microwave was dirty and stated the dry food splashes and dry food debris should be cleaned. During a review of a facility document titled, Section 8- Sanitation, dated 2023, indicated, .11. All .equipment .shall be kept clean . 2. During a concurrent observation and interview with the DS on 9/23/24 at 9:10 a.m. at the kitchen's initial tour, several metal pans were observed wet and stacked together and stored at the clean and ready-to-use areas. Those metal pans included: -Nine of 1/6 sheet metal pans -eight - 1/8 sheet metal pans, and -two - full sheet metal pans were observed to be wet. DS confirmed and stated that dishes, pots and pans needed to be completely dried before being stored to prevent moisture. DS stated added moisture would cause bacterial growth. During a review of a facility document titled, Dishwashing, dated 2023, indicated, .5. Dishes are to be air dried in racks before stacking and storing. 3. During a concurrent observation and interview with the DS on 9/23/24 at 10:52 a.m. at the kitchen's initial tour, a bulk of potatoes were stored in an enclosed container with the lid closed. When the lid was opened, a foul odor was noted coming from inside the bin. Four potatoes were not fresh with black and white indents. Two of them were with white fuzzy substances. All the potatoes were mushy when touched. DS confirmed and stated they were mold and the potatoes were rotten and mushy. DS further stated that the potatoes were bad and should be discarded. During a concurrent observation and interview with the DS on 9/23/24 at 10:55 a.m. at the kitchen's initial tour, a bulk of onions were stored in an enclosed container with the lid closed. When the lid was opened, there were gnats (a group of tiny, winged flies, also called blackflies) flying out from the bin. There were four onions with black and white indents and mushy to touch. There were two onions that were mushy and black. The bottom of the container had a mushy liquid substance. The DS confirmed and stated the onions were not fresh and should be discarded. During a review of a facility document titled, Storing Produce, dated 2023, indicated, .1. Check boxes of .vegetables for rotten, spoiled items one rotten .potato in a box can cause the produce to spoil faster. Throw away all spoiled items . During a review of facility's policy and procedure (P&P) titled, Corrective Action when food in the store room reaches above 85 degrees F (Fahrenheit), dated 2023, indicated, .Onions should feel firm and dry. They should be free of gray or black mold . Potatoes .withering or rot, the potato should be thrown out. 4. A concurrent interview and review of manual dishwashing directions on 9/23/24 at 11:11 a.m. with Dietary Aide (DA) and the DS was conducted. DA stated if the dishwashing machine was not working, he would report to the DS and would start to use the 3-compartment sinks for the dishwashing. DA was not sure of sanitizing solution and stated incorrect immersion time of 20 seconds for the dishes. A concurrent review of the directions on the sanitizer solution bottle, it stated 60 secs for immersion time. DS confirmed and stated the directions indicated 60 seconds for immersion time and further acknowledged she also did not know the correct immersion time because the facility switched to a new supply vendor. During a follow up interview on 9/24/24 at 02:47 p.m. with the Registered Dietitian (RD), she stated the dishwasher and the dietary aides in their position should have a knowledge of the manual dishwashing. During a review of a facility document titled, 3-Compartment procedure for manual dishwashing, dated 2023, the steps manual indicated .Clean .wash .rinse .Step 5. Immerse all washed items for 60 seconds (note time) .

Based on observation, interview, and record review, the facility failed to ensure the menu was being followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) for lunch meals on 9/23/24 and 9/24/24 when: 1. Resident 257 with dysphagia (difficulty swallowing) mechanical texture diet (a diet that consist of foods that are moist, mechanically altered, easily mashed) who: a. Received puree zucchini instead of chopped and mashable zucchini on 9/23/24 lunch meal b. Received puree apple bread pudding instead of bread pudding chopped into half inch (1/2) and soak in milk on 9/24/24 lunch meal 2. Resident 21 with CCHO (controlled carbohydrate) diet (a diet to control blood sugar level) received one slice of garlic breadstick instead of one half of garlic breadstick on 9/23/24 lunch meal. 3. Resident 20 with finger food diet (a diet that provides food in appropriate size and shape to be eaten without utensils) who received regular apple bread pudding in one piece instead of the bread pudding cut into four pieces on 9/24/24 lunch meal. These failures had the potential to result in compromising the medical and nutrition status of those three residents. The facility census was 59. Findings: 1. a. During a dining observation of lunch meal service on 9/23/24, beginning at 12:12 p.m., it was noted Resident 257 was on dysphagia mechanical texture diet and received puree zucchini on the meal tray. A concurrent review of a facility spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) titled, Fall Menus, Week 4 Monday, showed that dysphagia mechanical texture diet should receive zucchini as chop 1/2, mashable, no crumbs. During an interview on 9/23/24, at 12:54 p.m., the Registered Dietician (RD) stated dysphagia mechanical soft diet should not get puree zucchini when reviewed the facility spreadsheet and acknowledged it was not correct. b. During meal distribution observation of lunch meal on 9/24/24, starting at 12:10 p.m., it was noted Resident 257 with diet of dysphagia mechanical diet received a puree dessert. A concurrent review of a facility spreadsheet titled, Fall Menus, Week 4 Tuesday, showed that dysphagia mechanical texture diet should receive apple bread pudding, make w/o (without) apples .Chop 1/2' bread pudding, soak and drain for dessert. During an interview on 9/24/24, at 2:47 p.m., with Registered Dietitian (RD), RD stated that the staff needed to follow the menu and spreadsheet. 2. During a dining observation of lunch meal service on 9/23/24 beginning at 12:12 p.m., it was noted Resident 21 was on CCHO diet on meal ticket. Resident 21 received one slice of garlic breadstick. A concurrent review of a facility spreadsheet titled, Fall Menus: Week 4 Monday, showed that CCHO diet should have received one half of garlic breadstick. During an interview on 9/23/24, at 12:23 p.m., the RD verified and reviewed the facility spreadsheet and stated Resident 21 should have received half a slice of garlic bread. The RD stated extra bread may affect the blood sugar level. 3. During meal distribution observation for lunch meal on 9/24/24, starting at 12:10 p.m., it was noted that Resident 20 was on finger food, diet and received a regular apple bread pudding in one piece for dessert. A concurrent review of a facility spreadsheet titled, Fall Menus, Week 4 Tuesday, showed that finger food diet should had received apple bread pudding cut into 4's. During an interview on 9/24/24, at 1:00 p.m., with Dietary Supervisor (DS), DS acknowledged and confirmed that Resident 20's apple bread pudding should have been cut into four pieces. During a review of a facility document titled, Dietary Supervisor- Job Duties and Responsibilities, revised June 2020, indicated .Review therapeutic and regular diet plans and menus to assure they are following the physician's order . During a review of a facility document titled, Job Description Cook, revised 9/01/23, indicated, .follow recipes and prepares foods that correspond to menu cycles .prepared by Dietician .handle .prepared food in accordance with department procedures and in compliance with county, state and federal laws and regulations .

Based on observation, interview and record review, the facility failed to implement measures to prevent the development of a pressure ulcer (PU, injury to the skin and underlying tissue resulting from prolonged pressure on the skin) on the sacrum (tailbone) for one of 19 sampled residents (Resident 31) when: 1. A Risk for Pressure Ulcer Care Plan was not updated; 2. Shower/Bath skin assessments were not completed as scheduled; 3. Nursing weekly summary assessments did not include direct observation of the resident's skin; and 4. Turning and repositioning documentation was not accurate. These failures resulted in Resident 31 developing a facility acquired Stage 3 (affecting the top 2 layers of the skin as well as the fatty tissue) PU. Findings: A review of Resident 31's admission record indicated she was admitted in January 2023 with diagnoses including Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar) and unspecified urinary incontinence (lack of voluntary control over urination). A review of Resident 31's clinical record included the following documents: Review of a Minimum Data Set (MDS, an assessment tool), dated 8/3/23, indicated Resident 31 had severe memory impairment. It also indicated Resident 31 required the extensive assistance of one person for bed mobility, was frequently incontinent of urine and bowels and had no pressure ulcers but, was at risk for developing them. Review of a Prevention of Pressure Ulcer Risk Care Plan, initiated 1/19/23 and last revised 4/19/23, included interventions to perform body audits per protocol and to observe and record the condition of the skin every day during care and on assigned shower days. A review of bathing documentation dated 7/23- 8/10/23, indicated Resident 31 had been given showers on 7/26/23, 7/28/23, and 8/5/23. A review of a Weekly Nursing Summary, dated 8/9/23 and written by Licensed Nurse 5 (LN 5), indicated Resident 31's skin condition was good, dry, and fragile and there was no current wound or skin impairment. A review of a nursing progress note, dated 8/10/23, indicated the resident was found to have a new Stage 3 PU on her sacrum measuring 3.6 x 2 x 0.2 cm (centimeter, a unit of measurement). 1. In a concurrent record review and interview, on 8/23/23 at 9:30 a.m., the Assistant Director of Nursing (ADON) stated resident care plans were updated at least quarterly and confirmed Resident 31's risk for pressure ulcer care plan had not been updated since 4/19/23, and prior to her developing a pressure ulcer on 8/10/23. 2. In a concurrent record review and interview, on 8/23/23 at 9:18 a.m., the Infection Preventionist (IP) reviewed the facility's shower logbook and stated Resident 31 was scheduled for showers on Wednesdays and Saturdays. The IP confirmed shower sheets, which contained an area to document a skin assessment, were missing for scheduled showers on 7/29/23, 8/2/23, 8/5/23 and 8/9/23. In an interview, on 8/23/23 at 9:20 a.m., the ADON stated she did not believe Resident 31's Stage 3 PU developed overnight and that usually a PU began with a deep tissue injury (non-blanchable area of injury to the underlying tissues below the skin's surface) and a color change. The ADON stated if skin assessments had been completed with Resident 31's showers the PU could have been identified earlier. 3. In an interview, on 8/23/23 at 9:30 a.m., the ADON stated when completing the Weekly Nursing Summaries, the nurses should have checked the resident's skin, but they probably had not. In an interview, on 8/23/23 at 1:06 p.m., LN 5 stated when she completed the Weekly Nursing Summary on 8/9/23, she did not actually inspect Resident 31's skin. LN 5 stated she did not actually do a complete skin inspection whenever she completed the summary and instead reviewed the clinical record, looked for any changes in the progress notes and often asked the CNA (Certified Nursing Assistant) if there had been any changes with the resident. 4. In an observation, on 8/22/23 at 7:51 a.m., Resident 31 was in her wheelchair in the dining room for breakfast. In an observation, on 8/22/23 at 11:50 a.m., Resident 31 was lying on her back in bed. In an observation, on 8/22/23 at 12:06 p.m., Resident 31 was in her wheelchair and being transported to the dining room for lunch. In an observation, on 8/22/23 at 2:30 p.m., Resident 31 was lying on her back in bed. In an observation, on 8/23/23 at 7:26 a.m., Resident 31 was in her wheelchair in the dining room for breakfast. In an observation, on 8/23/23 at 8:27 a.m., Resident 31 was lying on her back in bed asleep. In an observation, on 8/23/23 at 1:34 p.m., Resident 31 was out of bed and not in her room. A review of Resident 31's turning and repositioning documentation, on 8/23/23 at 1:35 p.m., indicated Nursing Assistant 1 (NA 1) had documented the resident was repositioned at 1:34 p.m. In an interview, on 8/23/23 at 1:38 p.m., NA 1 was asked how she turned and repositioned Resident 31 at 1:34 p.m. if she was not in bed. NA 1 stated the documentation was for when she put the resident in her wheelchair at around 11:20 a.m. NA 1 stated that she included putting Resident 31 in and out of her wheelchair in the turning and repositioning documentation. When asked if Resident 31 could have been lying on her back, placed in her wheelchair, and then returned to bed on her back again, NA 1 stated it was possible because the documentation did not indicate what position she was placed in. In an interview, on 8/24/23 at 9:26 a.m., the ADON stated if nursing did not update the resident's care plan at least quarterly, an evaluation of how effective the nursing interventions were in preventing a pressure ulcer was not done. The ADON confirmed that without shower sheets between 7/26/23 and 8/10/23, documenting a skin assessment, she had no way of knowing if the CNAs had been checking Resident 31's skin. The ADON reiterated nurses should have been physically assessing the resident's skin when completing the Nursing Weekly Summary. The ADON stated she was aware from staff Resident 31 liked to lay on her back, was difficult to reposition on her side and frequently slid herself off any pillows or wedges they had used to attempt to reposition her on her side. When asked if Resident 31 had a non-compliance care plan, the ADON stated she did not and further confirmed there was no documentation her Responsible Party (RP) had been made aware of the non-compliance and provided education regarding the risks of her not complying with repositioning. The ADON agreed if the resident was lying on her back, placed in her wheelchair, and returned to bed on her back, she was having pressure applied to the same sacral area with each position change and the documentation did not reflect effective turning and repositioning of the resident. The ADON confirmed Resident 31's pressure ulcer was avoidable and could have been prevented. In an interview, on 8/24/23 at 11:18 a.m., the Director of Nursing (DON) agreed Resident 31's PU was avoidable. A review of the facility's policy titled, Goals and Objectives, Care Plans, revised 4/09, indicated care planned goals and objectives were reviewed and/or revised at least quarterly. A review of the facility's policy titled, Bath, Shower/Tub, revised 2/18, indicated that one of the purposes of a bath or shower was to observe the condition of the resident's skin. It also indicated documentation for the bath or shower included, All assessment data [e.g. any reddened areas, sores, etc. on the resident's skin] obtained during the shower/tub bath.

Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 13) was free of a significant medication error when tramadol (opioid medicine used for the short-term relief of moderate to severe pain) was not available for routine administration. This failure resulted in Resident 13 experiencing pain and psychosocial (the combined influence of psychological factors and the surrounding social environment on physical, emotional, and/or mental wellness) harm when pain was left untreated. Findings: A review of Resident 13's Admission Record indicated she was admitted to the facility on [DATE] with diagnoses which included vertebral wedge compression fractures (a type of crush or break of the spine) of thoracic vertebrae 5 (T5) to T10 (the middle section of the spine), fracture of fourth lumbar vertebra (the lower back section of the spine), neuropathy (nerve damage which leads to pain), lung cancer, osteoporosis (a condition in which the bones become brittle) and complete rotator cuff tear or rupture of left shoulder. During a review of Resident 13's Pain Interview, dated 8/11/23, the Pain Interview indicated Resident 13 experienced frequent pain that limited her day-to-day activities and made it difficult to sleep at night. The document indicated Resident 13's pain was severe, rated at a level 7 (pain scale of 0 to 10, with 10 being the highest level of pain), and staff assessment for pain was to include, 1. Non-verbal sounds . 2. Vocal complaints of pain . 3. Facial expressions (e.g . winces .) . During a medication pass observation on 8/21/23 at approximately 8:50 a.m. with Licensed Nurse 2 (LN 2), LN 2 was observed preparing twelve medications for Resident 13. LN 2 stated she would not be able to administer Resident 13's tramadol (a medication to treat severe pain) 50 milligrams (mg, a unit of measurement) scheduled for 8 a.m. because they had run out of her medication on 8/20/23. A review of Resident 13's medical record indicated the following active physician's orders: - Tramadol 100 mg: 1 tablet at bedtime for chronic pain, dated 8/11/23; - Tramadol 50 mg: 1 tablet every 6 hours as needed for pain for 30 days, dated 8/13/23; and, - Tramadol 50 mg: 1 tablet two times a day for chronic pain at 0800 (8 a.m.) and 1400 (2 p.m.), dated 8/11/23 During an observation on 8/21/23 at 8:57 a.m., LN 2 entered Resident 13's room to administer her medications. Resident 13 was observed sitting upright in her wheelchair, shaky, pale, and tearful. LN 2 told her she did not have her pain medication available for administration. LN 2 asked Resident 13 if she had the physician's cell phone number to contact the doctor herself to request another tramadol order be sent to the pharmacy. Resident 13 quietly replied, No. During the same medication pass observation, LN 2 was observed applying a Lidoderm (a medication to treat pain) 5% patch to Resident 13's back. As the patch contacted Resident 13's skin, she winced. During a concurrent observation and interview on 8/21/23 at 2:59 p.m. with Resident 13, Resident 13 was observed tense, lying still in her bed on her back. When asked how she was doing she stated, Not very good. Resident 13 stated she did not receive her tramadol dose scheduled for 8 a.m. that morning until 10 a.m. and reported her pain level was now at a 7. She stated when she did receive her tramadol on time, it brought her pain level down to a 4 or 5, which was tolerable for her. A review of Resident 13's Medication Administration Record (MAR), dated August 2023, indicated a pain level of 6 for both day and evening (assessed day, evening, and night) on 8/21/23. During an interview on 8/21/23 at 3:12 p.m. with Registered Nurse (RN), RN stated an acceptable pain level for a resident was 1 to 3, which was treated with mild pain medication such as acetaminophen. During a review of Resident 13's Care Plan, dated 8/11/23, the Care Plan indicated, Focus: Resident is at risk for pain . Goal: Will be relieved of pain 30 to 45 minutes after intervention is given daily . Interventions/Tasks: Administer medication as ordered . During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated March 2020, indicated, General Guidelines: 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain . the comprehensive care plan, and the resident's choices related to pain management. 2. 'Pain management' is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals . Implementing Pain Management Strategies . 5. Implement the medication regimen as ordered . During a review of the facility's P&P titled, Medication Administration- General Guidelines, dated March 2018, indicated, B. Administration . 10. Medications are administered within 60 minutes of scheduled time . According to The Clinical Journal of Pain, in an article titled, The Multimodal Assessment Model of Pain: A Novel Framework for Further Integrating the Subjective Pain Experience Within Research and Practice, dated March 2019, the article indicated, Although quantitative pain measures are vital to understanding and targeting mechanisms and benchmarking management, they often overlook important attributes of the subjective experience, such as personal context and meaning, which can profoundly shape the experience of pain. (https://journals.lww.com/clinicalpain/fulltext/2019/03000/the_multimodal_assessment_model_of_pain__a_novel.2.aspx; accessed 8/28/23)