Every finding on record at Grass Valley Healthcare Center

Based on observation, interview, and record review, the facility failed to provide a sanitary, homelike environment for a census of 83 residents when:Personal bathing items were not labeled or stored separately.There was no transition (a piece of material used to cover and connect the space where two different types of flooring meet) between the linoleum on the bathroom floor and the tile in the shower.These failures reduced the facility's potential to provide a sanitary, homelike environment for residents and had the potential to cause transfer of bacteria to residents and transfer of bacteria between residents.Findings:During an observation on 8/14/26 at 12:30 p.m. in the adjoining bathroom between rooms [ROOM NUMBERS], four unlabeled bathing sponges were hanging together from a single hook outside the shower. The sponges were in contact with each other. There was no transition between the bathroom floor linoleum and the shower tile. The linoleum was turned up exposing unfinished flooring that had dark spots on it.During an interview on 8/14/26 at 1:03 p.m. with the Infection Preventionist (IP), IP confirmed that the lack of transition between the shower floor and linoleum could create bacterial growth and potentially affect residents, and the unlabeled bathing sponges created the potential for spread of bacteria between residents.During an interview on 8/14/26 at 3:23 p.m. with the Director of Nursing (DON), the DON stated, My expectation is for labeling.During a review of the facility's policy and procedure (P&P) titled, ADL Personal Supplies, Cleaning, and Disposal, dated 10/30/2015, the P&P indicated, All single use items will be labeled with the resident's name.During a review of the facility's P&P titled, Homelike Environment Policy Statement, dated 02/2021, the P&P indicated, The facility staff and management maximizes to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment.

Based on observation, interview, and record review the facility failed to store items in a sanitary manner for two of six sampled residents (Resident 1 and Resident 2) when used urinals were stored uncovered in a drawer that contained the residents' personal items.This failure increased the risk of contamination and infection for the residents.Findings:Resident 1 admitted to the facility in late 2025 with diagnoses which included urinary tract infection and weakness.Resident 2 admitted to the facility in mid 2024 with diagnoses which included urinary tract infection and bacteria in the bloodstream.During an interview on 12/30/25 at 12:53 p.m. with Certified Nursing Assistant (CNA1), CNA 1 stated urinals should be stored in a drawer without other items.During a concurrent observation and interview on 12/30/25 at 1:28 p.m. with the Infection Preventionist (IP) of Resident 1's closet, Resident 1's bottom drawer of the closet contained an uncovered urinal, a clear drinking cup which held an uncovered toothbrush, and a bottle of cologne. The IP confirmed the findings and stated the urinal should not be stored with personal care items for infection control reasons.During a concurrent observation and interview on 12/30/25 at 1:32 p.m. with the IP of Resident 2's closet, Resident 2's bottom drawer of the closet contained an uncovered urinal, a blood pressure cuff, a red plastic dining place mat and a seat cushion. The IP confirmed the findings and stated she expected the urinal to be stored separately from other items.During an interview on 12/30/25 at 3:40 p.m. with the Director of Nursing (DON), the DON stated she expected urinals to be stored separate from personal items to prevent contamination and infection.During a review of the facility policy and procedure (P&P) titled, ADL [activities of daily living] PERSONAL SUPPLIES, CLEANING, AND DISPOSAL, dated 10/15, the P&P indicated, Purpose: To provide Adl [Activities of Daily Living] supplies for individual residents and prevent infections .Toileting items, including urinals, will be stored separately from other personal items.

Based on interview and record review the facility failed to provide appropriate and adequate supervision to prevent an avoidable accident when one of three sampled residents (Resident 1) left the facility without the facility's knowledge and supervision.This failure resulted in Resident 1 experiencing falls outside the facility, leading to multiple abrasions on the hands and knee and increased the risk of cold exposure and potential injury from passing motor vehicles. Findings: Resident 1 was admitted to the facility in the fall of 2025 with diagnoses which included traumatic brain injury (an injury to the brain caused by a sudden bump, or jolt to the head, which can disrupt its normal function), muscle weakness, and difficulty walking. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/6/25, the MDS indicated Resident 1 had moderate impairment of his memory and was independent with most activities of daily living (ADLs). During a review of Resident 1's document titled FALL RISK EVAL [FRE, fall risk evaluation], dated 10/30/25, the FRE indicated Resident 1 had intermittent confusion. During a review of Resident 1's document titled Wandering Risk Assessment [WRA], dated 11/3/25, the WRA indicated Resident LACKS capacity to understand and make decisions.low to moderate risk of elopement. During a review of Resident 1's document titled Progress Notes [PN], dated 11/17/25, the PN indicated It was reported by [Licensed Nurse (LN) 1] at 4:30 a.m. while doing rounds the cna [Certified Nurse's Assistant 1] identified [Resident 1] as missing.the last time she had a visual check on [Resident 1] was 3:30 a.m. Staff immediately following (sic) missing resident protocol.without success.Resident was located by staff members [family member] around 8:15 am.the charge [LN 1] did a body check on resident he has several abrasions.he stated he left the facility around 4am and headed to his home.he also stated he had several falls while he walked. During a review of Resident 1's facility Discharge Instruction Form [DIF], dated 11/17/25, the DIF indicated [right] hand, scattered abrasions.Scrape to [right] knee, outside area of [right] foot, reddened area to [left] great toe. During an interview on 11/24/25 at 8:34 a.m. with CNA 2, CNA 2 indicated [Resident 1] was more unsteady when he returned. I heard he left about three or four in the morning.He came back [11/17/25] around 8:45 a.m. [with a staff family member by car] soaking wet, was very cold.He was a little confused and a little unsteady. He had scratches on his right hand like he had fallen. They were fresh. There were scratches on his left knee, too.He never mentioned why he left. He mentioned he wanted to get keys for the church.The same day he left it was pouring [rain]. During an interview on 11/24/25 at 12:04 p.m. with the Director of Nurses (DON), the DON said, My expectation is to keep all our residents safe. [Resident 1's] long-term memory is good, but his short-term memory is bad. He thought the scratches were from an old motorcycle accident. During an interview on 12/25/25 at 6:52 a.m. with LN 1, LN 1 said, At 3:30 to 4 in the morning [11/17/25], [CNA 1] told me he was not in his room.He was found at the post office of [name of town]. It's about half an hour from here. He may have got a ride or walked there. We don't know. During a review of the facility policy and procedure (P&P) titled Safety and Supervision of Residents, dated 2001, the P&P indicated Resident safety and supervision and assistance to prevent accidents are facility wide priorities.

Based on interview, and record review, the facility failed to ensure one out of 24 sampled resident (Resident 17) was provided with an ongoing activity program that meets psychosocial needs (a combination of mental health, emotional, spiritual, or behavioral needs that are important to a person) when Resident 17's frequency of ongoing activity program visit was followed.These failures had the potential for Resident 17 to not achieve her highest mental, emotional, spiritual, and psychosocial well-being.Findings:A review of Resident 17's clinical record indicated Resident 17 was admitted February of 2018 and had diagnoses that included dementia (impairment of the ability to remember, think, or make decisions that interferes with everyday activities), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), skin cancer, and muscle weakness.A review of Resident 17's Minimum Data Set (MDS- an assessment tool used to guide care) Cognitive Patterns, dated 9/16/25, indicated Resident 17 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 2 out of 15 which indicated Resident 17 had a severely impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 17's annual MDS Preferences for Customary Routine and Activities, dated 3/16/25, indicated it was very important for Resident 17 to listen to music she likes and to do her favorite activities, and it was somewhat important for Resident 17 to have books, newspapers, and magazines to read.A review of Resident 17's active physician's order, dated 5/7/19, indicated, May participate in activity plan as not in conflict with treatment plan.A review of Resident 17's care plan, initiated 7/26/19, indicated, The resident [Resident 17] chooses not to attend activities. Mostly bed bound [someone unable to leave their bed due to inability to walk, even with assistance], 1:1 room visits. A review of Resident 17's care plan goal, initiated 4/5/21, indicated, Activities will visit 3 times a week through the review date. A review of Resident 17's care plan intervention, revised 1/6/25, indicated, Activity department will supply materials, audio, visual, entertainment as needed by resident, per preferences.During an observation on 9/22/25 at 9:57 a.m., in Resident 17's room, Resident 17 was observed awake and was lying on her bed. Resident 17's television was off, there was no radio or any music devices, and there were no books, newspapers, or magazines in her room.During another observation on 9/23/25 at 9:52 a.m., in Resident 17's room, Resident 17 was observed lying on her bed, eyes closed, and breathing was unlabored (something natural, flowing, or relaxed, and doesn't require effort). Resident 17's television was again off, there was no radio or any music devices, and there were no books, newspapers, or magazines in her room.During a third observation on 9/23/25 at 2:55 p.m., in Resident 17's room, Resident 17 was again observed lying on her bed, eyes closed, and breathing was unlabored. Resident 17's television was still off, there was no radio or any music devices, and there were no books, newspapers, or magazines in her room.During a fourth observation on 9/24/25 at 9:17 a.m., in Resident 17's room, Resident 17 was again observed lying on her bed, eyes closed, and breathing was unlabored. Resident 17's television was again off, there was no radio or any music devices, and there were no books, newspapers, or magazines in her room.A review of Resident 17's progress notes titled, ACTIVITY NOTE, for the months of June, July, August, and September 2025, indicated the following:-Resident 17 was only visited by an activity staff for activity one (1) time (6/13/25) for the month of June 2025. -Resident 17 was visited by an activity staff for activity three (3) times (7/3/25, 7/7/25, and 7/21/25) for the month of July 2025.-Resident 17 was visited by an activity staff for activity four (4) times (8/14/25, 8/20/25, 8/27/25, and 8/31/25) for the month of August 2025.-Resident 17 was visited by an activity staff for activity one (1) time per week (9/2/25, 9/13/25, and 9/15/25) for the month of September 2025 as of 9/24/25.During a concurrent interview and record review on 9/24/25 at 10:37 a.m. with the Activities Director (AD), Resident 17's activity records were reviewed. The AD confirmed that Resident 17's frequency of ongoing activity program visit was followed. The AD also confirmed that there were no documented refusals of Resident 17 with activities. The AD stated she would expect staff to try and follow the planned activity frequency and preferences of Resident 17 because there would be a risk of decline in the quality of life and activities of Resident 17 if the plan was not followed.During an interview on 9/24/25 at 2:07 p.m. with the Director of Staff Development (DSD), the DSD stated she expects that residents' ongoing activity program frequency to be followed because bed bound residents might feel isolated and there would be a risk for well-being issues. During an interview on 9/24/25 at 2:33 p.m. with the Director of Nursing (DON), the DON stated she expects that residents are provided with an ongoing activity program, and the frequency, resident preferences, and care plan should be followed because of the risk of isolation and well-being concerns.A review of the facility's policy and procedure (P&P) titled, Activity Programs, Revised 6/2018, indicated, 1. The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. 2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 3. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. 4. Activities are considered any endeavor, other than routine AD Ls, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health .7. Our activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident .9. All activities are documented in the resident's medical record .

Based on observation, interview and record review, the facility failed to ensure the menu was followed for therapeutic diets (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) during the lunch meals on 9/22/25 and 9/23/25 when:1. Two residents (Resident 19 and 77) with CCHO (controlled carbohydrate) diets (a therapeutic diet to manage diabetic disease and/or to stabilize blood sugar level) received one slice of garlic bread instead of one half (1/2) slice.2. 22 residents (Resident 3, 5, 16, 22, 28, 32, 37, 38, 40, 47, 50, 62, 63, 65, 66, 67, 70, 74, 77, 81, and 96) with fortified diets (a dietary pattern that includes foods that have been enriched with additional nutrients, such as calories and protein) did not get the fortified foods.3. Two residents (Resident 26 and 44) with puree (a very smooth, crushed or blended food usually for people with swallowing and/or chewing difficulties) diet received mashed potatoes and did not get the pureed red beans and rice as the menu indicated.4. Two residents (Resident 10 and 40) had diets with half (1/2) portion size got served with small portion size.These deficient practices had the potential to result in compromising the medical and nutritional status of 26 residents for a census of 80 who consumed meals from the facility kitchen. Findings:During dining observation on 9/22/25 at 12:04 p.m. and 12:16 p.m. in the dining room: 1.Resident 19 and Resident 77 were noted with CCHO diet received one slice of garlic bread with their lunch meals. A concurrent review of the spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) titled, Fall Menus, Week 4 Monday, indicated CCHO diet should receive 1/2 slice of garlic bread. During an interview and concurrent review of spreadsheet on 9/23/25 at 1:20 p.m. with Registered Dietitian (RD), RD stated residents with CCHO diet should receive 1/2 slice of garlic bread. During the lunch meal distribution on 9/23/25 beginning at 11:57 a.m., the following was noted: 2. 22 residents (Resident 3, 5, 16, 22, 28, 32, 37, 38, 40, 47, 50, 62, 63, 65, 66, 67, 70, 74, 77, 81, and 96) with fortified diets did not receive 1/2 ounce (oz., a unit of measurement) extra melted margarine on the red beans and rice and extra two teaspoons (tsp) salad dressing as fortified food. A review of facility document titled, Week 4, Fortified Breakfast, Fortified lunch, Fortified Dinner, Fall 2025, indicated fortified diets should get extra 1/2 oz melted margarine on the red beans and rice, and extra two tsp of salad dressing for lunch meal.During an interview on 9/23/25 at 1:22 p.m. with RD, RD stated residents should get the fortified food as stated on the fortified menu. RD stated the fortified diet was therapeutic diet to provide extra calories for the residents at risk for weight loss. RD stated if residents did not get the fortified food, residents would not get the calories that they need.3. During the lunch meal distribution on 9/23/25 beginning at 11:57 a.m., two residents (Resident 26 and 44) with puree diet orders did not get pureed red beans and rice. During an observation on 9/23/25, began at11:27 a.m. of the lunch meal distribution, it was noted Resident 26 and 44 received pureed mashed potatoes instead of pureed red beans and rice. A concurrent review of the facility document titled, Fall Menus, Week 4, Tuesday dated 9/23/25, indicated pureed diet should include pureed rice and beans in the lunch meal. During an interview on 9/23/25 at 1:29 p.m. with RD, RD confirmed [NAME] (CK)1 did not prepare the puree red beans and rice for the puree diet meal on lunch. 4. During the lunch meal distribution on 9/23/25 beginning at 11:57 a.m., two residents (Resident 10 and 40) had diet orders of 1/2 portion size for their meals but got served with small portion size. A review of the spreadsheet Fall Menus, Week 4 Tuesday, dated 9/23/25, it did not have 1/2 portion size included on the spreadsheet. During an interview on 9/23/25 at 11:45 a.m. with Dietary Supervisor (DS) 1, DS 1 stated 1/2 portion size was the same amount as small portion size. During an interview on 9/23/25 at 1:22 p.m. with RD, RD confirms 1/2 portion meals should get 1/2 of the regular portion. RD stated if regular portion was three oz. of meat, 1/2 portion would equate to 1.5 oz. of meat. RD stated verbal in-services have been done regarding 1/2 portion sizes, but there have not been formal in-services and there was no policy and procedure for the staff to reference. During a follow-up interview on 9/24/25 at 3:23 p.m. with RD, RD acknowledged the findings mentioned above during the dining observation on 9/22/25 and meal distribution observation 9/23/25. RD confirmed and stated the expectation was the dietary staff needed to follow the spreadsheet and fortified food menu.A review of facility policy and procedure (P&P) titled, JOB DESCRIPTION-Food and Nutrition Service Director, dated 2023, indicated .ability to follow prepared menus and portion control guides.DUTIES AND RESPONSIBILITIES: 1. Schedule and supervise the FNS Staff providing in-service training. 3. Is responsible for the food preparation and service of all food and ensures approved menus and accompanying recipes are followed.

Based on observation, interview, and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food service safety when:1. The ice machine was not clean; and2. The arrangement of the food stored in the freezer was not in a food safety manner; and3. Items found in the clean and ready-to-use storage areas: A few metal sheet pans were stored and stacked wet; and The metal sheet pans, food processor and metal strainers were found with brown substances; and4. Three dietary staff did not wear hair restraint and beard restraint appropriately; and5. Three dietary staff did not practice hand hygiene between soiled and clean dishes during the dishwashing process; and6. The metal coating of the can opener blade was worn off These failures had the potential to result in food contamination which could cause illness for 80 residents who received food prepared from the facility kitchen. Finding: 1. During an concurrent observation and interview on 9/22/25 at 11:06 a.m. with Dietary Supervisor (DS) 1, DS 1 stated the facility uses an outside vendor for the ice machine deep cleaning (cleaning and sanitizing the machinery parts on the top section of the ice machine and the ice storage bin on the bottom section of the machine with chemical solutions designed to remove lime scale and mineral deposits and to remove algae and slime, then sanitize with chemical agent) every six months. DS 1 stated DS 1 or Registered Dietitian (RD) cleaned and sanitized the ice machine monthly, and the last clean and sanitize was completed on 8/21/25. DS 1 stated the process for cleaning the ice machine included removing the ice before cleaning and sanitizing the ice storage bin. DS 1 stated the top machinery would be cleaned and sanitized too. She stated once the front panel of the top machinery opened, she would dissemble the curtain (a part that controls water flow, prevents splashing, and helps with the ice-making process) and the trough (a shallow, basin-like pan that holds water inside an ice-making machine) and got cleaned and sanitized. Then the clean solution added to the trough and run the clean cycle and add the sanitizer solution (a food-safe chemical mixture used after cleaning an ice machine to kill bacteria, algae, mold, and other microorganisms on food-contact surfaces) to run the sanitizing cycle. DS 1 opened the top machinery part of the ice machine. Upon the removal of the trough, there were black substances observed at the bottom of the evaporator (the crucial surface where water freezes into ice by being rapidly chilled by circulating refrigerant) and could be removed when wiping with a paper towel. A concurrent interview with DS 1, DS 1 confirmed the black substance observed and stated the bottom of the evaporator was scrubbed every time when monthly cleaning. DS 1 stated the areas with black substances that could not be reached or cleaned. During an interview on 9/24/25 at 3:23 p.m. with the RD, the RD stated the ice machine had to be kept clean. RD stated the ice machine gets deep cleaning monthly by dietary. RD stated they used an outside vendor every six months for cleaning the fan and the coils of the machine. RD explained the process for cleaning the ice machine was to first to take out all the ice and then dissembled the removable components of the top machinery of the ice machine, included: the curtain, water trough, probes and then used the cleaner to clean and sanitizer to sanitize the ice making panels and the rims, the bottom of the evaporator, and the walls below the evaporator, and the ice storage bin, the door of the ice bin. Then run the cleaner with the cleaning cycle and then run the sanitizer for the sanitizing cycle. RD stated the inside of the top machinery of the ice machine needed to be scrubbed and cleaned well to get rid of the dirty stuff. RD confirmed DS 1 cleaned the ice machine last cleaning on 8/21/25 and missed the area found with black substance. A review of the facility policy and procedure (P&P) titled, Ice Machine Cleaning Procedures, dated 2023, indicated, . The internal components cleaned monthly. 2. During an observation on 9/22/25 at 10:29 a.m., the reach-in freezer had four shelves with labels on the inside wall from top to bottom: top shelf labeled sausage, second shelf labeled beef, third shelf labeled chicken, and bottom shelf labeled pork. On the top shelf labeled sausage, there was a pack of diced cooked ham stored next to a box of ready-to-eat mac and cheese cups. On the second shelf labeled beef, there was a bag of raw beef patties next to the black bean burger patties. On the third level shelf labeled chicken, there was a pack of raw beef stored next to the boxes of diced chicken meats. On the bottom shelf labeled pork, there was a box of raw ground beef, a box of ready-to-eat garlic bread and a box of cooked beef, and a box of hash browns. A concurrent interview with DS 1, DS 1 stated she was not aware of the hierarchy (proper ranking by internal cooking temperature of food) of food storage and agreed the garlic bread and hash browns were ready-to-eat food and should be stored at the top level and the raw meat should be at the bottom. A concurrent interview with DS 2, DS 2 confirmed and stated the freezer storage should follow the proper food storage per the P&P. During an interview on 9/24/25 at 3:23 p.m. with RD, RD was not aware of the policy and procedure (P&P) for food storage arrangement. RD was made aware of the policy for Storage of Food and Supplies. RD stated it was best practice to follow food storage guidelines. A review of the facility P&P titled, Storage of Food and Supplies, dated 2023, indicated, POLICY: Food and supplies will be stored properly and in a safe manner . A review of the facility P&P titled, Refrigerated Storage and Storage of Frozen Food, indicated, 1. Store raw meat, poultry, and fish separately from cooked and ready-to-eat food to prevent cross contamination.4. Store cooked or ready-to-eat food above raw meat, poultry, and fish.this will prevent raw-product juices from dripping onto the prepared food and causing food borne illness.5. Store raw meat, poultry, and fish in the order from top to bottom.This order is based on the required minimum internal cooking temperature of each food .a. Whole fish, b.Whole cuts of beef and pork, c. Ground meat and fish.d. Whole and ground poultry. 3. During the observations on 9/22/25 at 9:22 a.m. and 9:25 a.m., the following items found issues and stored in the clean and ready-to-use storage areas: one full sheet metal pan with brown substances one of 1/6 sheet metal pan with brown substances one full sheet metal strainer with brown substances one full sheet metal pan was wet three of 1/6 sheet metal pans were wet the bowl of the food processor had brown substances During an interview on 9/22/25 at 9:25 a.m. with DS 1, DS 1 stated the brown substances on the pans and equipment were food particles and confirmed the pans listed above were wet. DS 1 stated the pans, dishes and equipment should be clean and air-dried before being stored in the storage area. DS 1 stated the person who puts away the dishes/pans and equipment should check for cleanliness and dryness before storing them away. During an interview on 9/24/25 at 3:23 p.m. with the RD, RD stated the pans, dishes and equipment should be clean without food particles and completely air-dried before store away to prevent bacteria growth. A review of the facility P&P titled, Dishwashing, dated 2023, indicated, . 1. Gross food particles shall be removed by careful scraping and pre-rinsing in running water, 5. Dishes are to be air dried in racks before stacking and storing. A review of the facility P&P titled, Sanitation, dated 2023, indicated, .All utensils.equipment shall be kept clean. 4. During an observation on 9/22/25 at 11:02 a.m., [NAME] (CK) 1 wore a disposable (medical) face mask without a beard restraint with facial hair on the neck area and the side burns were not covered and he was working at the cooking station. A concurrent interview with DS 1, she confirmed CK 1 had facial hair and needed to wear a beard restraint to cover the exposed hair. During an observation on 9/22/25 at 11:20 a.m., Dietary Aide (DA) 4 had exposed side burns and beard without a beard restraint while prepping the food trays on the meal carts. A concurrent interview with DS 1, she confirmed DA 4 had exposed side burns and a beard and stated DA 4 needed to wear a beard restraint. During an observation on 9/23/25 at 11:14 a.m., CK 2 had a beard without beard restraint, and he wore a hat without hair restraint and his hair on the back and sides of the hair was exposed. A concurrent interview with DS 1, DS 1 confirmed and stated CK 2 should wear a beard restraint for the beard, and a hair net should be on to contain all the hair before putting on a hat. During an interview on 9/24/25 at 3:23 p.m. with the RD, RD stated the dietary staff needed to follow the policy and procedure and cover their hair and beards completely with hair and beard restraint. A review of the facility P&P titled, Dress Code, dated 2023, indicated, .PROPER DRESS: .6. Hat for hair, if hair is short which completely covers the hair, 7. Hair net for hair, if hair is long (over the ears or longer), 8. beards and mustaches (any facial hair) must wear beard restraint. A review of the facility P&P titled, Personnel Management, dated 2023, indicated, .FNS employees. are required to follow the dress code. 5. During an observation of the dishwashing process on 9/22/25 at 9:57 a.m., it was noted DA 2 touched dirty trays from a meal cart with her bare hands and dumped the leftover food in the trash can; then used the same bare hands and touched the clean dishes without washing hands. At 9:58 a.m., DA 2 touched the dirty dishes on the dirty side of the dishwashing machine and then touched the clean dishes without washing hands. At 11:01 a.m., DA 2 used bare hands to push the dirty dishes in the dishwashing machine and then touched the clean dishes without washing hands. During another observation on 9/23/25 at 9:20 a.m., it was noted DA 1 and DA 3 used their bare hands touching dirty and clean dishes interchangeably without washing hands. DA 3 then touched the dirty dishes and used a towel on her waistline to dry her hands and then touched clean dishes. During an interview on 9/24/25 at 3:23 p.m. with RD, RD stated handwashing had to be performed between soiled and clean tasks during the dishwashing process to prevent cross contamination. RD stated it was an infection control concern. A review of the facility P&P titled, Sanitation, dated 2023, indicated, . 18. A minimum of two employees will be used when dishes are machine washed. One will handle soiled area, and one will handle the clean side. If an employee does need to go from soiled to dirty end, a strict hand washing routine must be followed. A review of the facility P&P titled, Handwashing, dated 2023, indicated, All employees will be instructed in the proper procedure of hand washing. A review of departmental in-services titled, Dietary In-Service, Topic: Handwashing and Dress Code, were completed by DS 1 and RD on 7/23/25 and 9/7/25 respectively. DA 1, DA 2, and DA 3 were not on the attendance sheets. The in-service handout showed, Handwashing Procedure.When to wash hands.bacteria and viruses can travel easily from one person to another or from people to food and food contact surfaces.it is important to wash hands frequently and after any task that may potentially contaminate your hands.wash your hands:.before handling clean equipment and serving utensils.when changing tasks.after handling soiled dishes, equipment, or utensils.Bottom line - if you touch anything else that may contaminate your hands, wash them. 6. During a concurrent observation and interview on 9/22/25 at 9:57 a.m. with DS 1, it was noted the blade tip of the can opener was chipped and discolored. DS 1 stated the metal coating was chipping away and needed to be replaced. During an interview on 9/24/25 at 3:23 p.m. with the RD, RD stated the blade on the can opener needed to be replaced. A review of the facility P&P titled, Can Opener and Base, dated 2023, indicated, .proper sanitation and maintenance of the can opener and base is important to sanitary food preparation. Metal shavings and shredding can result from a dull cutting blade. 6. Replace blade on can opener, as needed.

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 80 residents when:1. Enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use) was not implemented to Resident 5 and Resident 63;2. A facility staff did not wear required personal protective equipment (PPE) when performing resident care on Resident 56 who was on EBP; and,3. Facility staff entered a contact precaution room (an infection control measure used in healthcare settings to prevent the spread of infectious agents that can be transmitted by direct or indirect contact with a patient or their environment) without using all the required PPE.These failures resulted in an increased risk for cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another), and potential exposure of residents and staff to germs. Findings: 1a. A review of Resident 5's clinical record indicated Resident 5 was admitted June of 2025 and had diagnoses that included pressure ulcer (also known as bedsores- are areas of skin damage that develop when pressure is applied to the same spot for an extended period) of right heel, and Sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection) due to Methicillin-susceptible Staphylococcus aureus (MSSA- a bacteria that can be effectively treated with antibiotics like methicillin). A review of Resident 5's Minimum Data Set (MDS– a federally mandated resident assessment tool) Cognitive Patterns, dated 9/20/25, indicated Resident 5 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 12 out of 15 which indicated Resident 5 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 5's MDS Skin Conditions, dated 9/20/25, indicated Resident 5 has two (2) unstageable pressure ulcers (are full-thickness skin and tissue losses where the extent of damage cannot be determined due to the presence of debris covering the wound bed) that were present upon admission. During a concurrent observation and interview on 9/22/25 at 1:11 p.m. with Certified Nurse Assistant (CNA) 3, in Resident 5's room, CNA 3 was observed changing Resident 5's linens and transferred Resident 5 to his bed while only using gloves. CNA 3 confirmed the observation and stated she only wear gloves because the resident is not on precaution (EBP). During a concurrent observation and interview on 9/22/25 at 1:11 p.m. with Certified Nurse Assistant (CNA) 3, in Resident 5's room, CNA 3 was observed changing Resident 5's linens and transferred Resident 5 to his bed while only using gloves. CNA 3 confirmed the observation and stated she only wear gloves because the resident is not on precaution (EBP). During an interview on 9/23/25 at 9:39 a.m. with the Treatment Nurse (TN), the TN stated Resident 5 was admitted on [DATE] and he has the wound on his foot at that time already. During a concurrent observation and interview on 9/24/25 at 9:43 a.m. with the TN, in Resident 5's room, the TN was observed doing wound care and dressing change on Resident 5's right foot wounds while only using gloves. The Infection Preventionist (IP) then came to help the TN to hold Resident 5's right foot in place for better visualization in taking wound photo and measurement while also just wearing gloves. The TN confirmed the observation. 1b. A review of Resident 63's clinical record indicated Resident 63 was admitted February of 2025 and had diagnoses that included diabetes mellitus (a chronic condition causing too much sugar in the blood which inhibits the body's natural wound-healing capabilities), peripheral vascular disease (PVD- a condition where blood flow to the arms, legs, and feet are restricted due to narrowed or blocked blood vessels), and need for assistance with personal care. A review of Resident 63's MDS Cognitive Patterns, dated 7/18/25, indicated Resident 63 had a BIMS score of 15 out of 15 which indicated Resident 63 had an intact cognition. A review of Resident 63's Skin and Wound Evaluation, dated 7/23/25, indicated Resident 63 has an arterial wound (also known as arterial ulcers- are painful injuries in your skin caused by poor circulation) on his right foot which was acquired in the facility on 3/28/25. During a concurrent observation and interview on 9/22/25 at 10:55 a.m. with CNA 2, in Resident 63's room, CNA 2 was observed assisting Resident 63 with morning care, toileting, changing Resident 63's briefs, assisting with dressing and transferring Resident 63 to his wheelchair while only using gloves. CNA 2 confirmed the observation. During an interview on 9/22/25 at 12:41 p.m. with Licensed Nurse (LN) 4, LN 4 stated Resident 63 has a wound on his right foot which used to be infected that's why Resident 63 was on contact precaution (an infection control measure that involve wearing a gown and gloves to prevent the spread of germs through direct or indirect contact with a patient or their environment) before. LN 4 confirmed Resident 3 was not on EBP. A review of a facility document titled, Resident list on precautions, provided by the IP on 9/22/25, indicated Resident 5 and Resident 63 were not on EBP or any transmission-based precaution. During an interview on 9/22/25 at 4:01 p.m. with the IP, the IP stated their criteria for putting a resident on EBP is if the resident's wound was not progressing within 30 days. The surveyor requested the facility policy stating only residents with non-progressing wounds are needed to be on EBP, but the IP was not able to provide. During an interview on 9/24/25 at 1:57 p.m. with the IP, the IP stated as long as the resident's wound was showing signs of progression and healing from week to week, then the resident does not need to be on EBP. During an interview on 9/24/25 at 2:33 p.m. with the Director of Nursing (DON), the DON stated they follow their policy on implementing EBP. A review of the facility's P&P titled, Enhanced Barrier Precautions, revised 12/2024, indicated, 2. Enhanced barrier precautions apply when: .b. A res ident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained .13. Information regarding CDC-targeted MDROs and current recommendations on Enhanced Barrier Precautions are available at: https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html . A review of The Centers for Disease Control and Prevention (CDC- the national public health agency of the United States) online publication titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 4/2/24, indicated, Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization .Enhanced Barrier Precautions .Applies to: .All residents with any of the following: .Wounds and/or indwelling medical devices .regardless of MDRO colonization status .PPE used for these situations: .During high-contact resident care activities: Dressing .Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting .Wound care: any skin opening requiring a dressing .Required PPE .Gloves and gown prior to the high-contact care activity . (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html) 2. A review of Resident 56's clinical record indicated Resident 56 was admitted June of 2025 and had diagnoses that included neuromuscular dysfunction of the bladder (a condition where the nerves or muscles that control bladder function are impaired, leading to abnormal bladder control), and left thigh fracture (a break in the continuity of a bone). A review of Resident 56's Minimum Data Set (MDS– a federally mandated resident assessment tool) Cognitive Patterns, dated 9/9/25, indicated Resident 56 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 9 out of 15 which indicated Resident 56 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 56's MDS Bladder and Bowel conditions, dated 9/9/25, indicated Resident 56 has Indwelling catheter [a flexible tube inserted into the bladder and left in place to drain urine]. During a concurrent observation and interview on 9/22/25 at 12:23 p.m. with Licensed Nurse (LN) 4, in front of Resident 56's room, LN 4 confirmed that Resident 56's room door has a signage which indicated, ENHANCED BARRIER PRECAUTIONS (EBP) .EVERYONE MUST: Perform hand hygiene before entering the room .ANYONE PARTICIPATING IN ANY OF THESE SIX MOMENTS MUST ALSO: [NAME] gown and gloves .Morning & evening care . LN 4 stated Resident 56 was on EBP because of her foley catheter. A review of Resident 56's active physician's order, dated 9/23/25, indicated, EBP due to Indwelling Catheter. A review of Resident 56's care plan, initiated 9/23/25, indicated, The resident [Resident 56] is on enhanced barrier precautions (EBP) r/t [related to] Indwelling Catheter. A review of Resident 56's care plan intervention, initiated 9/23/25, indicated, Direct care staff to utilize gowns and gloves for all personal care. During a concurrent observation and interview on 9/22/25 at 4:07 p.m., with CNA 4, in Resident 56's room, CNA 4 was observed changing Resident 56's shirt and pants while only wearing gloves and not wearing a gown. CNA 4 confirmed that he only wore gloves when he assisted Resident 56 with dressing. CNA 4 stated he was aware that Resident 56 was on EBP, and they usually wear gloves and gown when they're dealing with Resident 56's catheter. CNA 4 further stated, They [facility staff] didn't say anything about wearing gloves and gown when changing her [Resident 56]. During an interview on 9/24/25 at 1:57 p.m. with the IP, the IP stated staff needed to wear gown when performing all the 6 high contact procedures, including dressing, to residents on EBP to prevent the risk of the resident acquiring infection. During an interview on 9/24/25 at 2:33 p.m. with the DON, the DON stated she would expect staff to follow EBP protocol for residents who are on EBP. A review of the facility's P&P titled, Enhanced Barrier Precautions, revised 12/2024, indicated, EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity .8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; .c. providing hygiene or grooming . 2. Resident 18 was admitted to the facility in July 2021 with multiple diagnosis which included pneumonia (lung infection) caused by methicillin-susceptible Staphylococcus aureus (bacteria found on the skin), type 2 diabetes mellitus (condition where the body either doesn't produce enough insulin or doesn't respond properly to the insulin) with diabetic nephropathy (lost of kidney function) and acute respiratory failure with hypoxia (lungs fail to adequately exchange oxygen, leading to low levels of oxygen in the body). A review of Resident 1's Minimum Data Set (MDS, an assessment tool) signed 9/22/25, indicated Resident 18 had moderate cognitive impairment. During a concurrent observation and interview on 9/22/25 at 9:57 a.m., with LN 3, Resident 18's room had signage posted on the wall next to the front door which indicated, STOP .CONTACT PRECAUTIONS EVERYONE MUST .PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit .Put on gown before room entry. Discard gown before room exit . LN 3 confirmed Resident 18 was on contact precautions because of MSSA (methicillin-susceptible Staphylococcus aureus) infection. LN 3 stated not wearing proper PPE could potentially cause the spread of germs. During an interview on 9/22/25 at 10:47 a.m., with the IP, the IP confirmed Resident 18 was on contact precautions because he had pneumonia with MSSA. IP stated all staff and visitors are expected to put on gown and gloves when entering contact precaution rooms. During a concurrent observation and interview on 9/22/25 at 12:37 p.m., CNA 1 entered Resident 18's room without wearing gown or gloves and delivered his lunch tray on his bedside table. CNA 1 confirmed she was not wearing any PPE and stated, It was my fault.I didn't know I had to wear PPE when entering the room.I had thought differently. A review of Resident 18's care plans initiated on 9/22/25, indicated, EBP (enhanced barrier precautions) Contact Precautions. A review of the facility's P&P titled, Isolation – Categories of Transmission-Based Precautions, revised 9/22, indicated, Contact Precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the environmental surfaces.Staff and visitors will wear gloves (clean, non-sterile) when entering the room .Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

Based on observation, interview, and record review, the facility failed to ensure safe and proper delivery of respiratory care consistent with the facility's policy and procedures (P&P) for one out of 24 sampled residents (Resident 11) when Resident 11's oxygen saturation (percentage of oxygen carried in the blood) was not consistently monitored.This failure had the potential to result in Resident 11 developing respiratory issues without staff knowledge and for Resident 11 to not achieve her highest practicable well-being.Findings:A review of Resident 11's clinical record indicated Resident 11 was admitted January of 2024 and had diagnoses that included chronic obstructive pulmonary disease (a group of diseases that causes airflow blockage and breathing-related problems), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently).A review of Resident 11's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 7/7/25, indicated Resident 11 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 15 out of 15 which indicated Resident 11 had an intact cognition (mental process of acquiring knowledge and understanding). A review of Resident 11's MDS Special Treatments, Procedures, and Programs, dated 7/7/25, indicated Resident 11 was on oxygen therapy while a resident in the facility.A review of Resident 11's care plan, revised 10/9/24, indicated, The resident [Resident 11] has oxygen therapy r/t [related to] decreased O2 SAT [oxygen saturation]/ Congestion. A review of Resident 11's care plan intervention, initiated 10/8/24, indicated, Check O2 sats.A review of Resident 11's active physician's order, dated 12/3/24, indicated, O2 [oxygen] @ [at] 2 L/min [liters per minute or LPM- unit of measurement for oxygen administration flow rate] via NC [nasal cannula- a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils] maintain O2 SAT < [sic] [greater than] 92% [percent- measurement of one part in every hundred] with Oxygen every shift.During a concurrent observation and interview on 9/23/25 at 12:40 p.m. in Resident 11's room, Resident 11 was seen sitting on her wheelchair, awake, and was on oxygen delivered via NC with the oxygen concentrator (machine) set at 2 LPM. Resident 11 stated she was always on oxygen because she has trouble breathing most of the time and staff usually monitors her oxygen level.A review of Resident 11's treatment administration records (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident) for August and September 2025 as of 9/23/25, indicated Resident 11's O2 saturation was not monitored on the following shifts:8/4/25- night shift8/5/25- night shift8/14/25- night shift8/15/25- night shift8/18/25- night shift8/24/25- night shift8/26/25- night shift8/28/25- night shift9/1/25- night shift9/6/25- night shift9/8/25- evening shift9/15/25- night shiftDuring a concurrent interview and record review on 9/24/25 at 11:53 a.m. with Licensed Nurse (LN) 2, Resident 11's clinical records were reviewed. LN 2 confirmed that Resident 11's O2 saturation monitoring was not consistently done. LN 2 stated Resident 11 was on oxygen therapy and her O2 saturation should be monitored every shift. LN also stated Resident 11's o2 saturation monitoring every shift should have been done to make sure Resident 11's O2 saturation was above the prescribed order. LN 2 further stated that Resident 11 might develop respiratory issues without the staff knowing if her O2 saturation was not checked every shift, especially during night shifts because the resident would be sleeping.During an interview on 9/24/25 at 2:07 p.m. with the Director of Staff Development (DSD), the DSD stated it was very important for nurses to monitor Resident 11's oxygen saturation, especially at nighttime because Resident 11 could desat [desaturate- a drop in a person's blood oxygen level below a normal range] without the staff being aware.During an interview on 9/24/25 at 2:33 p.m. with the Director of Nursing (DON), the DON stated she expects nurses to follow the physician's order for monitoring a resident's o2 saturation so they could monitor the resident's health accurately.A review of the facility's policy and procedure (P&P) titled, Pulse Oximetry (Assessing Oxygen Saturation), Revised 10/2010, indicated, 1. Review the physician's orders or facility protocol for pulse oximetry. 2. Review the resident's care plan to assess for any special needs of the resident .The Sa02 [saturation of oxygen] flow sheet should be placed in the medical record. In addition, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed .

Based on interview and record review, the facility failed to ensure one out of 24 sampled residents (Resident 56) received appropriate pain management services consistent with professional standards of practice, facility's policy and procedure (P&P), and physician's order when Resident 56's pain medication order was not consistently followed.This failure had the potential for Resident 56 to experience unrelieved pain and not attain her highest practicable well-being.Findings:A review of Resident 56's clinical record indicated Resident 56 was admitted June of 2025 and had diagnoses that included left thigh fracture (a break in the continuity of a bone), and cardiomyopathy (a group of heart muscle diseases that weaken or thicken the heart muscle, making it difficult for the heart to pump blood effectively).A review of Resident 56's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 9/9/25, indicated Resident 56 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 9 out of 15 which indicated Resident 56 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 56's MDS Health Conditions, dated 9/9/25, indicated Resident 56 occasionally experiences pain and had received scheduled and as needed pain medications and non-medication intervention for pain.During an interview on 9/22/25 at 10:57 a.m. with Resident 56, in Resident 56's room, Resident 56 stated she would usually experience pain and would need to ask for pain medication from the nurse. Resident 56 stated she was not sure if she was getting the right pain medication.A review of Resident 56's care plan, revised 9/12/25, indicated, The resident [Resident 56] has potential for alteration in comfort due to: .left femur [thigh bone] fracture, muscle spasms . A review of Resident 56's care plan intervention, initiated 6/23/25, indicated, Offer PRN [as needed] or routine pain meds [medications] per resident preference.A review of Resident 56's physician's order, dated 6/2/25, indicated, Morphine Sulfate [a pain medication] Oral Solution 20 MG/ML [milligram/milliliter- unit of measurement] .Give 0.25 ml by mouth every 2 hours as needed for mild trouble breathing/ Pain 1-3 [numeric pain scale from 1 to 10; 1 being the lowest and 10 being the highest form of pain].A review of Resident 56's physician's order, dated 6/2/25, indicated, Morphine Sulfate .Oral Solution 20 MG/ML .Give 0.5 ml by mouth every 2 hours as needed for mod [moderate]-severe trouble breathing/ Pain 4-10.A review of Resident 56's medication administration records (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for the month of July and September 2025 indicated Resident 56 received 0.25 ml of morphine sulfate which was indicated for 1-3 levels of pain on the following occasions:7/1/25 at 9:52 a.m.- pain level was 47/28/25 at 8:11 a.m.- pain level was 49/8/25 at 6:38 p.m.- pain level was 4During a concurrent interview and record review on 9/24/25 at 11:53 a.m. with Licensed Nurse (LN) 2, Resident 56's clinical records were reviewed. LN 2 confirmed that Resident 56's pain medication order was not consistently followed. LN 2 also confirmed there was no documentation that Resident 56's responsible party requested the 0.25 ml dose of morphine sulfate on 7/1/25, 7/28/25, and 9/8/25. LN 2 stated Resident 56 should have received the 0.5 ml dose of morphine sulfate on 7/1/25, 7/28/25, and 9/8/25 because there would be a risk for Resident 56's pain to be not effectively managed.During an interview on 9/24/25 at 2:07 p.m. with the Director of Staff Development (DSD), the DSD stated nurses should always administer the correct dose of pain medication per the ordered scale. The DSD further stated the resident would be under-medicated, and the pain would not be controlled if the resident received the lower dose of pain medication.During an interview on 9/24/25 at 2:33 p.m. with the Director of Nursing (DON), the DON stated that the physician's order should have been followed to be able to control the resident's pain.A review of the facility's P&P titled, Pain Assessment and Management, dated 2001, indicated, The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management .The medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate .A review of the facility's P&P titled, Administering Medications, revised 4/2019, indicated, Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interview and record review, the facility failed to ensure dental services were provided in accordance with professional standards of care for one out of 24 sampled residents (Resident 7), when facility staff did not assist Resident 7 in obtaining a dental appointment as physician ordered. This failure had the potential for Resident 7 to experience unnecessary pain and an increased risk for infection. Resident 7 was originally admitted to the facility in August 2024 with multiple diagnosis which included bacteremia (bacteria in the blood), depression (mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities) and anemia (low levels of healthy red blood cells). A review of Resident 7's Minimum Data Set (MDS, an assessment tool) signed 6/27/25, indicated, Resident 7 had severe cognitive impairment. A review of Resident 7's Order Summary Report, with start date 7/30/25, indicated, Dental referral for dental pain.During a concurrent interview and record review on 9/24/25, at 3:21 p.m., with the Social Services Director (SSD), Resident 7's Order Summary Report was reviewed. The SSD confirmed she was responsible for ensuring all residents with dental referrals are seen by the dentist. SSD stated all dental referrals for dental pain are scheduled immediately and residents are usually seen the next day. The SSD confirmed Resident 7 had a physician order for a dental referral for dental pain on 7/30/25 and stated Resident 7 was not seen by the dentist after that date. SSD further stated she was not aware of the dental referral and missed scheduling it. A review of the facility's policies and procedures (P&P) titled, DENTAL CARE, undated, indicated, To assure that residents are provided with the provision of dental services.Social services shall assist the resident in obtaining access to appropriate dental services.Social service staff shall assist the resident/responsible party in scheduling dental appointments.

Based on observation, interview and record review, the facility failed to ensure special dietary requirements were met for two of 80 residents (Resident 22 and 42) during lunch meal observation on 9/22/25. This deficient practice had the potential to result in meal dissatisfaction and decreasing meal intake that may lead to further compromising medical and nutrition status and/or weight loss of residents. Finding:During an observation of the lunch meal in the dining room on 9/22/25 at 11:57 a.m. with a concurrent review of Resident 22's and Resident 42's meal tickets (a ticket including resident's diet, date, allergies, specific food and beverage items, dislikes, and likes) the following was noted:1. Resident 22's meal ticket indicated, .8 ounces (oz., a unit of fluid volume) of vegetable juice. was one of Resident 22's food preferences but did not receive the vegetable juice with his meal.2. Resident 42's meal ticket indicated, no pepper, no non-salt seasoning but Resident 42 received the pepper and non-salt seasoning packets with her meal.During an interview on 9/22/25 at 12:07 p.m. with Resident 22's family member, and she stated Resident 22 usually got vegetable juice but did not get one today.During an interview on 9/22/25 at 12:12 p.m. with Certified Nursing Assistant (CNA) 5, CNA 5 confirmed Resident 42's meal ticket indicated no pepper and no non-salt seasoning with her meal. She confirmed the pepper and non-salt seasoning packets should not have been on Resident 42's meal tray.During an interview on 9/23/25 at 1:20 p.m. with Registered Dietitian (RD), RD stated the staff needed to follow the meal ticket to meet and honor residents' preferences.A review of facility policy and procedure (P&P) titled, JOB DESCRIPTION-Food and Nutrition Service Director, dated 2023, indicated .DUTIES AND RESPONSIBILITIES.Check trays to ensure diets are served as ordered.Visit residents to determine food acceptance and preferences.A review of facility P&P titled, Food Preferences, dated 2023, indicated POLICY.Resident's food preferences will be adhered to within reason.

Based on interview and record review, the facility failed to ensure physician orders were followed in accordance with professional standards of care for one out of 24 sampled residents (Resident 3), when Resident 3 did not receive treatments as ordered by the physician. This failure had the potential for Resident 3's wounds to not heal, put them at risk for further skin breakdown and not achieve their highest practicable well-being. Resident 3 was originally admitted to the facility in September 2024 with multiple diagnosis which included type 2 diabetes mellitus (condition where the body either doesn't produce enough insulin or doesn't respond properly to the insulin) with foot ulcer (open sore on the foot) and cellulitis (bacterial infection of the deeper layers of the skin) of right lower limb. A review of Resident 3's Minimum Data Set (MDS, an assessment tool) signed 8/21/25, indicated, Resident 3 was cognitively intact. A review of Resident 3's Order Summary Report, with start date 9/11/25, indicated, Tx [treatment]: Left medial [middle] ankle wound: cleanse with NS [normal saline], pat dry, apply calmoseptine [ointment to treat skin irritations] to peri wound [skin surrounding the wound], apply Medi honey [medical-grade honey in wound care] to wound bed, cover with 4x4, wrap with kerlix [cotton bandage] followed by ACE [elastic bandage] every day shift every Mon [Monday], Thu [Thursday] for Wound management Monitor for s/sx [signs and symptoms] infection.A review of Resident 3's Medication Administration Record (MAR-a legal document used to record medications given to the residents), for the month of September 2025, indicated treatment for left medial ankle wound was not done on 9/18/25 as physician ordered. A review of Resident 3's Order Summary Report, with start date 8/30/25, indicated, Tx: Dry skin to coccyx [triangular bone at the bottom of the spine]- apply A&D ointment [ointment to treat dry and inflamed skin] every day and evening shift for maintain skin integrity Eval [evaluate] for the need to cont [continue]/change Tx.A review of Resident 3's MAR for the month of September 2025, indicated treatment to the coccyx was not done on 9/11/25, 9/12/25, 9/17/25, and 9/19/25 as physician ordered. During a concurrent interview and record review on 9/23/25, at 2:10 p.m., with the Infection Preventionist (IP), Resident 3's Medication Administration Record (MAR, a legal document used to record medications given to the residents) for the month of September 2025 was reviewed. The IP stated the expectation was for nursing staff to follow physician's orders. The IP confirmed the treatment orders were not done as ordered on 9/11/25, 9/12/25, 9/17/25, 9/18/25 and 9/19/25. The IP further stated not following the physician orders could potentially cause further skin breakdown. A review of the facility's document titled, Job Description Medication Nurse, revised 11/20 indicated, The primary function of the Medication Nurse is to insure effective nursing care is provided as prescribed by the physician.perform treatments according to the physician's orders.

Based on interview and record review, the facility failed to ensure one out of 24 sampled residents (Resident 56) received treatment and care in accordance with professional standards of practice, and facility's policy, procedure (P&P), and care plan when Resident 56's foley catheter (a thin, flexible tube inserted into the bladder to drain urine) care and butterfly strap (a small, adhesive device designed to secure the catheter tubing to the skin, preventing accidental removal and reducing patient discomfort) monitoring was not done consistently.This failure had the potential for Resident 56 to develop infection and possible foley catheter dislodgement (removal) and/or other complications.Findings:A review of Resident 56's clinical record indicated Resident 56 was admitted June of 2025 and had diagnoses that included neuromuscular dysfunction of the bladder (a condition where the nerves or muscles that control bladder function are impaired, leading to abnormal bladder control), and left thigh fracture (a break in the continuity of a bone).A review of Resident 56's Minimum Data Set (MDS- a federally mandated resident assessment tool) Cognitive Patterns, dated 9/9/25, indicated Resident 56 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 9 out of 15 which indicated Resident 56 had a moderately impaired cognition (mental process of acquiring knowledge and understanding). A review of Resident 56's MDS Bladder and Bowel conditions, dated 9/9/25, indicated Resident 56 has Indwelling catheter [a flexible tube inserted into the bladder and left in place to drain urine].A review of Resident 56's care plan, revised 7/17/25, indicated, The resident [Resident 56] has Indwelling Catheter: [because of] Neurogenic bladder.During an observation on 9/22/25 at 10:57 p.m., in Resident 56's room, Resident 56 was observed connected to a urinary catheter tubing and bag draining a cloudy, deep yellow liquid. The urinary bag was covered with privacy bag and hung on Resident 2's bedside.A review of Resident 56's active physician's order, dated 6/17/25, indicated, Indwelling Bladder Catheter Care Q [every] Shift every shift for Cath [catheter] care.A review of Resident 56's treatment administration records (TAR - a daily documentation record used by a licensed nurse to document treatments given to a resident) for July, August, and September 2025 indicated Resident 56's foley catheter care was not done on the following shifts:7/3/25- day shift7/17/25- day shift8/28/25- night shift9/8/25- evening shift9/11/25- day shiftA review of Resident 56's active physician's order, dated 6/17/25, indicated, Monitor Indwelling Bladder Catheter Butterfly Strap Q Shift for Placement .A review of Resident 56's TAR for July, August, and September 2025 indicated Resident 56's foley catheter butterfly strap monitoring for placement was not done on the following shifts:7/3/25- day shift7/17/25- day shift8/28/25- night shift9/8/25- evening shift9/11/25- day shiftDuring a concurrent interview and record review on 9/24/25 at 11:53 a.m. with Licensed Nurse (LN) 2, Resident 56's clinical records were reviewed. LN 2 confirmed that Resident 56's foley catheter care and butterfly strap monitoring for placement was not consistently done. LN 2 stated if it was not charted then it was not done. LN 2 stated that Resident 56's foley catheter care should be done consistently because of the risk of infection and the butterfly strap placement should be monitored consistently because of the risk of catheter dislodgement.During an interview on 9/24/25 at 2:07 p.m. with the Director of Staff Development (DSD), the DSD stated nurses must follow the frequency of foley catheter care and butterfly strap placement monitoring per the physician's order to make sure the resident in comfortable, clean, and the foley catheter does not have any build up to prevent infection.During an interview on 9/24/25 at 2:33 p.m. with the Director of Nursing (DON), the DON stated she expects nurses to follow the doctor's order for foley catheter care and butterfly strap placement monitoring which is every shift. The DON further stated that the butterfly strap placement monitoring was to make sure the catheter was in place and to prevent catheter displacement, and the foley catheter care was to prevent infection of the resident.A review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, Revised 8/2022, indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Review the resident's care plan to assess for any special needs of the resident .Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site .The following information should be recorded in the resident's medical record: .The name and title of the individual(s) giving the catheter care .

Based on interview and record review the facility failed to follow their pain management policies and procedures (P&P) for three out of three residents (Residents 1, 2, and 3) when: 1. Resident 1 had high PRN (as needed and must be asked for) pain medication usage for eight months prior to evaluating the need to change the current pain medication regimen. 2.The facility failed to determine if Resident 1's behavior of screaming was caused by pain, anxiety, or related to a diagnosis of dementia. 3a. Non-pharmacological interventions (any health intervention that was used to assist with managing chronic pain and did not involve the use of medication. Examples included but were not limited to distraction, music, re-positioning, stretching, or activities) were not implemented or monitored for effectiveness for Resident 1. 3b. Non-pharmacological interventions were not implemented or monitored for effectiveness for Resident 2. 3c. Non-pharmacological interventions were not implemented or monitored for effectiveness for Resident 3. These failures had the potential to cause resident harm, inconsistent pain control, a decline in health status, and to negatively impact the residents' overall well-being. Findings: 1. A review of the facility's P&P titled, Pain Assessment and Management, revised 10/1/22, indicated, The purposes of this procedure are to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The P&P indicated, the facility would review how often the individual requested and received PRN pain medication and would consider administering regularly scheduled pain medication rather than PRN. The P&P indicated, the facility would monitor the resident to ensure the pain was being adequately controlled. A review of the Client Resident Profile, dated 8/5/24, indicated, Resident 1 was admitted to the facility on [DATE] and Resident 1 was not her own responsible party (RP, decision maker). A review of the Medical Diagnosis, dated 8/5/24, indicated, Resident 1 was admitted to the facility with the diagnoses of pressure ulcer of sacral region, unstageable (a painful wound that was caused by pressure, located at the tail bone area. The wound was unstageable because dead tissue covered the wound making wound depth measurements and visual inspection impossible), depression (a sad mood), and dementia (memory loss). A review of Resident 1's admission Minimum Data Set (MDS, a resident assessment tool), dated 8/15/24, indicated, the facility performed a Brief Interview for Mental Status assessment (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) and scored a 5 out of 15 which indicated severe cognitive (memory, orientation, judgement) impairment. The MDS indicated Resident 1 had received scheduled and PRN pain medication and occasionally had pain. A review of Resident 1's care plan (a document that described resident healthcare needs, goals, and interventions [actions taken by facility staff] required to achieve those goals) titled Pain, dated 8/6/24, indicated, the facility staff would monitor the resident for requests for pain treatment and review pain medication dosing schedules for resident satisfaction. A review of the Order Details, dated 8/5/24, indicated the Physician ordered Gabapentin (an anticonvulsant medication that was used to treat seizure disorders and treated nerve pain) 400 milligrams (mg, a unit of measure) by mouth three times a day for pain that was caused by Resident 1's pressure ulcer. A review of the Order Details, dated 8/5/24, indicated the Physician ordered Oxycodone (a strong narcotic that was used to treat moderate to severe pain) 10 mg by mouth every four hours as needed (PRN) for moderate to severe pain (pain was rated on a scale of 0 through 10 out of ten, 0 meant no pain and 10 meant the worst pain, moderate to severe pain was rated as a 4 through 10). During an interview on 7/29/25 at 3:05 pm, Director of Nursing (DON) stated, the amount the PRN [pain medication] was provided [to Resident 1] was the same as if it had been given on a routine basis. A review of Resident 1's Medication Administration Record (MAR), dated 8/5/24 through 8/31/24, indicated that a request for PRN Oxycodone was made 62 times. A review of Resident 1's MAR, dated 9/1/24 through 9/30/24, indicated that a request for PRN Oxycodone was made 85 times. A review of Resident 1's MAR, dated 10/1/24 through 10/31/24, indicated that a request for PRN Oxycodone was made 73 times. A review of Resident 1's MAR, dated 11/1/24 through 11/30/24, indicated that a request for PRN Oxycodone was made 71 times. A review of Resident 1's MAR, dated 12/1/24 through 12/31/24, indicated that a request for PRN Oxycodone was made 77 times. A review of Resident 1's MAR, dated 1/1/25 through 1/31/25, indicated that a request for PRN Oxycodone was made 73 times. A review of Resident 1's MAR, dated 2/1/25 through 2/28/25, indicated that a request for PRN Oxycodone was made 62 times. A review of Resident 1's MAR, dated 3/1/25 through 3/21/25, indicated that a request for PRN Oxycodone was made 49 times. From 8/5/24 through 3/21/25, Resident 1 or her RP was required to ask for pain medication 552 times before the pain medication regimen was re-evaluated and changed. During an interview on 7/30/25 at 8:44 am, the facility's Physician (MD) stated, Resident 1's pain control isn't really bad, we previously discussed pain medications and accommodated the request made by the RP. A review of Resident 1's Order Details, dated 3/21/25, indicated, MD changed the PRN Oxycodone order to include the addition of Oxycodone 10 mg one tablet by mouth three times a day for pain. During an interview on 7/30/25, at 9:34 am, Pharmacist (PHARM) E stated, when we see high usage of PRN pain medication, there is some recommendation to give an extended release [a longer acting medication that controlled pain for a longer period]. PHARM E confirmed, when there was a high PRN pain medication usage, the pharmacist will recommend the pain medication regimen to be re-evaluated. PHARM E stated, the best person to talk to [regarding Resident 1] was PHARM F. During a concurrent interview and record review on 7/30/25 at 11:06 am, PHARM F stated, high usage of PRN pain medication was hard to answer because it is different for each resident. PHARM F reviewed the MAR dated 9/1/24 through 9/30/24 and confirmed more than half of the PRN pain medication that was administered to Resident 1, indicated she had pain that was scored at a 7 or 8 out of 10 (pain that was rated 7 through 10 was considered severe pain). PHARM F stated, I sent a letter to the doctor in January, a documented progress note, indicating high PRN med use. Pharm F was asked if there was a time frame regarding high PRN medication use and notifying the doctor and no time frame was provided. A review of Resident 1's progress note titled, Pharmacy Consultant Note, dated 1/30/25 (five months after Resident 1's admission to the facility), indicated, Resident takes PRN oxycodone often. The progress note did not indicate that the Physician had been notified. 2. A review of the facility's P&P titled, Pain Assessment and Management, revised 10/1/22, indicated, the facility would be able to recognize non-verbal signs of pain to include screaming. The P&P indicated, facility staff would consider cognitive .influences [for example, a diagnosis of dementia] on the president's ability or willingness to verbalize pain are considered when assessing and treating pain. During an interview on 7/29/25 at 2:10 pm, LN B stated, she [Resident 1] yells all the time, not always due to pain, it could be anxiety or just behaviors, unsure which. During an interview on 7/30/25 at 11:06 am, PHARM F stated, so many medications were added and changed to determine if she [Resident 1] had pain or if it was just screaming. PHARM F confirmed, it was unknown if Resident 1 was screaming due to pain, anxiety, or dementia related behaviors. During a concurrent interview and record review on 7/30/25 at 2:37 pm, medical records were requested that indicated the facility had determined the root cause of Resident 1's yelling and screaming was related to pain or a different condition. DON provided psychotropic (medications that affected how the brain worked) notes, dated 12/16/24, 12/18/24, 3/24/25, 4/15/25, 4/30/25, 5/22/25, and 7/28/25. DON confirmed there was no documentation present, including the psychotropic notes that indicated the facility had discussed or determined if Resident 1 was yelling due to pain, anxiety, or dementia related behaviors. 3a. A review of the facility's P&P titled, Pain Assessment and Management, revised 10/1/22, indicated, Non-pharmacological interventions may be appropriate alone or in conjunction with medications. The P&P indicated some examples of non-pharmacological interventions included but were not limited to, adjusting the room temperature, repositioning, ice packs, exercise, relaxation, music, diversions, and activities. The P&P indicated, the facility would monitor and evaluate the effectiveness of interventions in place. A review of the RAI (Resident Assessment Instrument, a set of instructions that assisted facility staff to accurately code the MDS) instructions for pain management, dated 10/1/24, indicated, Non-medication pain (non-pharmacologic) interventions for pain can be important adjuncts to pain treatment regimens. The RAI indicated, interventions included, but were not limited to use of heat and or cold therapy, exercise, and ultra-sound (use of sound waves to treat pain). A review of Resident 1's MDS, dated [DATE], indicated, Resident 1 occasionally had moderate (significant but not severe) pain and did not receive non-pharmacological pain interventions. A review of Resident 1's care plan titled, Pain, dated 8/6/24 indicated, Provide the resident with reassurance that pain is time limited. Encourage resident to try different pain-relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound. A review of Resident 1's Medication Review Report, dated 7/30/25, that included all active and current orders, did not include an order to provide Resident 1 with non-pharmacological interventions or to monitor for effectiveness. During an interview on 7/30/25 at 9:18 am, LN G stated, there isn't anywhere to chart daily non-pharmacological interventions, it's documented in the weekly assessments. A review of Resident 1's Weekly Nursing Summary V.5, dated 1/8/25, indicated, Resident 1 did not receive non-pharmacological pain interventions that week. There was no place to document what non-pharmacological interventions had been provided, if any. A review of Resident 1's Pain Assessment Records, dated 8/12/24, indicated, the facility's occupational therapist (healthcare professional that helped residents to perform tasks that were required for independent living) was working with Resident 1 with positioning in wheelchair for comfort. The Pain Assessment Records, dated 11/5/24, 2/7/25, 3/6/25, and 6/27/25, indicated, nonpharmacological interventions had not been provided for pain and the section that required documentation describing interventions and effectiveness was blank. 3b. A review of Resident 2's Medical Diagnosis, dated 12/6/24, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of radiculopathy, lumbar region (nerve pain, caused by a pinched nerve, in the lower back) and age related osteoporosis without current pathological fracture (weak, brittle bones that were caused by aging and did not include any broken bones). A review of Resident 2's quarterly MDS, dated [DATE], indicated, Resident 2 occasionally had moderate (significant but not severe) pain and did not receive non-pharmacological pain interventions. A review of Resident 2's care plan titled, Pain, dated 12/6/24, indicated, Provide the resident with reassurance that pain is time limited. Encourage resident to try different pain-relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound. A review of Resident 2's Medication Review Report, dated 7/30/25, that included all active and current orders, did not include an order to provide Resident 1 with non-pharmacological interventions or to monitor for effectiveness. A review of Resident 2's Pain Assessment Records, dated 12/9/24, 3/9/25, and 6/13/25, indicated, non-pharmacological interventions had not been provided for pain and the section that required documentation describing interventions and effectiveness was blank. 3c. A review of the Clinical Resident Profile, dated 6/24/24, indicated Resident 3 was admitted to the facility on [DATE]. A review of Resident 3's Medical Diagnosis, dated 6/24/24, indicated Resident 3 was admitted to the facility with the diagnosis of acquired absence of right and left leg above the knee (both legs were surgically removed just above the knee, sometimes people felt pain where their leg used to be). A review of Resident 3's annual MDS, dated [DATE], Resident 3 occasionally had moderate (significant but not severe) pain and did not receive non-pharmacological pain interventions. A review of Resident 3's care plan titled, Pain, dated 6/25/24 indicated, Provide the resident with reassurance that pain is time limited. Encourage resident to try different pain-relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound. A review of Resident 3's Medication Review Report, dated 7/30/25, that included all active and current orders, did not include an order to provide Resident 1 with non-pharmacological interventions or to monitor for effectiveness. A review of Resident 3's Pain Assessment Records, dated 6/28/24 and 6/26/25 indicated, non-pharmacological interventions had not been provided for pain and the section that required documentation describing interventions and effectiveness was blank. During an interview on 7/30/25 at 2:37 pm, DON confirmed, non-pharmacological interventions had not been provided or documented for effectiveness for residents in the facility that experienced pain.

Based on interview and record review, the facility failed to ensure that Resident 1's rights were protected when:1. Licensed Nurse (LN) B administered a PPD test (purified protein derivative, injected under the skin to determine if a person had tuberculosis, a contagious bacterium that had the potential to cause death) after Resident 1's responsible party (RP, decision maker) had declined administration of the PPD test. 2. The facility provided medication to Resident 1 based on the RP's decisions rather than assessment data and concerns regarding Resident 1's appearance of being sedated. These failures violated Resident 1's rights. Findings: 1. A review of the Resident [NAME] of Rights, dated 12/1/12, indicated, residents had the right to refuse any treatment or procedure. A review of the facility's policies and procedures (P&P) titled, Requesting, Refusing, and/or Discontinuing Care or Treatment, revised 2/1/21, indicated, the resident and or the residents RP had the right to refuse treatment. A review of the Client Resident Profile, dated 8/5/24, indicated, Resident 1 was admitted to the facility on [DATE] and Resident 1 was not her own RP. A review of the Medical Diagnosis, dated 8/5/24, indicated, Resident 1 was admitted to the facility with the diagnoses of pressure ulcer of sacral region, unstageable (a painful wound that was caused by pressure, located at the tail bone area. The wound was unstageable because dead tissue covered the wound making wound depth measurements and visual inspection impossible), depression (a sad mood), and dementia (memory loss). During an interview on 7/24/25 at 10:10 am, Resident 1's RP stated, on August 11th Resident 1 was given a TB shot [PPD test] without my permission. During a concurrent interview and record review on 7/29/25, at 2:10 pm, with LN B, Resident 1's Medication Administration Record (MAR), dated 8/11/24 was reviewed. LN B confirmed, the MAR indicated, LN B performed a PPD skin test on Resident 1 and stated, when he [RP] came back to the room, I alerted him I gave the PPD, I did not know it was refused previously, and the order to give the PPD was still in the computer. LN B reviewed the MAR, dated 8/5/24, and confirmed the MAR indicated the PPD had been refused. LN B stated, my view of the MAR was not of the entire month, it only showed what was due that day, so I couldn't see that it had been refused. During an interview on 7/29/25 at 10:15 am, Director of Nursing (DON) confirmed, Resident 1 had been provided the PPD skin test on 8/11/24 and stated, the nurse didn't remove the PPD order from the system and that's why LN B provided the PPD. After it was originally refused, the nurse should have removed the order and entered a note. 2. A review of the Resident [NAME] of Rights, dated 12/1/12, indicated, residents had the right to be free from excessive medication. A review of the Medication Review Report, dated 7/30/25, indicated, Resident 1 received Buspirone HCL (Buspar, a medication that was used to treat anxiety) 15 milligrams (mg, unit of measure), give 1 tablet by mouth three times a day for anxiety manifested by continuous calling out after needs have been met. The Medication Review Report, indicated, Resident 1 received oxycodone HCL (a strong opioid pain medication that had the potential to cause sedation and drowsiness. When using oxycodone and Buspirone together, potential risks and side effects included an increased risk of profound sedation [depressed consciousness], drowsiness, and impaired judgement) 10mg, give one tablet by mouth three times a day for pain and may also give every 4 hours as needed for pain that was scored 4-10 out of 10 on the pain scale. During an interview on 7/24/25 at 10:10 am, Resident 1's RP stated, I'm concerned about her [Resident 1's] anxiety, they started her on a lower level once a day, then they increased to twice a day, then we moved it to three times a day. I just told them, it's helped a lot, there are still minor break outs [related to Resident 1's yelling out], so I asked to up the dosage. During an interview on 7/30/25 at 8:44 am, facility's physician (MD) stated, Resident 1's RP is concerned about the pain, he was pushing for stronger pain medications, we accommodated his request and her pain control really isn't bad. During an interview on 7/30/25 at 9:18 am, LN G stated, Resident 1's RP would by-pass the nurse and go to the DON to complain Resident 1 was in pain and demand more pain meds. I went once to assess Resident 1's pain after the RP said she was in pain, and the RP said, say your pain is a 7, then Resident 1 agreed her pain was a 7. LN G stated, prior to RPs arrival Resident 1 stated she had no pain. LN G stated, sometimes the PRN (as needed dose of oxycodone) was held because nurses felt uncomfortable giving it because she appeared to be sedated or sleepy and the RP would demand that pain meds still be given. LN G stated, there were times when Resident 1 was provided PRN pain medication [oxycodone] due to the RP pushing pain meds and convincing Resident 1 she was in pain, so it's given. During a review of the IDT (Interdisciplinary Team, a group of facility staff such as department heads and staff that provided direct resident care, met to discuss resident care concerns and goals) Note, dated 5/21/25, indicated, PHARM F was notified Resident 1's RP had concerns about Resident 1's medication and RP felt sometimes Resident 1 was sedated. The ID note indicated that the doctor had ordered a decrease in Resident 1's pain medication and the RP did not want the pain medication changed. The IDT note indicated that the RP did not feel Resident 1 was sedated and was more concerned about addressing Resident 1's calling out. During an interview on 7/30/25 at 11:06 am, Pharmacist (PHARM) F, stated, one time while I was at the facility, I was told the RP didn't care about sedation anymore and just wanted to keep Resident 1 comfortable. During a review of the Care Plan Conference Notes, dated 5/29/25, indicated, Resident 1's RP was in attendance and Concerns-increased sedation/groggy were discussed. The Care Plan Conference Notes, indicated, Resident 1's Buspar would be increased to 15 mg today and MD suggest decrease of Oxycodone dose, declined at that time by RP.

Based on interview and record review, the facility failed to follow their policies and procedures (P&P) regarding medication administration documentation for one out of three sampled residents (Resident 1) when Licensed Nurse (LN) B initialed the medication administration record (MAR) for a medication that LN A prepared and administered to Resident 1. This caused inaccurate documentation and had the potential to negatively impact resident safety.Findings: A review of the facility's P&P titled, Administering Medications, revised 4/1/19, indicated, The individual administering the medication initials the residents MAR on the appropriate line after giving each medication and before administering the next dose. A review of the Client Resident Profile, dated 8/5/24, indicated, Resident 1 was admitted to the facility on [DATE] and Resident 1 was not her own responsible party (RP, decision maker). A review of the Medical Diagnosis, dated 8/5/24, indicated, Resident 1 was admitted to the facility with the diagnoses of pressure ulcer of sacral region, unstageable (a wound that was caused by pressure, located at the tail bone area. The wound was unstageable because dead tissue covered the wound making wound depth measurements and visual inspection impossible), depression (a sad mood), and dementia (memory loss). During a concurrent interview and record review on 7/29/25 at 2:10 pm, with LN B, Resident 1's MAR, dated 3/20/25 was reviewed. LN B confirmed, the MAR indicated, LN B had administered oxycodone (a strong pain killer) 10 milligrams (unit of measure), one tablet, by mouth, on 3/20/25, at 6:32 pm, to Resident 1. LN B stated, I checked off the oxycodone [in the MAR], but I didn't give it, LN A did. LN B stated, it is not normal for me to sign off a medication that I did not administer. During an interview on 7/29/25 at 3:05 pm, Director of Nurses (DON) stated, nurses should not sign out medication they did not administer.

Based on observation, interview, and record review, the facility failed to maintain infection control practices when facility staff disinfected the Hoyer lift (mechanical device used to safely transfer residents from one place to another) in the hallway, did not wear gloves, or perform hand hygiene (washing hands or using alcohol-based hand sanitizer) afterwards. This failure had the potential to spread infections to other residents, facility staff, and visitors.Findings: A review of the facility's policies and procedures, (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 9/1/22, indicated, facility staff would clean and disinfect medical equipment in-between resident use. A review of the facility's P&P titled, Personal Protective Equipment (PPE, items worn to prevent the spread of infection such as gowns or gloves), revised 10/1/18, indicated, PPE requirements were specific to job requirements and facility staff would wear the appropriate PPE for specific tasks. A review of the facility's P&P titled, Infection Prevention and Control, revised 12/1/23, indicated, the facility utilized infection control practices to maintain a safe environment. A review of the CaviWipes Safety Data Sheet, dated 6/29/22, indicated, facility staff were required to wear gloves while using CaviWipes (a brand name, cleansing and disinfecting wipes that were used to clean resident care equipment). The safety data sheet indicated repeated exposure could cause dry, cracked skin (this had the potential for bacteria to enter through cracked skin and cause the spread of infection). During an observation on 7/25/25 at 12:54 pm, Certified Nurse Assistant (CNA) C and CNA D were observed wiping down the Hoyer lift without wearing gloves, in the hallway, outside of room [ROOM NUMBER]. When CNA C and CNA D finished, they walked immediately into room [ROOM NUMBER] with the Hoyer lift and were not observed performing hand hygiene. During a concurrent interview and record review on 7/25/25 at 1:00 pm, with CNA C and CNA D, the entirety of the observation made was described. CNA C and CNA D confirmed the observation. CNA C stated, we should wear gloves and acknowledged not performing hand hygiene after cleaning the Hoyer lift and before entering room [ROOM NUMBER]. CNA D produced a plastic container that had a black lid with the name of CaviWipes on the label. CNA D reviewed the instructions on the label and confirmed, the label indicated gloves were to be worn while using the product. During an interview on 7/25/25 at 1:44 pm, the facility's infection preventionist (IP) confirmed the observation made of CNA C and CNA D wiping down the Hoyer lift and stated, they should be cleaning [the Hoyer lift] in the room, not in the hall, and wearing gloves. IP confirmed, hand hygiene should have been performed after wiping down the Hoyer lift.

Based on observation, interview, and record review, the facility failed to: 1. Label/date and dispose of specific food in accordance with the professional standards for food service safety 2. Have dietary staff follow hygienic practices in the facility's kitchen 3. Have accurate values and documentation for the dish machine chemical solutions. These failures resulted in the potential to result in putting residents at risk for food borne illnesses (illness caused by consuming contaminated foods or beverages). Findings: 1. During a concurrent observation and interview on [DATE] at 10:03 AM, with Dietary Aide C (DA C) and the Dietary Manager (DM), it was observed in the refrigerator in the facility kitchen that there was a clear, plastic container with a green lid labeled, Egg, with a date of [DATE], with approximately six eggs inside of the container. Another clear, plastic container with a green lid labeled, Turkey, with a date of [DATE] was identified in the facility kitchen refrigerator, and was acknowledged as a turkey sandwich by DA C. It was confirmed by DA C and DM that the eggs in this container and the turkey sandwich were expired and needed to be disposed of. During a concurrent observation and interview on [DATE] at 10:05 AM with DA C, a container of Egg beaters, egg whites that DA C confirmed was opened did not have an open date label. A meat, that DA C identified as ham, was stored in the facility refrigerator without a labeled date on the packaging. An opened sliced cheese packet consisting of 120 slices of Pasteurized Processed American Cheese was stored in the facility refrigerator without an open date label. An opened shredded cheese packet was stored in the facility refrigerator without an open date label. It was confirmed by DA C that these items were opened and did not have the appropriate labeling. During a review of the facility's policy and procedure titled, Labeling And Dating Of Foods, dated 2023, indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated . Newly opened food items will need to be closed and labeled with an open date and used by the date that follows . 2. During an observation on [DATE] at 10:18 AM and on [DATE] at 1:47 PM, DA A was observed on his personal cellular phone in the kitchen preparation area. During an interview on [DATE] at 4:00 PM with the Registered Dietician (RD), stated that personal belongings are to be kept outside of the kitchen preparation area and in a designated area for their belongings. The RD stated that phones cannot be used, and if they have an emergency call, they must leave the kitchen preparation area to take the phone call. RD stated that a dietary staff member cannot work (for example, producing food, doing dishes, etc.) and use their phone as it is, An infection control issue, and can cause cross contamination. During a review of the facility's policy and procedure titled, Dress Code, dated 2023, indicated, No cell phones in kitchen area. During a review of the facility's policy and procedure titled, Spring Hill Manor Cell Phone Policy, dated [DATE], indicated, Personal cellular phone use is discouraged while you are working. Cell phones will be turned off or on vibrate and stored with your personal affects in a locker or in your car while giving care or on the clock . Violations will result in disciplinary actions up to and including termination. 3. During concurrent observation and record review of a document titled, Dish Machine Temperature Log, dated [DATE], on [DATE] at 9:46 AM, the test strip values for chlorine (a chemical used to sanitize the dishware) were 200 ppm (parts per million, a unit of concentration) for each breakfast with the dates [DATE] to [DATE]. The test strip values for chlorine were 200 ppm on [DATE] and 150 ppm on [DATE] for lunch. The test strip values for chlorine were 150 ppm on [DATE] and 200 ppm on [DATE] and [DATE]. During a concurrent observation and record review of a document titled, Dish Machine Temperature Log, dated [DATE], on [DATE] at 8:08 AM, the test strip values for chlorine were now all consistently 100 ppm, with what appeared to be visible eraser [NAME] and the number 1 written over the number 2 to indicate 100 ppm rather than 200 ppm. During an interview on [DATE] at 4:00 PM with the RD, she confirmed and acknowledged that it did appear that there were eraser [NAME] and numbers written over other numbers. During a review of the facility's document titled, Dish Machine Temperature Log, dated [DATE], indicated, Chlorine should be 50 to 100 ppm.

Based on observation, interview, and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff with documentation that dietary staff had been provided appropriate competencies and trainings. This failure had the potential to result in dietary staff providing inadequate and potentially harmful services that could result in foodborne illnesses (illness caused by consuming contaminated foods or beverages). Findings: During concurrent observation and record review of a document titled, Dish Machine Temperature Log, dated [DATE], on [DATE] at 9:46 AM, the test strip values for chlorine (a chemical used to sanitize the dishware) were 200 ppm (parts per million, a unit of concentration) for each breakfast with the dates [DATE] to [DATE]. The test strip values for chlorine were 200 ppm on [DATE] and 150 ppm on [DATE] for lunch. The test strip values for chlorine were 150 ppm on [DATE] and 200 ppm on [DATE] and [DATE]. During a review of the facility's document titled, Dish Machine Temperature Log, dated [DATE], indicated, Chlorine should be 50 to 100 ppm. During a concurrent observation and interview on [DATE] at 10:03 AM with Dietary Aide C (DA C) and the Dietary Manager (DM), it was observed in the refrigerator in the facility kitchen that there was expired food. It was confirmed by DA C and DM that the food was expired and needed to be disposed of. It was observed that food in the facility kitchen's refrigerator did not have a labeled date on it. It was confirmed by DA C that these items were opened and did not have the appropriate labeling. During a concurrent observation and record review of a document titled, Dish Machine Temperature Log, dated [DATE], on [DATE] at 8:08 AM, the test strip values for chlorine were now all consistently 100 ppm, with what appeared to be visible eraser [NAME] and the number 1 written over the number 2 to indicate 100 ppm rather than 200 ppm. During a concurrent interview and record review on [DATE] at 4:00 PM with the Registered Dietician (RD), stated that new and existing dietary staff (9 out of 9 staff members) did not have trainings or competencies documented and further explained that she needed to provide inservices (specialized training in relation to the job position) to the kitchen staff. RD provided a copy of a document that listed requested items and wrote, No, next to the request for competencies/trainings of all dietary staff and clarified that this meant she did not have any documentation. The RD confirmed and acknowledged that it did appear that there were eraser [NAME] and numbers written over other numbers, which could be due to ineffective competency. During an interview on [DATE] at 4:30 PM with the Dietary Manager (DM), he stated that there wasn't documentation for the dietary staff's competencies and/or trainings and it needed to be provided. During an interview on [DATE] at 9:00 AM with Dietary Aide B (DA B), stated that he had been hired at this facility for approximately two years and within the two years had no written tests to complete to acknowledge competencies. He also stated that he was trained by being shown how to do a task (for example, how to do the temperature logs for the dishwasher), but it was not documented/he did not have to sign or fill out any form after being taught. During a review of the facility's policy and procedure titled, Demonstrating Food Safety and Job Competency For Food and Nutrition Services Employees, dated 2023, indicated, Food and Nutrition Services employees will be tested on the competency of their skill . Each employee must successfully complete the following within each year (12 months) . Verification of Demonstrated Job Competencies (Cooks or Diet Aids) . 2 written tests. The Director of the Food and Nutrition Services and/or Facility Registered Dietician will conduct the tests on each employee and complete the form as it is written . The Director of the Food and Nutrition Services and/or Facility Registered Dietician will sign off as each skill is demonstrated properly on the competency forms.

Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 43) was free of unnecessary psychotropic medication (drug prescribed to affect the mind, emotions or behavior) when Resident received clonazepam (a type of medication used to treat anxiety, seizures and panic disorders) on an as needed (PRN) schedule for longer than the 14 day limit without clinical justification. This failure had the potential for adverse effects such as sedation, falls, headaches weight gain, dizziness, nausea and abnormal involuntary movements. Findings: Review of Resident 43's record indicated they were admitted to the facility with diagnosis including anxiety disorder, encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition) ,Type 2 diabetes mellitus and syncope (fainting or passing out and falling down). Resident 43's Physician Orders dated 08/07/22, included an order for clonazepam 1 mg by mouth as needed for anxiety manifested by verbally expressed every evening. Clonazepam was discontinued on 09/13/2022 38 days later. Review of Resident 43's Medication Administration Record (MAR) for August/September 2022, indicated that they were administered clonazepam one mg every evening from 08/07/2022 to 09/13/2022, (38 days). There was no documentation found in the record that the attending physician documented a rationale to extend the medication past 14 days. During concurrent interview and record review on 06/09/2022 at 8:20 AM, Director of Nursing (DON) and Assistant Director Of Nursing (ADON), both confirmed there was no physician note for reason/rationale to continue clonazepam beyond 14 day PRN time limit. DON and ADON confirmed it was a mistake, and it should have been done. Review of facility policy titled Antipsychotic Medication Use dated December 2016, policy indicated the need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.