Every finding on record at Greenfield Care Center of Fillmore, LLC

Based on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 1, 2 and 3) received services for incontinence care assistance to maintain personal hygiene. This failure had the potential to raise risk of moisture associated skin damage (MASD) if exposed to various body wastes and fluids over an extended period of time.During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include acute respiratory failure with hypoxia (condition where the lungs cannot move enough oxygen into the bloodstream), post-traumatic stress disorder (mental health condition that's caused by an extremely stressful or terrifying event), muscle weakness, severe intellectual disabilities (a major delay in mental and daily life skills where a person needs daily, hands-on support for most activities). During an observation on 8/20/26 at 2:15 p.m., Resident 1 was observed in his room lying in bed, unable to answer questions asked. During a review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated 6/20/26, the MDS indicated that Resident 1 has severely impaired cognitive skills for daily decision making; always incontinent of both bowel and bladder; and was dependent (helper does all the effort or assistance of two or more helpers is required) for toilet hygiene. During a review of Resident 1 's care plan (CP), initiated 3/26/24, the CP indicated, resident 1 was incontinent of bowel and bladder related to limited mobility and cognitive loss and at risk for skin breakdown. During an interview on 8/20/26 at 1:59 p.m., with Resident 1's Personal Caregiver [PC 1], PC 1 stated being familiar with Resident 1 and worked directly with Resident 1 Monday to Friday for the past 2 months. PC 1 explained she informed Resident 1's assigned Certified Nursing Assistant (CNA 1) about 4 times that it smells like bowel movement and that Resident 1 needed to be changed. During an interview on 8/20/26 at 2:25 p.m., with CNA 1, CNA 1 stated residents' briefs are checked about every 2 hours and changed if they are soiled. During an interview on 8/20/26 at 1:59 p.m., with Licensed Nurse (LN) 3, LN 3 stated she was Resident 1's nurse and was familiar with Resident 1. LN 3 stated residents' briefs should be checked and changed every 2 hours. LN 3 stated she was unsure how long Resident 1's brief was sitting in a soiled brief for and was unsure the last time Resident 1's brief was changed. During a concurrent interview and record review on 8/20/26 at 3:28 p.m., with the Assistant Director of Nursing (ADON), Resident 1's bowel and bladder function documentation was reviewed. Resident 1's bowel and bladder documentation indicated missing entries for day shift on 8/16/26 and day shift on 8/17/26. ADON stated CNAs should be documenting the blader and bowel function every shift and documentation was missing on the above-mentioned dates. During a review of Resident 2's Clinical Record (CR), the CR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that include autistic disorder (condition that affects how a person communicates, interacts with others, learns, and behaves) and functional quadriplegia (complete inability to move all four limbs). The clinical records further indicated Resident 2 Cognitive stills for daily decision making is severely impaired and is dependent with toileting hygiene. During a concurrent interview and record review on 8/20/26 at 3:28 p.m., with the Assistant Director of Nursing (ADON), Resident 2' bowel and bladder function documentation was reviewed. Resident 2's bowel and bladder documentation indicated missing entries for day shift on 8/16/26 and day shift on 8/17/26. During a review of Resident 3's Clinical Record (CR), the CR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that include uninhibited neuropathic bladder (lack of normal brain control over the bladder, which causes sudden, uncontrollable urges to urinate and leaking), and anoxic brain damage (condition caused by a lack of oxygen to the brain), and muscle weakness. The CR further indicated that Resident 3 was in a persistent vegetative state (condition where a person appears awake and breathes on their own, but shows no signs of awareness) and is dependent with toileting hygiene. During a concurrent interview and record review on 8/20/26 at 3:28 p.m., with the Assistant Director of Nursing (ADON), Resident 2's bowel and bladder function documentation was reviewed. Resident 2's bowel and bladder documentation indicated missing entries for day shift on 8/16/26. During a concurrent interview and record review on 8/20/26 at 3:12 p.m., with the ADON, the facility's policy and procedure (P&P) titled, Incontinent care, dated 7/2012 was reviewed. The P&P indicated Check for wetness at least every two hours or as often as needed based on the resident's needs. ADON stated there is no documented evidence that Residents 1, 2 or 3 were checked and changed at least every 2 hours. During a review of the facility's policy and procedure (P&P) titled Activities of Daily Living (ADL), Supporting revised on 3/2018, the P&P indicated, . Appropriate care and services will be provided for residents who are unable to carry out ADLs independently. including appropriate support and assistance with: elimination (toileting).

Based on observation, interview, and record review, the facility staff failed to maintain privacy and right for one of 19 residents sampled (Resident 1) on Enhanced Barrier Precautions (EBP an infection control strategy in nursing homes) inicated by foley catheter ( a flexible, indwelling tube inserted through the urethra into the bladder to drain urine ) and G-tube (gastrostomy tube - a flexible tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications) when care was provided in the activity room in presence of other resdients. This facility failure has the potential to lead to resident's decline in mental health and a decline in overall physical well-being During an observation on 3/18/26 at 4:00 p.m., in the dementia care unit activity room. Licensed Vocational Nurse (LN 1) and Certified Nurse Assistant (CNA 3) were observed providing tube feeding to Resident 1 and there were no privacy practices provided to the resident observed during the procedure. A review of the medical record for Resident 1, dated 2/18/26, revealed physician orders for Enhanced Barrier Precautions (EBP ) indicated by foley catheter and G-tube every shift. During an interview with Director of Nursing (DON) on 03/18/2026 at 5:35 p.m., DON indicated, that infection control practices (EBP) and dignity must be practiced for all residents, including protecting bodily privacy during treatment procedures. During a review of Policies and Procedures (P&P) titled Dignity dated 01/2026, the P&P inidicated in part, 11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on interview and record review, the facility failed to ensure information regarding a Physician Orders for Life-Sustaining Treatment (POLST-physician orders indicating the patient's wishes during a medical crisis, such as cardiopulmonary resuscitation [CPR], and/or artificial nutrition/hydration [receiving food and water through a tube], was provided to one of nineteen sampled residents (Resident 3) or the legally recognized decisionmaker. This failure results in the unsigned POLST to be invalid and had the potential to cause uncertainty among healthcare staff regarding the resident's personal preferences with end of life care.During review of Resident 3's Physician Orders for Life-Sustaining Treatment (POLST) form dated 2/11/23, the POLST indicated orders to Attempt Resuscitation/CPR, full treatment, and use of long-term artificial nutrition including feeding tubes. The POLST was marked to indicate the information was discussed with the resident and that there was no advance directive. The POLST was signed and dated 2/11/23 by the physician, listed the name of Resident 3's sister as the legally recognized decisionmaker however it was not signed by the resident or sister. During review of Resident 3's comprehensive Minimum Data Set (MDS - a federally mandated, standardized clinical assessment tool used to evaluate the functional capabilities, health needs, and care requirements of residents) dated 1/5/26, the MDS indicates Resident 3 has a BIMS score (Brief Interview for Mental Status - a 0-15 point tool used to assess cognitive function, covering memory, orientation, and recall. Scores are categorized into three levels: 13-15 = Intact Cognition, 8-12 = Moderate Impairment, and 0-7 = Severe Impairment) of 15. During a concurrent interview and review on 3/18/26 at 2:00 p.m. with Registered Nurse Supervisor (RNS), Resident 3's POLST was reviewed. RN Supervisor acknowledged the POLST was not signed by the resident or the resident's representative. During a review of the facility's policy and procedure (P&P) titled, Physician Orders for Life Sustaining Treatment (POLST) or Request Regarding Resuscitative Measures Form, dated -1/2025, the P&P indicated in part, . A health care provider shall explain the form and medical intervention and procedures offered on the form. This shall be completed by the healthcare provider based on patient preferences and medical indications. This form must be signed by a physician and the patient or his/her legally recognized health care decision maker.

Based on interview and record review, the facility failed to provide written information to one of nineteen sampled residents (Resident 37) about a bed-hold (a reservation that allows one to stay in, or return to, a care facility) when Resident 37 was transferred to a hospital. This failure had the potential of Resident 37 not being fully informed of their right to request a bed hold and to return to the facility after hospitalization, potentially leading to an inappropriate discharge. ( I am not sure, if we can write this because the both hospital SNF know about the 7 day hold and there was no outcome. If resident was interviewed and they complaint about an issue with the document not being given)Review of an online article published by the California Advocates for Nursing Home Reform (CANHR) titled, Nursing Home Residents Have The Right To A 7-Day Bed Hold When hospitalized , dated May 2018, indicates in part, .In addition to including information about bed-hold policies in the admissions agreement, the facility must give a written bed-hold notice to the resident and/or the resident's family upon being transferred to the hospital, as is required by both federal law and state regulations .(https://canhr.org/nursing-home-residents-have-the-right-to-a7-day-bed-hold-when-hospitalized /) During a review of Resident 37's Progress Notes (PN), dated 10/11/25, the P&P indicated, Resident 37 was drowsy, had signs of unusual weakness, a low oxygen saturation level, and an elevated heart rate and temperature. The resident was transferred to the hospital. Further evaluation at the hospital indicated the resident had a kidney infection. Resident 37 was discharged to the facility on [DATE]. Review of Resident 37's Bed Hold Notification, dated 2/3/23, indicates the resident signed the document on admission but the section titled To be Completed upon Transfer was blank. During an interview on 3/19/26 at 4:04 p.m. with Registered Nurse Supervisor (RNS), RNS was asked about Resident 37's hospital transfer form. RNS stated that nurses send residents to the hospital with a copy of the face sheet and a list of their medications. When asked about the information provided to Resident 37 regarding the bed hold policy, RNS stated that residents are informed of the bed hold policy during the admission process and that those records were kept with medical records. During a review of the facility's policy and procedure (P&P) titled, Bed Hold Notice, dated 7/2025, the P&P indicated, It is the policy that this facility shall inform the resident, or the resident's representative, in writing of the right to exercise the bed hold provision under the State Plan (7 days for California), at the time of admission, and at the time of transfer for hospitalization or therapeutic leave.

Based on interview and record review, the facility failed to resubmit a Preadmission Screening and Resident Review (PASRR - a tool to determine if the person had or was suspected of having a mental illness or intellectual disability) for two out of nineteen sampled residents (Resident 5 and Resident 45) when the residents were diagnosed with a new mental illness. This failure had the potential to result in Resident 5 and Resident 45 to not receive the appropriate medical services for their mental illness diagnoses.During review of Resident 5's medical records, the admission Record (AR), dated 5/13/25, indicated Resident 5 was admitted with a diagnosis of paranoid schizophrenia (intense, irrational delusions and auditory hallucinations, often involving themes of persecution or conspiracy, feeling watched, followed, or plotted against, that leads to severe anxiety [feeling of fear, dread, or uneasiness], social withdrawal, and potential agitation). Resident 5's medical record showed a level I PASRR on 5/2/25 and was determined that a level II PASRR was not required.After Resident 5 was admitted , the resident was diagnosed with anxiety on 7/26/25 (after admission), post-traumatic stress disease (PTSD - re-experiencing flashbacks, nightmares, and frightening thoughts of a terrifying event) on 9/10/25, and unspecified psychosis (hallucinations, delusions, disorganized thinking, or behavior that is not attributable to a substance or known medical condition) on 10/1/25. Resident 5's Order Summary (OS), indicated Zyprexa (an antipsychotic medication used to manage hallucinations, delusions, and mood) was started on 10/17/25. A repeat PASRR was not re-submitted. During review of Resident 45's AR dated 7/6/24, the AR indicated the resident was originally admitted on [DATE] with diagnoses that included anxiety and unspecified psychosis. A PASRR level I was completed 2/16/24 and a level II PASRR was not required. Resident 45's care plan was updated on 10/20/25 for psychosocial wellbeing problems/needs related to anxiety. Review of Resident 45's order summary indicated the resident was started on 0.5 mg (milligrams - metric unit of mass) of Trazadone (an antidepressant medication widely used off-label to treat insomnia due to its sedating effects, and sometimes for depression, anxiety, or PTSD-related nightmares). A new PASRR was not initiated after the resident's care plan was updated or after starting Trazadone. During a concurrent interview and review on 3/19/26 at 11:54 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 5's and Resident 45's PASRR's were reviewed. MDSC stated that PASRR's are resubmitted when a resident has been hospitalized for a prolong period of time or when there is a significant change in mental status or a cognitive decline. MDSC stated a repeat PASRR is not repeated when a resident is prescribed psychotropic drugs (chemical substances that change brain function, resulting in alterations in perception, mood, consciousness, or behavior) or if diagnosed with a new mental disease diagnosis. After reviewing Resident 5's and Resident 45's admission records, order summaries and care plans, MDSC acknowledged the residents did not have repeat PASRR's after changes with their mental conditions. During a review of the facility's policy and procedure (P&P) titled, Preadmission Screening and Annual Resident Review (PASARR), dated 4/2024, the P&P indicates in part, . The purpose of this policy is to define and set expectations regarding the appropriate pre admission assessment of all individuals with a mental disorder and individuals with intellectual disability. It is the policy of the facility to coordinate the assessment process with the Pre admission Screening and Annual Resident Review program (PASARR) under Medicaid and Subpart C to the extent practicable to avoid duplicative testing and effort. This includes incorporating the recommendations from the PASARR level II determination and evaluation in the residents assessment, care plan, and transition of care; and referring all level II residents and all residents with new or evident conditions related to Level II review upon significant change in status assessment.

Based on interview and record review, facility staff failed to ensure a care plan (CP - written document that outlines the specific nursing interventions and goals for a patient's care, based on their assessed needs and diagnoses) pertaining to noncompliance with dialysis was reviewed, evaluated for effectiveness, and revised accordingly for one out of the nineteen sampled residents ( Resident 3). This deficient practice has the potential to place Resident 3 at significant risk for hospitalization, severe cardiovascular events, and even death due to unmet medical needs.During a review of Resident 3's Order Summary (OS), 3/20/26, the OS indicates, Resident #3 goes to dialysis every Tuesday, Thursday and Saturday. Review of Resident 3's Progress Notes (PN), dated 12/24/25, 1/3/26, 1/8/26, 1/17/26, 1/20/26, 1/27/26, 2/5/26, 2/28/26, and 3/19/26 indicate the resident refused to go to dialysis. During a review of Resident 3's Care Plan (CP), dated 5/15/24, the CP indicates the resident is at risk for complications related to refusing to go to dialysis. During a concurrent interview and review on 3/20/26 at 9:25 a.m. with Minimum Data Set nurse (MDS), Resident 3's care plan for dialysis non-compliance was reviewed. MDS stated the resident had a pattern of not wanting to go to dialysis. When MDS was asked what changes or revisions had been done to Resident 3's noncompliance with dialysis, MDS was unable to verbalize or provide documentation indicating Resident 3's CP interventions were evaluated and revised based on the resident's pattern of refusing to attend dialysis treatments. MDS acknowledged Resident 3's care plan interventions for dialysis noncompliance were not revised although the resident continued to be non-compliant. During a concurrent interview and review on 3/20/226 at 9:45 a.m. with Registered Nurse Supervisor (RNS), Resident 3's CP for dialysis noncompliance was reviewed. RNS stated that resident CP's are reviewed by the MDS nurse and are updated depending on the resident's current status at the time of MDS assessment and lookback period. RNS further stated that interventions should be reevaluated by the target date. RNS acknowledged that Resident 3's CP interventions should have been discussed with the interdisciplinary team (IDT - a group of professionals from different disciplines who work collaboratively to provide patient-centered care) and revised if the interventions are determined to be ineffective or not working. During review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 4/2024, indicates A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change.The interdisciplinary team reviews and updates the care plan:.when the desired outcome is not met.

Based on interview, intervview and facility policcy and procedure, the facility failed to ensure timely wound assessment assessment was done for one of nineteen sampled residents (Resident 7) when there were no documentation to show track changes in size, tissue type, moisture levels, and infection signs, on certain weeks.This failure had the potential to affect treatment plans and delay healing.During a review of Resident 7's admission Record (AR) dated 3/20/26, the AR indicated that Resident 7 is a [AGE] year-old male who was initially admitted to the facility on [DATE], current diagnoses includes, Acute Respiratory Failure with Hypoxia (condition where the respiratory system fails to oxygenate the blood properly resulting in low oxygen saturation), Pressure Ulcer of Sacral Region stage 4 (full thickness loss of skin with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone), Abnormal Finding of Blood Chemistry (laboratory values documented as outside the normal reference range), Diarrhea (passage of three or more loose, watery stools per day), Fever (elevated body temperature associated with illness or infection), Pain, Hyperlipidemia (condition characterized by high levels of cholesterol in the blood).During a review of Resident 7's Weekly Wound Assessment (WWA: regular evaluation of a wound's healing progress, typically conducted every 7 days, to track changes in size, tissue type, moisture levels, and infection signs), of right hip skin shear, WWA were documented on 2/18/26, 3/3/26 and 3/10/26. The review indicated that the facility failed to create WWA for the week of 2/25/26.During a review of Resident 7's WWA of left buttock stage 4 pressure injury, WWA were documented on 2/10/26, 2/17/26, 2/24/26 and 3/10/26. The review indicated that the facility failed to create WWA for the week 3/3/26During a concurrent interview and record review of Resident 7's WWA on 3/20/26 at 11:45 a.m. with Infection Preventionist (IP) indicated, that the WWA for right hip skin shear was not initiated on week of 2/25/26 and WWA for left buttock stage 4 pressure injury was not also initiated on week 3/3/26. IP acknowledged that the facility failed to create WWA for right hip skin shear on week of 2/25/26 and WWA for left buttock stage 4 pressure injury on week 3/3/26.During a concurrent interview and record review of Resident 7's WWA on 3/20/26 at 12:07 p.m. with Wound Nurse (WN), indicated, that the WWA for right hip skin shear was not initiated on week of 2/25/26 and WWA for left buttock stage 4 pressure injury was not initiated on week 3/3/26. WN acknowledged that the facility failed to create WWA for right hip skin shear on week of 2/25/26 and WWA for left buttock stage 4 pressure injury on week 3/3/26.A review of facility's policy and procedure (P&P) titled Wound Care, Rev. 01/24 indicated in part. Policy Statement . It is the policy for the facility to provide guidelines for the care of wounds to promote healing. The policy indicated, Documentation.6) All assessment data (i.e., wound bed color, size, drainage, odor, pain, etc.) obtained when inspecting the wound, weekly by the wound nurse/designee.Review of [NAME] and [NAME], Tenth Edition, Fundamentals of Nursing, page 365 in the section titled, Informatics and Documentation, indicated, Documentation is a key communication strategy that produces a written account of pertinent data, clinical decisions and interventions, and patient responses in a health record. Documentation in a patient's health record is a vital aspect of nursing practice.

Based on observation, interview, and record review, the facility failed to ensure:Expired items in the medication storage room were disposed of according to policy and procedures and manufacturer's instructions. Treatment medications and medical supplies in the treatment cart were properly labeled and expired medication and supplies were discarded.The temperature for station 3 medication refrigerator was within acceptable range. These failures had the potential for residents to receive expired medications and and ineffective treatment supplies.1.During a concurrent observation and interview on 3/18/26 at 2:25 p.m. with Registered Nurse Supervisor (RNS), the medications inside the refrigerator located in the respiratory storage room were inspected. A box of Acetaminophen suppositories (a rectal medication used to treat mild pain or fever) had expired on 9/1/25 and a bottle of Acidophilus Probiotic (beneficial bacteria supplements that promote digestive health, enhance immunity, and help maintain healthy gut flora) was opened on 2/10/26 had expired on 3/9/26. RNS confirmed and acknowledged both medications were expired.During a concurrent observation and interview on 3/18/26 at 2:30 p.m. with RNS in the respiratory storage room, the respiratory supplies were found:Mask, Non-Rebreathing Elongated, Adult with Safety Vent and 7 ft. Start Lumen Tubing (expiration date 3/03/26)Sterile Water for Irrigation 500 mL (opened with an expiration date of 7/2025)Piston Enteral Feeding Syringe (expiration date of 12/1/25)Female catheter to female ENFit Adapter (expiration date 2/1/26)Full suction kit (manufacturing date of 7/30/2019 [shelf life of 5 years] expired 7/29/24)Disposable Exhalation Port (dates of manufacture 5/28/20 & 6/2/20, [shelf life of 5 years] expired on 5/27/25 and 6/1/25)Curaplex Nasal Oxygen Cannula, Adult with 7 ft Tubing and Non-Flared Tip (expiration date 9/7/25)Flex Trach Adaptors with expiration dates of 9/30/24 and 11/2/23Emma Airway Adapter Adult/Pediatric (expiration date 8/28/24)[NAME] RCI 25 ft. Star Lumen Tubing (expiration date 2/26/25)Medline Tracheostomy Clean and Care Tray (expiration date 10/31/25)RNS confirmed and acknowledged the following supplies made available for use were expired and should be discarded.During a concurrent observation and interview on 3/18/26 at 3:33 p.m. with RNS in station 3 medication storage room, two bottles of Acidophilus Probiotic (beneficial bacteria supplements that promote digestive health, enhance immunity, and help maintain healthy gut flora) opened on 2/1/26 with a 30 day open expiration date of 3/1/26, and a box of Unifine Safe Control (pen needles) with an expiration date 6/25/25 were found. RNS confirmed and acknowledged the following supplies available for use were expired and should be discarded.2. During a concurrent observation and interview on 3/19/26 at 9:27 a.m. with Wound Nurse (WN), Treatment Cart 1 was inspected. WN acknowledged the following supplies were opened and available for use but should be discarded:Thera Calazinc Body Shield (skin barrier protection ointment) was opened; package indicates single use only.100 mL bottle of normal Saline, dated 3/18/26 was half empty and that the package label indicates do not reuse.SkinTegrity ECO hydrogel (a clear, non-oily wound dressing containing glycerin and aloe designed to maintain a moist environment for healing dry to minimally exudating wounds) with open date of 2/3/26.During a concurrent observation and interview on 3/19/26 at 9:37 a.m. with RNS, treatment cart 1 supplies were inspected. RNS stated the TheraCalazinc is a one-time use only and should not be in the treatment cart for use once it's been opened; the normal saline was used, no longer sterile and should have been discarded after it was used; and the SkinTegrity ECO hydrogel was opened and was expired since it is only good for 30 days after opening.During a concurrent observation and interview on 03/19/2026 at 9:54 a.m. with Registered Nurse (RN 5), the sub-acute unit treatment cart was inspected. Two ointments of Collagenase Santyl (a prescription medicine that removes dead tissue from wounds so they can start to heal), an Ammonium Lactate cream (a topical medication used to treat dry, scaly skin), and silver sulfadiazine (a topical antibiotic used to prevent and treat wound infections) were opened and available for use without an open date recorded. Additionally, a one-time use normal saline irrigation solution bottle of 100 milliters (mL) was partially empty and available for use with an open date of 3/18/26. RN 5 acknowledged the ointments were expired and should be discarded. RN 5 stated the 100 mL normal saline bottle was good for 24 hours.During an interview on 3/19/26 at 10:02 a.m. with Registered Nurse (RN 3), RN 3 was asked what the expiration of 100 mL normal saline bottles is once they are opened. RN 3 stated the bottles expire 24 hours after opening and are used for multiple residents during the 24 hour period.During an interview on 3/19/26 at 4:00 p.m. with Minimum Data Set Nurse (MDSC) who is also responsible for ordering nursing supplies, MDSC acknowledged the 100 mL normal saline irrigation solution bottles must be discarded once the bottle is opened and used on a resident.During a concurrent observation and interview on 3/19/26 at 10:13 a.m. with RNS, station 3 treatment cart was inspected and found to have expired medications and supplies. RNS acknowledged the following should not be in the cart and available for use:Zinc Oxide ointment (a topical medication used to treat and prevent skin irritations, such as diaper rash, minor burns, cuts, and chafing skin) opened on 1/23/26 with a 30 day expiration date ofViaLok Vial access device (a needle-free, sterile, single-use device designed to safely access medication vials) with an expiration date of 10/13/25Two ammonium lactate lotions (a prescription or over-the-counter topical medication used to treat severe dry, scaly skin) with an expiration date of 7/5/25 prescribed for residents that were no longer listed the facility's censusOne-time use normal saline irrigation solution bottle of 100 mLTwo DeCloggers (flexible tubing used to clear obstructed feeding tubes) were opened and had signs of previous use and/or contamination based on the yellowish brown stains on the packaging.During review of the DeClogger instructions for use (IFU), copyright dated 2022, the IFU indicates in part, The DeClogger should be disposed of after a single use.Cross-contamination risk. Do not reuse DeCloggers as this may spread contamination from one patient to another patient. 3. During a concurrent observation and interview on 3/18/26 at 10:31 a.m. with the Wound Nurse (WN) in station 3 storage room, the medication refrigerator temperature was at 56 F (degrees Fahrenheit). The thermometer was clipped on a wire rack inside the middle of the refrigerator door. WN acknowledged the temperature reading was outside of acceptable range. WN immediately contacted the Registered Nurse Supervisor (RNS). RNS acknowledged the temperature was out of range but requested if it can be rechecked a few minutes later since it was within acceptable range previously. During review of the facility's Refrigerator Temperature Log for Station 3, the log indicated for March 1-17, 2026, the temperatures ranged between 37 F - 40 F. During an observation on 3/18/26 at 11:49 a.m. with RNS, the station 3 medication refrigerator temperature was rechecked and found to be at 46 F. RNS acknowledged the temperature was outside acceptable range and stated the temperature was dropping. RNS stated the electrical cord was not plugged in all the way into the electrical socket when it was checked earlier and asked if the temperature could be rechecked again while the refrigerator continued to stabilize. During an observation on 3/18/26 at 2:05 p.m. with RNS, the temperature for station 3 medication refrigerator was rechecked. The thermometer was located inside the freezer with a temperature of 24 F. RNS acknowledged the temperature was out of range and that the thermometer should not be placed in the freezer. RNS denied knowing who had moved the thermometer that was previously hanging on the inside of the refrigerator door. During a concurrent observation, interview, and record review on 3/19/26 at 8:24 a.m. with Registered Nurse (RN 4) in station 3 medication storage room, RN 4 acknowledged the refrigerator temperature was observed to be at 40 F. Station 3 Refrigerator Temperature Log, dated March 2026, was reviewed. RN 4also acknowledged the refrigerator's temperature was not recorded on 3/18/26. During a concurrent observation and interview on 3/19/26 at 2:08 p.m. with RN 4, the station 3 medication storage refrigerator was observed to be at 42 F. RN 4 stated new medication for the resident's was ordered overnight from the pharmacy.During a review of the facility's policy and procedure (P&P) titled, Policy and Procedure on Expiration Date of Central Supplies, dated 7/2025, indicates in part, Policy: To ensure potency of all medical supplies, expiration date is being monitored. Procedure: The following strategies will be done to achieve the goal. 1. The central supply personnel assigned check the items in the central supply room under the supervision of the licensed nurse every two weeks. 2. Licensed nurses will check for the expiration date of any supplies they get from the central supply before its usage. 3. The pharmacy consultant will check the medication cart for any expired medication for destruction of for immediate reordering. 4. The QA will check the supplies in the central supply room monthly during their consulting visit.During a review of the facility's policy and procedure (P&P) titled, Administering Topical Medications, dated 7/2025, the P&P indicates in part, The purpose of this procedure is to provide guidelines for the safe administration of topical medications.Check the expiration date on the medication. Return any expired medications to the pharmacy. During a review of the facility's policy and procedure (P&P) titled Policy and Procedure On Medication Refrigerator Temperature, dated 1/2025, indicates in part, Policy: Per regulations, the medication refrigerator temperature range should be between 36 Fahrenheit and 46 Fahrenheit. Procedure: 1. Check the temperature before using the medication in the refrigerator. 2. Report to your supervisor or the DON immediately if the temperature is out of range and for immediate repair as needed. 3. Please document the temperature once per day every night shift and indicate the time and initial.

Based on observation, interview and record review, the facility failed to maintain essential kitchen equipment on the ice machine clean and in safe operating condition. This failure has the potential to expose residents to contaminated ice and increased risk for food related illnesses. During an observation and insepction of the ice machine on 03/18/26 at 2:36 pm at the kitchen, a white tissue test was performed on the lower bin made of stainless steel inside the ice machine. After wiping the base of the bin, the white tissue contains a minimal amount of greyish-black residue. Repeating the procedure further back into the bin also showed minimal greyish residue. The Dietary Manager (DM), Maintenance Representative (MR) and Dietician (DIET) validates the findings. During an interview with the MR, MR states that he had cleaned the parts of the ice machine and inspects water flow where mineral scale or limescale build up occurs. MR verbalized he must have missed cleaning the other parts of the ice machine. During a review of the manufactures' manual, titled Ice-O-Matic dated 01/14, the Ice-O-Matic Service and Installation Manual indicated in part ICE Machine Cleaning and Sanitizing Instructions: Cleaning Stainless Steel: 1. Clean the stainless steel thoroughly once a week. Clean frequently to avoid build up of hard stubborn stains. Also, hard water stains left to sit can weaken the steel's corrosion resistance and lead to rust. During a review of the FDAFCA, dated 2022, the FDAFCA indicated, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. The objective of cleaning focuses on the need to remove organic matter from foodcontact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. (FDA Food Code Annex; 4-601.11).During a review of Policies and Procedures (P&P) titled Ice Machine Cleaning Procedure, undated, the Ice machine Cleaning Procedure indicated in part,3. Clean the inside of the machine with a sanitizing agent per the manufacturer's instructions. 5. Be sure special attention is paid to cleaning the door molding and lid of the machine.

Facility failed to practice infection control when: 1. appropriate Personal Protective Equipment (PPE: clothing and equipment used in order to provide protection against hazardous substances or environments) for enhanced barrier precautions (EBP: an infection control strategy for nursing homes requiring staff to wear gowns and gloves during high contact care of residents) was not worn for two residents, Resident 1 and Resident 2.2. respiratory tubes were not changed in a timely manner for Resident 25 and 3. the facility failed to discard open or used saline bottles found in medication carts and de-cloggers (a flexible, threaded rod used to restore the patency [openness] of obstructed enteral feeding tubes). This failure had the potential to expose residents for further infection and contamination. 1.During a concurrent observation and interview on 3/18/26 at 10:31 a.m. with Licensed Vocational Nurse (WN), WN was observed performing a blood sugar check without wearing a gown on Resident #2 who was on EBP. WN stated only gloves were required because performing a blood sugar check was not a high contact care process. During an interview on 3/18/26 at 11:35 a.m. with the Infection Control Nurse (IP), IP stated any direct contact with a resident on EBP requires mask, gloves and gown. 3. During a concurrent observation and interview on 03/19/2026 at 9:54 a.m. with Registered Nurse RN 5, the sub-acute treatment cart was inspected. A normal saline irrigation solution bottle of 100 mL was partially empty and available for use inside the cart with an open date of 3/18/26. RN 5 agreed the label on the bottle indicates Do Not Reuse and then stated the bottle was good for 24 hours according to the facility nurse consultant. During an interview on 3/19/26 at 10:02 a.m. with Registered Nurse (RN 3), RN 3 was asked what the expiration of 100 mL normal saline bottles is once they are opened. RN 3 stated the bottles expire 24 hours after opening and confirmed the bottles were used for multiple residents during the opened 24 hour period. During an interview on 3/19/26 at 4:00 p.m. with Minimum Data Set Nurse (MDSC) who is also responsible for ordering nursing supplies, MDSC acknowledged the 100 mL normal saline irrigation solution bottles must be discarded once the bottle is opened and used on a resident. During a concurrent observation and interview on 3/19/26 at 10:13 a.m. with RNS, station 3 treatment cart was inspected and found to have open one-time use supplies available for use. RNS acknowledged the following should not have been available for re-use: One bottle of normal saline irrigation solution 100 mL with an open date of 3/18/26 Two DeCloggers were opened and had signs of previous use and/or contamination based on the yellowish-brown stains on the packaging. During review of the DeClogger instructions for use (IFU), copyright dated 2022, the IFU indicates in part, The DeClogger should be disposed of after a single use.Cross-contamination risk. Do not reuse DeCloggers as this may spread contamination from one patient to another patient. 2. During an observation on 3/17/26 at 2:49 p.m. inside the room of Resident 25, the oxygen tubing was observed labeled 3/4, indicating the last date it had been changed. During an interview on 3/19/26 at 4:20 p.m., RN 2 stated that oxygen tubing is changed every Sunday, once per week. During a concurrent observation and interview on 3/20/26 at 10:04 a.m. with RN 3 in Resident 25's room, the oxygen tubing was labeled 3/18, indicating a different change date. The picture taken on 3/17/26 showing tubing labeled 3/4 was shown to RN 3. RN 3 confirmed that tubing should be changed weekly per facility policy and acknowledged that failure to do so could increase the risk of infection. During a concurrent interview and record review on 3/20/26 at 10:10 a.m. with RT 1 in the hallway near room [ROOM NUMBER], the picture of the oxygen tubing labeled 3/4 was shown to RT 1. RT 1 acknowledged that the oxygen tubing had not been changed in a timely manner. A review of the facility's policy and procedure titled Oxygen Therapy, Rev. 09/2012, indicated in part: Policy Statement. It is the policy of this facility that oxygen therapy is administered as ordered by the physician or as an emergency measure until the order can be obtained. The policy indicated, Procedures. 10) Oxygen tubing is to be replaced every week. Oxygen masks or nasal prongs are to be replaced every week. Oxygen concentrator filter is to be cleaned every week and replaced as needed secondary to wear and tear or other form of defect. Findings: Resident 1 was undergoing G-Tube (equipment used to deliver food or nutrition safely) feeding at the activity center with staff not wearing appropriate PPE. During a review of medical record of Resident 1, Resident 1 has orders dated 02/18/26 for EBP inicated by foley catheter and G-tube every shift. During an observation on 03/18/2026 at 4:00 pm on Resident 1, at the activity room of the dementia care unit, LIcensed Vocational Nurse (LVN)1 and Certified Nurse Assistant (CNA) 3 were providing tube feeding on Resident 1 wearing gloves but not he appropriate protective equipment. During an interview on 03/19/2026 at 9:00 AM at the nurses' station of the dementia unit with CNA 4 and CNA 5, CNA 4 and CNA 5 state that when providing care of Resident 1, we would bring Resident 1 back to the room and wear appropriate PPE. During an interview on 03/18/26 at 5:35 pm with the Director of Nursing (DON) the DON validates that infection control practices and dignity must be practiced for all residents. During a review of Policies and Procedures (P&P) titled Enhance Barrier Precations dated 2024, the Enhance Barrier Precautions indicated in part, 3. EBP are to be implemented in addition Standard Precautions when other transmissio-based precautions do not apply when facility identies any resident with c. ii urinary catheters; iii feeding tubes. 4b. PPE is required for all staff providing high contact resident care activities to include i. gown and gloves with 7. Device caare or use:central line, urinary catheter, feeding tube, tracheostomy/ventilator.

Based on observation, interview and record review, the facility failed to develop a comprehensive and individualized plan of care (care plan) for 3 of 20 Sampled residents ( Resident 35, 11 and 47) when: 1. Resident 35's preference for communicating. 2. Resident 11's alarming devices on a wheelchair and bed. 3. Resident 47's need for the appropriate communication device based on physical condition . These failures had the potential for not meeting resident's needs. Findings: 1. During a review of Resident 35's most recent MDS Annual Assessment, Assessment Reference Date (ARD - the end of observation period), dated 12/21/24, section A for language indicated, Resident 35's preferred language is Spanish. Further review of the language assessment, section A1110B was coded 0 (meaning an interpreter was not needed to communicate with a doctor or health care staff). During an observation and interview on 3/5/25, at 10:59 a.m. with Resident 35, Resident 35 was observed responding in Spanish after being questioned in English translated by a Spanish speaking Certified Nursing Assistant (CNA 2) related to Resident 35's need for a Spanish speaking interpreter. Resident 35 verbalized, wanting to have an interpreter to discuss about his plan of care. Resident 35 further verbalized, that no one had offered and asked him this question before. During a concurrent record review and interview on 3/6/25, at 8:22 a.m. with the MDS Coordinator (MDSC), Resident 35's clinical record was reviewed. MDSC verified that Resident 35 speaks only Spanish and required a Spanish speaking interpreter when caring for Resident 35. MDSC further verified, the missing plan of care that addressed Resident 35's preferred language for communication. During an interview on 3/7/25, at 10:41 a.m. with the Director of Nursing (DON), the DON acknowledged, the missing care plan for communication for Resident 35. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised date 4/24/24, the P&P indicated, 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 50707 2. During a review of Resident 11's Admission Record (AR), dated 3/6/25, AR indicated Resident 11 was admitted on [DATE] with diagnoses that include dementia (a progressive state of decline in mental abilities) and repeated falls. During a concurrent observation and interview on 3/4/25 at 12:40 p.m., with CNA 3, Resident 11 was observed in the activity room with a tab alarm (a safety device that sounds an alarm when a person tries to leave a bed, chair, or wheelchair) on his wheelchair. CNA 3 verbalized Resident 11 has three tab alarms, one on the wheelchair and two on the bed. During a concurrent interview and record review on 3/7/25 at 1:39 p.m., with the Director of Nursing (DON), Resident 11's care plans were reviewed. There is no documented evidence of a care plan to address the tab alarms. The DON stated, There is no care plan . there should be a care plan for alarms. During a review of the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing, revised 4/2024, the P&P indicated, Resident-Centered Approaches to Managing Falls and Fall Risk. 8. The use of alarms will be monitored for efficacy. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, revised date 4/24/24, the P&P indicated, 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 50657 3. During review of Resident 47's, Admission Record (AD) dated 3/5/25, the AD indicated a list of diagnoses including acute and chronic respiratory failure with hypoxia (difficulty breathing and not getting enough oxygen in the blood), gastrostomy (an opening into the stomach from the abdominal wall used to insert a tube to provide a route for liquid feeding), contracture of muscles (stiff muscles and bones), quadriplegia (partial or total loss of function in all four limbs and the torso) and tracheostomy (an incision on the front of the neck to open a direct airway to breathe). During an observation on 3/05/25 at 7:50 a.m. inside Resident 47's room, a push button call light was noted placed next to the resident on the bed however, not within the reach of the resident because Resident 47's was Quadriplegic and had a loss of functions to all four limbs. During a concurrent observation and interview on 3/07/25 at 9:11 a.m. with Certified Nursing Assistant (CNA 4), inside Resident 47's room, CNA 4 observed call light was laying over the bedside table. And CNA 4 explained that Resident 47 had just been bathed and CNA 4 forgot to put call light back within the resident's reach. CNA 4 stated the push button call light was not appropriate for the resident because Resident 47 is unable to push the button. During a concurrent observation and interview on 3/07/25 at 9:21 a.m. with the Director of Nursing (DON), inside Resident 47's room, the DON acknowledged the push button call light was inappropriate for Resident 47. DON stated, A more appropriate call light would be a pad alarm placed by his head. It is during the admission process that the appropriate type of call light is assessed, but in this case, it was not done. During a review of the facility's policy and procedure titled, Answering the Call Light, dated September 2022, the P&P indicated Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines: 1. Upon admission and periodically as needed, explain, and demonstrate use of the call light to the resident. 2. Ask the resident to return the demonstration .5. Ensure that the call light is accessible to the resident when in bed .

Based on observation, interview, and record review, the facility failed to meet professional standards when : 1. Resident 719 supplemental oxygen was administered without a physician order. 2. Acetylcysteine (an oral inhalation used to help with breathing) was not administered as ordered by the physician for one of four sampled residents (Resident 27). 3. A respiratory therapist (RT1) failed to follow the facility's policy and procedure on medication administration ( nebulizer /aerosol medication) and documentation for one of four sampled residents (Resident 27). 4. Resident 4's insulin (a medication to lower blood sugar levels) was not administered per physician's ordered insulin sliding scale parameters. 5. Resident 4's insulin medication was not administered in a timely manner. These failures can result to residents medications ordered at a specified dose for a designated reason with specific timing and maximum dosing parameters when needed to be missed. Findings: Review of [NAME] and [NAME], 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice indicates, Nurses are obligated to follow physician order unless they believe they orders are in error or would harm clients. 1. During a review of Resident 719's Admission Record (AD), the AD indicated Resident 719 was admitted on [DATE] with diagnoses that include COVID-19 (contagious viral infection that affects breathing) and acute cough (a cough that begins suddenly and lasts for two to three weeks). During a concurrent observation and interview on 3/6/25 at 3:02 p.m. with Licensed Nurse (LN) 1, Resident 719 was observed in bed receiving supplemental oxygen through a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). LN 1 stated Yes, [Resident 719] uses oxygen. During a review of Resident 719's Minimum Data Set (MDS - a standardized tool used to assess and plan care of residents in a nursing home) dated 2/18/25, the MDS Section O- special treatments, procedures and programs indicated, Resident 719 received oxygen therapy on admission and while a resident in the facility. During a concurrent interview and record review on 3/6/25 at 3:50 p.m., with the Assistant Director of Nursing (ADON), Resident 719's Medication Review Report was reviewed. There is no physician order for the supplemental oxygen. ADON stated, I don't see an order and acknowledge there should be one. During a review of the facility's policy and procedure (P&P) titled Oxygen Administration, revised October 2010, the P&P indicates Preparation 1. Verify that there is a physician order for this procedure. 2. During review of Resident 27's Admission Record (AR), the AR indicated Resident 27 was admitted on [DATE] with diagnoses that include acute and chronic respiratory failure with hypoxia (difficulty breathing and not getting enough oxygen in the blood), chronic obstructive pulmonary disease (progressive and irreversible damage to the airways and air sacs in the lungs causing breathing difficulties), and a tracheostomy (an incision on the front of the neck to open a direct airway to breathe). During an interview on 3/04/25 at 10:40 a.m. with Resident 27, Resident 27 stated the Acetylcysteine was not administered on the night of 3/03/25 and in the morning (3/04/25). Resident stated, I need that medication, I have breathing problems. During an interview on 3/04/25 at 3:29 p.m. with RT1, RT1 stated Resident 27 received the acetylcysteine twice on 3/03/25 during the 7 a.m. -7 p.m. shift but was unaware if the third treatment of acetylcysteine was given by the nocturnal shift. RT1 acknowledged not being able to administer the acetylcysteine the morning of 3/04/25 because there was no more acetylcysteine left. RT1 stated the medication refill was received on 3/04/25 in the afternoon. During a review of Resident 27's Medication Administration Record (MAR, a legal record of the drugs administered to a patient), dated March 1, 2025 - March 31, 2025, the MAR indicated, Resident 27 did not receive acetylcysteine on 3/04/25 at 09:00 a.m. as scheduled. Further review of the electronic MAR notes indicated, Acetylcysteine Inhalation Solution 20% .Waiting for meds from pharmacy. Pt. aware. There was no documented evidence indicating the physician had been notified of the missed acetylcysteine dose. During a review of the facility's policy and procedure (P&P) titled, Policy and Procedure in Medication Administration, dated January 2024, the P&P indicated in part, 1. Drugs must be administered in accordance with the written orders of the attending physician. 3. During a concurrent observation and interview on 3/05/25 at 4:06 p.m. with RT1, outside Resident 27's room, RT1 was observed holding a clear plastic cap with clear liquid. RT1 stated she was about to give Resident 27 the Acetylcysteine Inhalation Solution 20 % that had just been received from the pharmacy. After administering the inhalation medication, RT1 reviewed the MAR. The MAR indicated acetylcysteine was administered at 1300 and the next scheduled dose was at 5:00 p.m. RT1 stated the acetylcysteine was not given at 1300 because the resident prefers to have it done at 4:00 p.m. RT1 stated it was documented as given in the electronic medical record so the MAR doesn't flag in red. During a review of the facility's P&P titled, Policy and Procedure in Medication Administration, dated January 2024, the P&P indicated in part, 1. Drugs must be administered in accordance with the written orders of the attending physician .12. Medications must be immediately charted following the administration by the licensed nurse that administers the medication .13. All medications will be administered following the scheduled medication administration for medication for routine medications unless otherwise specified by MD which is different from the routine medication administration schedule. 4. During review of Resident 4's AD, the AD indicated Resident 4 was admitted on [DATE] with diagnoses that include gastrostomy (an opening into the stomach from the abdominal wall used to insert a tube to provide a route for tube feeding) and type 2 diabetes mellitus (chronic condition where the body does not use insulin properly or does not produce enough insulin to regulate blood sugar levels) with hyperglycemia (high blood sugar). During a review of Resident 4's MAR, dated 01/01/25 - 01/31/25 and 02/01/25 - 02/19/25, the MAR's indicated Insulin Aspart (a synthetic, rapid-acting insulin analog used to treat diabetes) Solution Cartridge 100 Unit/mL subcutaneously (under the skin) before meals and at bedtime related to Type 2 Diabetes Mellitus with Diabetic Neuropathy (a complication of diabetes that damages the nerves, affecting their ability to send and receive signals), unspecified. Inject as per sliding scale: If 150-200 = 6 units, 201-300 = 9 units, 301 - 400 = 12 units, >400 = 15 units and notify MD. Upon further review of Resident 4's MAR's, the MAR's indicated insulin was not given, and the reasons were coded as 5 (Hold/See Nurse Notes) on the following dates and times: 1/07/25 at 06:00 a.m., BS was 192 (6 units should have been administered per MD order) 1/19/25 at 11:00 a.m., BS was 155 (9 units should have been administered per MD order) 1/19/25 at 17:00 p.m., BS was 150 (6 units should have been administered per MD order) 1/29/25 at 06:00 a.m., BS was 217 (9 units should have been administered per MD order) 1/30/25 at 06:00 a.m., BS was 178 (6 units should have been administered per MD order) 1/31/25 at 06:00 a.m., BS was 189 (6 units should have been administered per MD order) 2/01/25 at 06:00 a.m., BS was 171 (6 units should have been administered per MD order) 2/05/25 at 06:00 a.m., BS was 177 (6 units should have been administered per MD order) 2/08/25 at 06:00 a.m., BS was 160 (6 units should have been administered per MD order) 2/12/25 at 06:00 a.m., BS was 191 (6 units should have been administered per MD order) 2/17/25 at 06:00 a.m., BS was 186 (6 units should have been administered per MD order) 2/25/25 at 06:00 a.m., BS was 151 (6 units should have been administered per MD order) 2/26/25 at 06:00 a.m., BS was 170 (6 units should have been administered per MD order) 2/28/25 at 06:00 a.m., BS was 163 (6 units should have been administered per MD order) During a review of Resident 4's Progress Notes (PN - a written record of a patient's health and treatment), dated 02/03/25 - 03/06/25, the PN indicated the Aspart insulin was held for episodes of low BS. There was no documented evidence indicating the physician had been notified of low episodes of BS. During an interview on 3/07/25 at 4:15 p.m. with the Assistant Director of Nursing (ADON), ADON acknowledged the insulin sliding scale was not followed for Resident 4 on multiple dates in January and February 2025. During a review of the facility's P&P titled Policy and Procedure in Medication Administration, dated January 2024, the P&P indicated, 8. Diabetic resident on insulin should follow MD order and comply with the sliding scale. M.D. should be notified if blood sugar is below 60 or over 400. FBS (fasting blood sugar) should be done before diabetic medication is administered. Hold diabetic medication if there is an NPO order unless M.D. has specific ordered. 5. During a review of Resident 4's MAR, dated 01/01/25 - 01/31/25 and 02/01/25 - 02/28/25, and the Location of Administration (LOA, a record with the name of the medication, scheduled time, administration time, route, and location of administration) indicated three insulin orders were administered greater than one hour before or after the scheduled time for the following: Insulin Aspart (a synthetic, rapid-acting insulin analog used to treat diabetes) Solution Cartridge 100 Unit/mL subcutaneously (under the skin) before meals and at bedtime related to Type 2 Diabetes Mellitus with Diabetic Neuropathy (a complication of diabetes that damages the nerves, affecting their ability to send and receive signals), unspecified. Inject as per sliding scale. 1/10/25 scheduled at 17:00 administered at 19:47 (1 hour and 45 minutes later) 1/25/25 scheduled at 11:00 administered at 14:15 (3 hours and 15 minutes later) 1/25ter/25 scheduled at 17:00 administered at 19:47 (2 hours and 45 minutes later) 1/27/25 scheduled at 11:00 administered at 12:41 (1 hour and 41 minutes later) 1/28/25 scheduled at 11:00 administered at 12:31 (1 hour and 31 minutes later) 1/29/25 scheduled at 17:00 administered at 18:50 (1 hour and 50 minutes later) 2/02/25 scheduled at 17:00 administered at 18:45 (1 hour and 45 minutes later) 2/03/25 scheduled at 17:00 administered at 18:18 (1 hour and 18 minutes later) 2/04/25 scheduled at 11:00 administered at 13:17 (2 hours and 17 minutes later) 2/07/25 scheduled at 17:00 administered at 19:25 (2 hours and 25 minutes later) 2/12/25 scheduled at 17:00 administered at 18:27 (1 hour and 27 minutes later) 2/13/25 scheduled at 17:00 administered at 18:49 (1 hour and 49 minutes later) 2/25/25 scheduled at 21:00 administered at 23:13 (2 hours and 13 minutes later) Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 54 units subcutaneously two times a day related to type 2 diabetes mellitus with hyperglycemia [scheduled times are 0900 and 1700] and Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 9 units [order date 11/20/24 - 1/22/25], 11 units [order date 1/22/25 - 2/17/25], and 13 units [order date 2/17/25] subcutaneously at bedtime related to type 2 diabetes mellitus with hyperglycemia [scheduled time listed as 2100]. 1/05/25 scheduled at 09:00 administered at 10:35 (1 hour and 35 minutes later) 1/07/25 scheduled at 09:00 administered at 10:30 (1 hour and 30 minutes later) 1/10/25 scheduled at 17:00 administered at 22:29 (5 hours and 29 minutes later) 1/10/25 scheduled at 21:00 administered at 22:33 (1 hour and 33 minutes later) 1/12/25 scheduled at 17:00 administered at 18:24 (1 hour and 24 minutes later) 1/17/25 scheduled at 17:00 administered at 18:50 (1 hour and 50 minutes later) 1/19/25 scheduled at 09:00 administered at 12:45 (3 hours and 45 minutes later) 1/23/25 scheduled at 09:00 administered at 10:56 (1 hour and 56 minutes later) 1/25/25 scheduled at 09:00 administered at 14:14 (5 hours and 14 minutes later) 1/25/25 scheduled at 17:00 administered at 19:46 (2 hours and 46 minutes later) 1/29/25 scheduled at 09:00 administered at 10:40 (1 hour and 40 minutes later) 1/29/25 scheduled at 17:00 administered at 18:51 (1 hour and 51 minutes later) 1/30/25 scheduled at 17:00 administered at 19:00 (2 hours later) 2/02/25 scheduled at 09:00 administered at 12:04 (3 hours and 4 minutes later) 2/02/25 scheduled at 17:00 administered at 18:44 (1 hour and 44 minutes later) 2/03/25 scheduled at 17:00 administered at 18:17 (1 hour and 17 minutes later) 2/05/25 scheduled at 09:00 administered at 11:15 (2 hours and 15 minutes later) 2/07/25 scheduled at 09:00 administered at 10:20 (1 hour and 20 minutes later) 2/07/25 scheduled at 17:00 administered at 19:25 (2 hours and 25 minutes later) 2/08/25 scheduled at 17:00 administered at 18:21 (1 hour and 21 minutes later) 2/09/25 scheduled at 17:00 administered at 18:20 (1 hour and 20 minutes later) 2/12/25 scheduled at 17:00 administered at 18:27 (1 hour and 27 minutes later) 2/13/25 scheduled at 17:00 administered at 18:48 (1 hour and 48 minutes later) 2/15/25 scheduled at 09:00 administered at 11:08 (2 hours and 8 minutes later) 2/18/25 scheduled at 17:00 administered at 18:46 (1 hour and 46 minutes later) 2/23/25 scheduled at 17:00 administered at 18:37 (1 hour and 37 minutes later) 2/25/25 scheduled at 21:00 administered at 23:14 (2 hours and 14 minutes later) 2/26/27 scheduled at 09:00 administered at 12:26 (3 hours and 26 minutes later) During an interview on 3/07/25 at 4:15 p.m. with the Assistant Director of Nursing (ADON), ADON acknowledged the insulin was not administered as scheduled for Resident 4 on multiple dates in January and February 2025. During a review of the facility's P&P titled, Policy and Procedure in Medication Administration, dated January 2024, the P&P indicated in part, 4. Medication must not be prepared in advance and must be administered within one hour before or after administration time per M.D. order.

Based on inspection of the facility's Medication storage room on Unit 3, interview with the facility's IP, and review of the facility's policy and procedures the facility failed to: 1. follow their policy and procedure for sharps waste, 2. ensure that Emergency Drug supplies (E-Kits), had not been opened for more than 72 hours as outlined in the facility's policy and procedure, 3. ensure that no expired medications were available for use, 4. ensure that medications were administered in accordance with the hospital's policies and procedures and 5. ensure that medications are immediately documented in the Medication Administration record (MAR) after the administration of medications to a resident. Findings include: 1) Inspection of the facility's Blue and white (non-controlled) waste containers (which were open, and not closed or sealed), the surveyor found three syringes full of drugs with needles still attached to the syringes. One syringe contained the dilutant for Glucagon (1 ml) and the other two syringes contained (Enoxaparin 40mg/0.4 ml). Enoxaparin is a low molecular weight heparin (also known as an anticlotting drug). During an interview with the facility's Infection Prevention Nurse (IP) on 3/4/2025 at 10:35 am, the IP stated that the facility's P & P indicates that sharps (needle syringes) are not to be put into these containers (non-controlled waste bins), which were open and not locked. [NAME] indicated that the facility's policy and procedure labeled syringe and needle disposal, dated 1/2025 read: Policy, used syringes and needles are disposed of safely and in accordance with applicable state laws and safety regulations .Immediately after use, syringes and needles are placed into a puncture resistant, one-way containers specifically designed for that purpose .the disposal containers are fitted with a lid that prohibits reaching into the container. 2) Further inspection of the medication storage room on Unit 3 revealed an Antibiotic Emergency drug kit (E-Kit). This E-kit had been opened on 2/24/2025 at 5:00 pm when one of the facility's nursing staff had retrieved Metronidazole 500mg capsules for unsampled resident 65. This emergency drug kit had not been replaced since it had originally been opened on 2/24/2025. This E-Kit had not been replaced, as outlined in the facility's policy and procedure for 8 days, after opening. Review of the facility's policy and procedure entitled: Emergency Kit (E-Kit) Use, dated 1/2025, read: 6. The pharmacy is to be notified as soon as possible that the E-Kit has been opened so that it can be replaced within 72 hours (3 days). Additional inspection of the facility's Narcotic E-Kit on station 3, revealed that this E-Kit had been opened by facility staff for the removal of Alprazolam 0.25 mg tablets on 2/20/2025 at 1:00 am for one resident. The Narcotic E-Kit had been opened for 12 days, without being replaced, contrary to the facility's policy and procedure above. 3) Inspection of the Director of Nurse's medication storage room on 3/4/2025 at 2:55 pm, revealed one case of Ceftazidime 2-gram vials for reconstitution and injection (a total of 10 vials), with an expiration date of 7/2024 (almost 8 months beyond the drug manufacturer's expiration date). 4) Interview with the medication Nurse on the facility's subacute station on 3/5/2025 and 3/6/2025 between 8:25 am and 11:00 am, revealed that these medication nurses (LVNs 1 & 3), indicated that all of the medication Nurses, on all of the Nursing units within the facility, have to start passing their medications to the residents, as early as 7:20 am and/or as late as 7:40 am (for medications which are due at 9:00 am according to the physician orders), in order for the nurses to finish their medication administration tasks in the morning, around 11:00 or 11:15 am. Concurrent interviews with Nursing staff on Stations 1, 3, and 4 confirmed that they all have to start passing medications every morning about 7:20 am. When these Nurses were asked why they had to start medication pass every day outside of the facility's policy and procedure which is entitled: Policy and procedure in Medication Administration, dated 1/2025, read: 4. Medication must and administered within one hour before or after administration time per M.D. order. The 1 hour before or 1 hour after policy and procedure means that the medication nurse could start passing their medications to the residents at 8:00 am and they must complete their medication pass by 10:00 am. The facility's policy and procedure above also read: 13. All medications will be administered following the scheduled medication administration for routine medication unless otherwise specified by M.D. which is different from the routine medication administration schedule. Review of the current physician's orders revealed that, no physician orders had been written which specified any different times for the administration of any medications. All of the Nurses indicated that it was impossible for them to pass all of the morning medications timely, for the following reasons: 1. each medication Nurse was also responsible for administering all of the treatments on their station, 2. these medication Nurses were also responsible for any admissions which came onto the unit, 3. medication Nurses were responsible for addressing any resident falls which occurred on their units, 4. Receiving and accepting any new medications and emergency drug kits which are being delivered to the facility, these are just a few examples why these Medication Nurses are unable to provide the morning medications to the residents. Further interview the Medication Nurses revealed that if the Medication Nurses had additional help with some of these tasks, that they may be able to get the residents their medications timely every day. 5) During an interview with Medication Nurse LVN 1, on 3/5/2025 at 11:15 am she acknowledged that she goes back after giving her medications in the morning and signs for these medications, after she finishes her medication passing the morning. She stated that: she does this in part because when she starts passing medications before 8:00 am and if she enters these medication administrations into the facility's computer then, these medications which had been given before 8:00 am, would get flagged by the computer for these administration entries. This practice is also contrary to the facility's policy and procedure entitled: Policy and procedure in Medication Administration, dated 1/2025, read: 12. Medications must be immediately charted following the administration by the license Nurse who administered the medication. This medication Nurse failed to follow this policy and procedure.

Based on Medication Pass observation, review of the resident's Medication Administration Record (MAR) and Physician's orders, Two out of two medication nurses observed for a total of 45 medication pass opportunities. Out of these 45 medication pass opportunities, there were a total of 8 medication errors which were observed. These 8 medication errors resulted in an overall medication error rate of 17.7% for the facility. Findings include: This LVN 3 administered medications to sample Resident 29 on 3/6/2025 at 9:00 am, which included Divalproex DR 250 mg tablet. The medication nurse proceeded to crush all of this resident's medications including this resident's Divalproex which had the designation of DR on the label of the bubble pack. Review of the manufacturer's package insert for this medication read: .The tablets should be swallowed whole and can be taken with or without food, Divalproex sodium delayed-release tablets are intended for oral administration. Divalproex sodium delayed-release tablets should be swallowed whole and should not be crushed or chewed, based on the drug manufacturer Aidarex Pharmaceuticals LLC.'s package insert. The DR on the product label stands for Delayed Release. By crushing this DR formulation, the Nurse altered the delivery of this making it immediate release rather than delayed release, which this product had been designed to be delivered. This resulted in one medication error. During a medication pass observation on 3/5/2025 at 8:27 am with LVN 1, this nurse passed medications to sampled Resident 63, this Medication Nurse administered 10 medications to this resident, with Cranberry juice and Ready Care (Med Pass). Upon review of Resident's Physician's orders and Resident 63's Medication Administration Record (MAR), the following 9:00 am medications had not been administered to this resident as ordered by the resident's physician: 1. Cetizine HCL 10 mg, 2. Magnesium Oxide 400 mg, 3. MiraLAX 3350 Powder, 4. Thera tears Ophthalmic Solution 1 drop in both eyes, and 5. Cranberry Oral tablet 450 mg. During an interview on 3/5/2025 at 11:15 am with the medication Nurse (LVN 1), this nurse acknowledged that her medication process is to give all of her medications to the residents first and then go back later to sign off all of the medications that she had previously given. The medication Nurse during the interview on 3/5/2025 at 11:15 am was asked if she had given this resident any other medications to this resident outside of the time that the surveyor had observed medication pass and the medication Nurse indicated that she had only given Resident 63 medications when the surveyor had been present for that morning. The medication Nurse had also been asked if she could recall giving any of the five medications above to resident 63 on the morning of 3/5/2025 and the nurse confirmed that she did not remember giving any of these medications to resident 63 that morning. Medication Nurse (LVN 1) had also been observed during the medication pass, administering medications to sampled Resident 27. The medication Nurse was observed administering Testosterone Gel 1.62 % to Resident 27. Two pumps of the Testosterone had been administered to Resident 27, yet during a review of the physician's order indicated that this resident should have only been administered 1 pump of Testosterone. Resident 27 also received Diclofenac Sodium cream (approximately 1 inch in total) [non-steroidal anti-inflammatory cream), which had been administered to both sides the resident's neck. Review of the Physician's order, written on 8/28/2024 read: .apply 2 inches to affected area. The medication Nurse only administered half of the dose of the Diclofenac to this resident. The culmination of these 8 medication errors resulted in this facility's medication error rate of 17.7%.

Based on observation, interview, and record review the facility failed to ensure the exhaust hoses of the portable air conditioning units (PACU) were properly installed as directed (not duct taped to the window frames) and filters were routinely cleaned according to manufacturer's guidelines (MFU) in 12 of 12 PACU's found inside Rooms 15, 20,21,22,23,24,25,26,27,28,30, and 32. This failure had the risk for entrapment in the event of a fire secondary to the windows becoming inoperable due to exhaust hoses duct taped to the window frames, with the potential for poor air quality as filters were not cleaned as directed. Findings: During an observation on 3/04/25 at 10:40 a.m. the slider kits (plastic frame where exhaust hoses are attached) of the PACUs, inside Rooms 15, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, and 32 were noted to be short in length, horizontally installed, and card boards were used to fill in the gaps in the windows. The sliders were then duct taped to the window frames, preventing the windows to be opened when needed. During a review of the PACUs MFU titled, Keystone KSTAP14B, indicated in part, the window slider kit can be fixed with a bolt. Further review of the MFU, showed a window diagram of a window that can still be closed and opened once the slider is fixed or bolted, with foam cut according to the slide kit's length and placed/attached to the sliding window edge. During a concurrent observation and interview on 3/06/25 at 3:40 p.m., with the facility's Maintenance Supervisor (MS) was asked how often the air filters were cleaned, and why the exhaust hoses were duct taped to the window frames preventing the windows to be opened, the MS stated the air filters on the PACUs are cleaned every three months. The MS was not able to present any documentation or a tracking method for the cleaning of air filters. The MS further stated, the slider kits the PACUs came with were for smaller windows and not for the facility windows size/type. During a concurrent interview and record review on 03/07/25 at 9:49 a.m. with the MS inside room [ROOM NUMBER], the PACU's MFU was reviewed with the MS. Under the section for Care and Maintenance, the MFU stated, Clean the air filter at least once every two weeks to prevent inferior fan operation because of dust .This unit has two filters. Take the upper filter out .Remove the lower filter .Wash the air filter by immersing in gently warm water (about 40 degrees Celsius/104 degrees Fahrenheit) with a neutral detergent. Rinse the filter and dry it in a [NAME] place. The MS stated he was unaware the PACU's had two filters or that cleaning had to be done every two weeks.

Based on observation, interview and record revie and facility policy and procedure, the facility failed to ensure Interdisciplinary Team (IDT- a group of healthcare professionals from various disciplines who collaborate to provide comprehensive, patient-centered care) assessed resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for 1 of 20 sampled residents (Resident 51). This failure can result with resident not taking the medication correctly. Findings: During a concurrent observation and interview on 3/6/25 at 2:45 p.m., in Resident 51's room, two vials of DuoNeb (a medication in a small plastic container that contains as a liquid that you breathe into the lungs with a nebulizer (special breathing machine) breathing treatments were observed in Resident 51's drawer. When resident was asked about the medication, Resident 51stated he administers the medication himself. During a concurrent observation and interview on 3/6/25 at 3:02 p.m. in Resident 51's room, Licensed Nurse (LN 1) confirmed the two DuoNeb vials in Resident 51's drawer and stated, they shouldn't be there, and that the resident was not allowed to administer the breathing treatments himself. During an interview with the Director of Nursing (DON) on 3/6/25 at 1:39 p.m., DON stated that an IDT meeting is required to determine whether a resident can safely self-administer medications, along with a physician order. DON acknowledged there was no IDT meeting for the authorization for Resident 51 to self-administer medications. During a review of the facility's policy and procedure (P&P) titled Self- Administration of Medications, revised February 2021, the P&P indicated, 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.

Based on observation interview and record review, the facility failed to have the most current survey results accessible to the public, in the facility survey results binder. This facility failure denied the opportunity for residents, family members, and legal representatives of residents, to be aware of the most recent survey results. Findings: During a concurrent observation and interview, on 3/6/25 at with the Director of Nursing (DON) inside the facility's main entrance, the facility's survey results binder was reviewed. The most current survey results in the binder were from 5/22/24. The survey results binder lacked the survey results from 8/8/24 through 2/19/25. The DON acknowledged the survey results binder was not current and verbalized the survey results binder would need to be updated. During a review of the facility's policy and procedure tilted Survey Results, Examination of dated 4/7, indicated in part A copy of the most recent standard survey, including any subsequent extended surveys, follow-up revisits reports, etc., along with state approved plans of correction of noted deficiencies, is maintained in a 3-ring binder located in an area frequented by most residents, such as the main lobby or resident activity room, hallway.

Based on observation, interview and record review, the facility failed to accurately assess 2 of 20 sampled residents (Resident 35 and 39) using the Minimum Data Set (MDS - a standardized tool used to assess and plan care of residents in a nursing home) when: 1. Resident 35 - had an inaccurate language assessment. 2. Resident 39 - had an inaccurate functional status assessment. These failures resulted in the facility reporting inaccurate data to Centers for Medicare & Medicaid Services (CMS) that does not reflect Resident 35 and 39 statuses in MDS assessment. Findings: 1. During a review of Resident 35's Admission Record (AR), dated 3/6/25, the AR indicated, Resident 35's primary language is Spanish. During a review of Resident 35's most recent MDS Annual Assessment, Assessment Reference Date (ARD - the end of observation period), dated 12/21/24, section A for language indicated, Resident 35's preferred language is Spanish. Further review of the language assessment, section A1110B was coded 0 (meaning an interpreter was not needed to communicate with a doctor or health care staff). During an observation and interview on 3/5/25, at 10:59 a.m. with Resident 35, Resident 35 was observed responding in Spanish after being questioned in English translated by a Spanish speaking Certified Nursing Assistant (CNA 2) related to Resident 35's need for a Spanish speaking interpreter. Resident 35 verbalized, wanting to have an interpreter to discuss about his plan of care. Resident 35 further verbalized, that no one had offered and asked him this question before. During a concurrent record review and interview on 3/6/25, at 8:22 a.m. with the MDS Coordinator (MDSC), Resident 35's MDS Annual Assessment for language was reviewed. MDSC acknowledged, Resident 35 requiring a Spanish speaking interpreter. MDSC further acknowledged, the inaccurate assessment. During an interview on 3/7/25, at 10:41 a.m. with the Director of Nursing (DON), the DON acknowledged, the inaccurate MDS language assessment. 2. During a review of the P&P titled, Resident Assessment Instrument (RAI), dated October 2024, the P&P indicated, During each assessment period, the IDT [Interdisciplinary Team] will gather data to complete all sections of the MDS . Each person completing a section of the MDS attests to its accuracy by affixing his/her electronic signature to that section of the MDS .GG115 Functional Limitation in Range of Motion (ROM - describes how far and in what directions your joints can move). Code for limitations that interfered with daily functions or placed resident at risk of injury in the last 7 days. Coding 0 - no impairment, 1 impairment on one side . During a review of Resident 35's AR, dated 3/6/25, the AR indicated, Resident 35 had a diagnosis of Multiple Sclerosis (a condition that affects the brain and spinal cord), foot drop on the foot (difficulty lifting the front part of the foot, causing to drag the toes during walking), difficulty in walking and muscle wasting and atrophy (thinning of muscle and loss of muscle tissue). During a review of Resident 39's MDS Significant Change (multiple areas of major decline or improvement on resident status) Functional Assessment, ARD 2/8/25, Resident 39's Functional Limitation on ROM was coded 0 (no impairment) on upper and lower extremities. During a review of Resident 39's Occupational Therapist (OT - healthcare professional that focuses on helping people participate in daily activities), dated 2/4/25, the OT assessment indicated, Resident 39 has an impairment on the left upper and lower extremities. During a concurrent record review and interview on 3/6/25, at 11:18 a.m. with the MDSC, Resident 39's MDS Significant Change Functional Assessment and OT assessment were reviewed. MDSC acknowledged, Resident 39's inaccurate functional assessment. During an interview on 3/7/25, at 10:41 a.m. with the DON, the DON acknowledged, Resident 39's inaccurate MDS functional assessment. A review of the facility's policy and procedure (P&P) titled, Resident Assessment Instrument (RAI), dated October 2024, the P&P indicated, During each assessment period, the IDT [Interdisciplinary Team] will gather data to complete all sections of the MDS . Each person completing a section of the MDS attests to its accuracy by affixing his/her electronic signature to that section of the MDS .Coding instruction for 110B .Code 1, Yes: if the resident .indicates there is no need or want of an interpreter to communicate with a doctor or healthcare staff. Ensure that preferred language is indicated.

Based on review of the facility's medication refrigerator logs, review of the facility's policy and procedures, and interview with the facility's I P Nurse the facility failed to ensure that the refrigerator temperatures had been documented and remained within the temperature requirements as outlined by the facility's policy and procedure. Findings include: Inspection of the facility's Medication refrigerator temperature logs for station 3 on 3/4/2025 at 4:10 pm revealed that on 12/4/2024 the refrigerator temperature had been recorded as 35-degree Fahrenheit (which was below the facility's policy range). Review of the facility's policy and procedure entitled: Policy and Procedure on medication refrigerator temperature, date 1/2025, read: Per regulations, the Medication refrigerator temperature range should be between 36 degrees Fahrenheit and 46 degrees. Further review of the facility's refrigerator logs revealed that on 2/19/2025, that no temperature had been documented on the facility's refrigerator temperature logs, so the facility was unable to indicate what the actual temperature of the refrigerator was on that date.

Based on observation, interview and record review, the facility failed to follow policies and procedures for labelling and dating foods. This failure has the potential for Foodborne illnesses (infections or intoxications caused by consuming contaminated food or beverages). Findings: During an observation on 03/05/25 at 9:00 AM, the following were observed: 6 large bins each containing rice, pinto beans, long grain rice, brown rice and split peas with different dates but does not indicate received date/opened date and or expiry date; 1 bin labelled pasta with dated 9/18/24 not indicating expiry date or open date and contains 2 packs of pasta with 2 different dates; 1 box containing mixed vegetables, baby lima beans, green beans but the labeled delivery dates on the side of the box is not specific for the packaged produce. During an interview on 03/05/25 at 07:30 AM with the Kitchen Manager (KM) and Dietician (DT), both staff acknowledge the labelling is not specific and should indicate the expiry date and or opened date. During a review of Policies and Procedures (P&P) titled Labelling and Dating of Foods dated 2023, the labelling and dating of foods indicated in part Newly opened food items will need to be closed and labelled with an open date and used by date that follows the various storage guidelines .

Based on observation, interview and record review, the facility failed to implement interventions of a smoking care plan and ensure adequate supervision and assistance were provided as assessed for one of three sampled residents (Resident 1). This failure resulted in Resident 1 smoking by himself off the facility premises and falling from the wheelchair to the ground sustaining an acute fracture of the left humerus (partial or complete break in the bone, upper arm between shoulder and elbow). Findings: During a concurrent observation and interview, on 2/12/24 at 10:03 a.m., inside Resident 1's room, the resident was awake and on bed with the left forearm resting on a pillow. Resident 1 stated, Out in the front of facility .having a cigarette and finished and headed back into the facility .I was trying to step up on the curb and slid and fell forward on my left shoulder .Left shoulder hurt after the fall. Resident 3 saw the fall and staff took fifteen minutes to come help. During a concurrent observation and interview, on 2/12/24 at 11:44 a.m., with the Assistant Director of Nursing (ADON), the location where Resident 1 fell was observed. The fall area was beside the facility's parking lot away from the facility's front/entrance door to a separate medical clinic's parking lot. The ADON pointed to an area in the medical clinic's parking lot, and indicated, the location where the resident fell . The ADON stated, I was in the office and noticed that staff were going outside, and I was told someone fell outside. I went outside and saw staff assisting him. He was face down with a soft helmet (a protective head covering) on, and the wheelchair was off to the side. During a review of the clinical record for Resident 1, the : Face sheet (document with resident's information) with printed date of 2/12/24, listed diagnoses, including, history of traumatic brain injury (head injury), generalized muscle weakness, flaccid (not firm) hemiplegia (loss of ability to move one side of the body). The Minimum Data Set (MDS -assessment) dated 12/22/23, indicated Resident 1 was with a BIMS (brief interview for mental status) score of 14 (cognition intact). The resident uses a wheelchair as the mode for locomotion, walking 10 feet is not attempted due to medical condition. Resident 1 was assessed as independent in bed mobility, and sit to stand/transfers requires supervision. The medication review report (MRR) dated 2/12/24 with an order dated 5/17/23, have an active status order of no smoking at all times. No stop date was noted on the MRR for the order dated 5/17/23 ( meaning it is an ongoing/current order). The care plan for Resident 1 dated 2/23/23 for risk of falling indicated, risk for falling related to impaired balance, motor agitation, pain, poor coordination, unstable health condition, unsteady gait, use of psychotropic medications. Interventions included: provide frequent reminders to as for assistance as resident forgets his capabilities, give resident verbal reminders not to ambulate/transfer without assistance, observe frequently and place in supervised area when out of bed, place resident on fall prevention program, provide frequent staff monitoring, teach safety measures remind to call for assistance, staff to frequently monitor need for assistance and check safety. Another care plan for Resident 1 for risk for injury related to smoking dated 7/6/23, had multiple interventions including one dated 7/6/23 indicating staff member to stay with resident while he is smoking. No care plan was located in the resident's clinical record about the MRR dated 2/12/24 of no smoking at all times. The nurses' notes dated 2/6/24, indicated Resident 1 had a witnessed fall outside. Resident 1 was smoking with another resident and found on the ground face down. Resident 1 stated, He was trying to go up the curb and slid resulting to a fall. The nurses' notes further indicated upon assessment, Resident 1 complained of left shoulder pain. The MD (physician) and family were notified of the fall and pain. With orders for left shoulder X-ray. The radiology report dated 2/7/24 had documented findings of acute fracture of the proximal humerus. During an interview on 2/12/24 at 1:20 p.m., with the Director of Nursing (DON), the DON indicated, the resident should be supervised when he is smoking and was not. During a telephone interview with the DON on 3/6/24 at 9:18 a.m., the care plan for risk for injury related to impaired balance dated 02/23/2023 was reviewed with the facility's policy and procedure (P&P) titled, falls & fall risk managing, undated was reviewed. The P&P indicated, Fall risk factors 2 - Resident conditions that may contribute to the risk of falls include: cognitive impairment, pain, poor grip strength, medication side effects, functional impairments. 3 - Medical factors that contribute to the risk of falls include: d) neurological disorders, e) balance and gait disorders. Resident-Centered approaches to managing falls and fall risk 1 - The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Monitoring subsequent falls and fall risk 1 - The staff will monitor and document each resident ' s response to interventions intended to reduce falling or the risks of falling. Potential interventions for fall prevention - Mobility, place resident in view of staff when out of bed. The DON verbalized, Resident 1 was not in a supervised area when the resident fell , and the P&P falls and fall risk managing was not followed. The DON further verbalized Resident 1's care plan was not followed.

Based on interview and record review, the facility failed to adhere to its post fall protocol not to lift, move, or transfer a resident unless assessed to be free from pain after a fall, to protect one of 17 sampled residents (Resident 2) from further pain and injuries after a fall. Resident 2 complained of pain to the right hip immediately after a fall, during range of motion (ROM -movement of extremities), transfer from floor to wheelchair, and from wheelchair to bed. This failure placed the resident at risk for increased pain, dislocation of the fractured bone, and complications of fracture, including deformity, bleeding, blood clot, and death. Findings: Review of the facility's comprehensive assessment of Resident 2, dated 10/23/14, indicated Resident 2 had memory problems, required one person physical assistance with walking, transfer, and dressing. The facility's Progress Notes indicated Resident 2 slid and fell on [DATE] at 7:45 p.m. in the facility's dining area. Resident 2 was walking towards the door on a vinyl laminated floor without assistance, a walker or nonskid shoes, when she slid and fell . The Progress Notes indicated Resident 2 complained of pain to right hip during an assessment on 1/11/15 at 7:45 p.m., immediately after the fall, and during transfer from the floor into a wheelchair. Resident 2 complained of pain again to the right hip 1 hour and 15 minutes after the fall, (9 p.m.), while being transferred from a wheelchair to a bed. During an interview on 2/20/15 at 10:20 a.m., a certified nurses' assistant (CNA 4) stated Resident 2 was on the floor in a sitting position upon falling on 1/11/15, repeating the words " You hurt me, You broke me" in Spanish...she (Resident 2) was in pain ...during transfer from the floor into a wheelchair, and from the wheelchair into the bed, she complained of more pain. The nurse then called the doctor who ordered an X-ray." During interview on 2/20/15 at 12:05 p.m., (LN 6) stated "It was my decision to go ahead and have Resident 2 picked up from the floor to the wheelchair. We did not immobilized the leg during transfer...she (Resident 2) complained of pain before the range of motion (ROM), and more pain during the ROM of the leg and when we transferred her from the wheelchair to bed." During an interview on 12/20/15 at 10 a.m., the Assistant Director of Nursing (ADON) stated "The facility's protocol on falls was not to lift, move, or transfer a resident unless assessed to be free from pain. The charge nurse on duty should have assessed for changes in range of motion, level of consciousness, pain, and call 911. The resident (Resident 2) should have been left on the floor until the 911 and paramedics comes to transfer." Review of the facility's Policy and Procedure titled "Post falls" dated and revised 12/2004 stated "Evaluate resident's condition before moving." The facility failed to adhere to its protocol on falls, which indicate not to lift, move, or transfer a resident unless assessed to be free from pain. Eleven hours and twenty seven minutes after the fall, (7:12 a.m.), the facility transferred Resident 2 to an acute care hospital. At the acute care hospital, the resident underwent [REDACTED].

Based on observation, interview, and record review, the facility failed to provide supervision and assistive devices to prevent accident and/or injury in two of 17 sample residents (Resident 2 and 5). 1. The facility failed to provide Resident 2 with non skid shoes and a walker during ambulation to prevent a fall and injury. As a result of these failures, Resident 2 fell and sustained a hip fracture, and underwent hip surgery. 2. The facility noted Resident 5 falls during unsupervised and unassisted transfers, but failed to provide interventions including assistive devices (walker, a tab alarm (an alarm to alert the staff of unsafe transfer), frequent staff monitoring, and mattresses at bedside to prevent falls and/or injuries. As a result of these failures, Resident 5 fell for the third time, in six months and 5 days, while transferring from bed unassisted and unsupervised. Resident 5 sustained a left femur fracture (left hip fracture), which placed the resident at risk for deformity, complications of fracture, and death. Findings: 1. During a concurrent observation and interview on 2/17/15 at 10:20 a.m., Resident 2 was observed walking inside a dining room being assisted by two nursing staff. The resident appeared confused, talking to self, and requesting to go home. A Certified Nursing Assistant (CNA 3) stated "The resident used to walk and transfer with one person assist...the assistance was increased to two person after the resident fell and broke a hip last month." Review of the clinical record for Resident 2 on 2/18/15 at 2 p.m., revealed [DIAGNOSES REDACTED]. The facility's fall risk assessment, dated 7/21/14 revealed the resident was a high risk for falls due to history of falls, poor balance, unsteady gait, confusion, decrease in muscle coordination, and need for an assistive device (walker). The facility's comprehensive assessment of Resident 2, dated 10/23/14 indicated Resident 2 had memory problems, required one person physical assist with walking, transfer, and dressing. The fall prevention careplan dated 8/29/14, outlined measures including, check footwear for safety, laces tied, shoes on, non skid soles, encourage use of handrails and walker. The facility's Interdisciplinary Team (IDT) report dated 1/11/15 indicated Resident 2 slid and fell on [DATE] at 7:45 p.m., in the dining room with a vinyl laminate floor, while walking alone without a walker or nonskid shoes. The X-ray report dated 1/11/15 indicated a fractured femur with mild displacement (dislocation). Resident 2 was transferred to an acute care hospital, where she was hospitalized and underwent a hip surgery. Review of the facility's investigation of the fall (Initial Allegation of Abuse Repot Form), dated 1/11/15 indicated prior to the fall on 1/11/15, Resident 2 bends forward, leans to the side and "very unsteady" while walking. The resident fell in the dining room and sustained a right hip fracture. The report also indicated Resident 2 was not using a walker during the fall, and her shoes were "not as skid proof as they need to be, cute but slippery." During a phone interview on 2/20/15 at 10 a.m., CNA 4 stated "The resident doesn't use a walker without assistance. The resident fell on [DATE] around 7:45 p.m.. in the dining room with vinyl laminate floor. The resident did not have a non skid shoes on during the fall, was walking towards the door when she slipped and fell on her buttocks to the floor. 2. Record review on 2/17/15 revealed Resident 5 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the facility's Fall risk Assessment, dated 6/17/14, identified Resident 5 as a "High Risk" for falls due to: intermittent confusion, poor safety awareness, balance problems while standing/walking, decrease muscular coordination, requires use of assistive device (walker), medications, and predisposing diseases. The facility's comprehensive assessment, dated 12/14/14 indicated Resident 5 required supervision of one person with activities of daily living, including cueing with transfers, walking, and bed mobility. A review of the facility care plan fall dated 9/22/14 indicated Resident 5 was a fall risk. The facility's interventions to prevent Resident 5 from falls or injury included: keep bed in lowest position, encourage resident to assume a standing position slowly, give resident verbal reminders not to ambulate/transfer without assistance, and frequent staff monitoring. The facility was unable to provide documentation to indicate it provided Resident 5 with frequent staff monitoring, use of assistive device (including a walker), a tab alarm to alert the staff of unsafe transfer, and mattresses at bedside to prevent falls and/or injuries. A review of the facility's nurses notes indicated Resident 5 fell due to unassisted and unsupervised transfers on 7/25/14, 11/5/14, and 1/30/15. On 7/25/14, Resident 5 fell during an unsupervised transfer from bed to a standing position to reach a walker, and hit her head on the floor. The resident sustained [REDACTED]. Resident 5 fell again on 11/5/14, while transferring from a seated position to a standing position unassisted. On 1/30/15, Resident 5 fell while attempting to transfer out of bed without supervision and assistance. The Resident was found "on her knees near her bed," and sustained a left hip fracture. During an interview on 2/19/15 at 5:00 p.m. the responsible party for Resident 5 stated that she had asked the facility to place floor mats at the sides of the bed and for a tab alarm after the first fall (7/25/14) back in July, to prevent the resident from falls and injuries. The facility failed to implement these interventions. During an interview on 2/20/15 at 10:48 a.m. a licensed nurse (LN 7) confirmed that the facility did not implement the use of a tab alarm to prevent falls until after the third fall on 1/30/15. During an interview on 2/20/15 at 10:48 a.m. a certified nurses assistant (CNA 5) confirmed that the facility did not implement the use of a tab alarm to prevent falls until after the third fall on 1/30/15. The facility was aware Resident 5 had a higher risk for falls and injuries during transfer (due to balance problems with standing and walking and decreased muscular coordination) but failed to implement interventions including assistive devices and supervision prevent another fall and/or injury.

Based on record review, interview, and observation, the facility failed to position Resident 1 in the mechanical lift sling and position staff as directed by the manufacturer specifications to ensure a safe environment was established prior to transferring Resident 1 from bed to the shower chair for one resident (Resident 1). On 9/27/12, Resident 1 suffered a fall from a mechanical sling lift, striking his face and head on the metal frame of the mechanical lift and sustaining numerous facial injuries, one of which required nine sutures to repair. The facility's awareness of Resident 1's past and current behaviors, past fall from the sling and failure to stand beside and/or stabilize the resident's body was a direct failure to develop safe transfer techniques for Resident 1 and resulted in the fall, injury and emergency room visit. Findings: Record review on 10/1/12 indicated Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. An annual comprehensive assessment of Resident 1's functional abilities, performed on 8/18/12, assessed Resident 1 as able to usually understand as well as usually be understood. Resident 1 has some short and long term memory impairment with a history of inattentiveness, disorganized thinking and frequent bouts of short temper and being easily annoyed. Resident 1 is assessed as having no problematic behavioral symptoms and received no antipsychotics or antianxiety medications. Resident 1 is vision impaired but refuses to wear corrective lenses. Resident 1 depends fully on facility staff for all activities of daily living needs, such as turning, toileting, eating and bathing. Resident 1 has left sided upper and lower extremity paralysis and receives nourishment through a gastric feeding tube (a tube surgically inserted into the stomach to aid in feeding). Resident 1 is 71" tall and weighs 186 pounds. Resident 1's mode of transfer mobility from bed to chair to bed, is by being placed in a cloth sling operated by hand held remote, attached to a metal lift that is operated manually by the facility staff. During an interview on 10/1/12 at 12:20 p.m., with a certified nursing assistant (CNA 1) who routinely cares for Resident 1, CNA 1 indicated that Resident 1 had developed a habit of periodically resisting care, pinching, hitting, and verbalizing profanity toward all and, as a result, all bedside care was done in pairs. CNA 1 also noted that Resident 1 had "recently" started grabbing when being transferred with the metal lift. Record review on 10/1/12, of Resident 1's care plan for mobility, dated 8/4/10, documented "must use Hoyer lift (metal mechanical lift) with two person assist". Further record review of Resident 1's medical records on 10/1/12, indicated that on 4/18/12, while being transferred from the bed to a geri chair (a type of padded reclining chair on large casters) with the assistance of two CNA's and a sling lift, Resident 1 grabbed for the arm of the chair as he neared it, throwing himself off balance and had an assisted fall to the floor, with no injuries involved. Resident 1's care plan was revised, at that time, to reflect "grabs with right hand" and transfers were changed from "2 person" to "2-3 person assist". There was no indication in the careplan that staff should be positioned on Resident 1's right side during transfers despite having knowledge Resident 1 reaches with the right arm during transfers. Record review on 10/1/12 indicated that, on 9/27/12, while being transferred with two aides, from the bed to a shower chair with a mechanical sling lift, Resident 1 suddenly reached for a strap in front of him, leaned to the right and fell out of the lift, hitting his head and face on the metal framed feet of the lift. During an interview on 10/1/12 12:20 p.m. with the staff involved in the transfer, Resident 1 was described as being in the sling facing away from the mechanical lift and the staff operating the lift (not consistent with manufacturer specifications). One facility employed nursing aide in training (SNA) was facing the lift at Resident 1's feet and and the routinely assigned CNA (CNA 1) was standing behind the lift, outside the reach of Resident 1, guiding the lift with a tethered remote control device. Neither CNA 1 or SNA was positioned at the non-paralyzed right side of Resident 1's body, nor was Resident 1 facing the lift and operator, nor were either staff steadying the sling by holding onto the stabilizing handles in the back of the sling. Resident 1 was transported to the hospital and received nine sutures to a gash above the right eye. Resident 1 also sustained cuts to the bridge of the nose, a bump on the head, and numerous abrasions to the right hand, shoulder, elbow and left knee. During an interview on 10/01/12, at 1:15 p.m., with the assistant director of staff development trainer (LN 1), LN 1 explained lift equipment training was provided to all employees on hire, along with a return demonstration. The facility did not schedule annual demonstrated competency relative to the mechanical lifts. LN 1 explained he had not read the manufacturer's lift instruction manual nor was the manufacturer's DVD utilized during staff training. LN 1 stated the DVD "was "boring". When asked if there was a facility policy or procedure for the use of mechanical lift equipment, LN 1 indicated that there was none. Review of the facility's " Hoyer Lift lesson plan " for new CNA orientation, the following description was given for use of a mechanical lift: " 14. Pumping the lever, lift the resident from the bed " This describes a hydraulic lift, not the electrical lift being used by the facility. No up to date, Lift-specific training information was provided to the surveyor at the time it was requested or afterward. In an interview with CNA 1 on 10/01/12 at 1:15 p.m., regarding staff positioning during the resident ' s transfer, CNA 1 indicated that the new SNA had been trained in lift usage by the facility that week and that, just before the transfer, CNA 1 went over what they (CNA 1 and SNA) would be doing during the transfer. CNA 1 further indicated that SNA was at the feet of the resident, guiding and CNA 1 was at Resident 1's head, operating the lift. During an interview regarding positioning with SNA on 10/3/12 at 10:45 a.m., SNA explained that, at the time of the fall, she was facing Resident 1 and guiding Resident 1's feet while CNA 1 was behind the lift, manually pushing the mechanical lift using the remote control to guide the sling. Neither SNA or CNA 1 was positioned beside Resident 1's body or using the stabilizing handles. During an observation of the facility's transfer technique and concurrent interview with CNA 1 and LN 1, on 10/03/12 starting at 2:30 p.m., CNA 1 with LN I (staff trainer) present, showed the surveyor, in a step by step process, how Resident 1 would be transferred from the bed to the lift to the shower chair. At no time did LN I give any indication that the procedure described was not consistent with the facility or manufacturer training procedure. During the same interview, CNA 1 explained that a lift was made more difficult if Resident 1 was squirming. Both CNA 1 and LN 1 stated that Resident 1 "squirms all the time, all the time". Record review on 10/10/12, of the VanderLift manufacturer's manual, received from the facility indicated the following under "Transfer criteria": indicated patients or situations such as "unpredictable behavior" may require the help of "more additional staff members." In an interview with the SNA on 10/03/12 at 10:45 am, SNA confirmed " (the) CNA was behind him (Resident 1) and controlling the Lift and I (SNA)was at the front of him, controlling the feet " . When asked if the CNA was standing behind the sling or behind the Lift stand, SNA stated " Behind the Lift stand, with the remote " . Review of the Vander Lift manufacturer ' s skills observation assessment form related to positioning of staff during movement of the patient while in the sling, it indicated " 1 person pushes (the) lift while the other controls the resident, using the " hand loops " . During an interview on 11/14/12 at 10:30 a.m., with the distributor sales representative (DSR) for the facility lift, the DSR indicated with a two person transfer, the resident should be "facing the lift operator" at all times and the second person should be guiding the resident's body, either by use of a hand or hands on the shoulder or by use of the stabilizing handles on the back of the sling. Record review on 11/15/12 of the Emergency Department Report dated 9/27/12 for Resident 1 indicated that Resident 1 presented to the emergency department "with significant laceration to the scalp." The report indicated Resident 1 sustained a "five centimeter (two inch) scalp laceration" which required nine sutures to repair.