Every finding on record at Greenhaven Healthcare Center

Based on observation, interview and record review the facility failed to eliminate accident hazards in the resident's environment for one of three sampled residents (Resident 1) when: Resident 1 sustained a hematoma (localized collection of pooled blood that gathers outside of a blood vessel, usually caused by injury, trauma, or surgery) after a chair was removed from the secure wall mount by a staff member and left leaning against Resident 1's room wall. Resident 1 later bumped into the chair, which then fell onto her left knee causing the accident.This failure resulted in an avoidable accident with a minor injury to Resident 1's left knee.According to the admission Record, the facility admitted Resident 1 in February 2022 with multiple diagnoses including heart failure and glaucoma (eye condition). Resident 1 was discharged in June 2026. A review of Resident 1's Change in Condition assessment dated [DATE] indicated, Resident 1 sustained a hematoma to her left knee after a chair hit her left knee in her room.A review of Resident 1's progress noted dated 5/11/26 indicated, Resident 1 reported the pain is worsening on her left knee. Resident 1 was sent to acute care hospital for treatment per physician order.During an interview on 6/11/26, at 11:14 a.m., with the Director of Nursing (DON) DON stated on 5/11/26 Resident 1 told one of the nurses a chair fell onto her left knee and it was painful. DON stated later that day Resident 1 was sent to the hospital after the pain was not resolved with an ice pack and Tylenol. DON stated the interdisciplinary team (IDT) did an investigation into the accident, and determined a staff member removed the chair from mount that day per the residents request and left it leaning against the wall. DON stated neither she nor any other staff were aware of Resident 1's request to keep the chair off the mount. DON stated Resident 1 is not strong enough to remove the chair from the secure wall mount, and that a staff member had to have removed it, and leaned it against the wall prior to the accident.A review of IDT Review of Change in Condition Incident dated 5/12/26 indicated, Res [Resident 1] stated that the chair leaning on the wall fell off and hit her Lt knee.Route Cause of Change in Condition/Incident: Folding chair fell and hit res Lt [left] knee.During an observation on 6/11/26, at 11:43 a.m, in the room Resident 1 resided in while she was admitted to the facility, with the DON, a wall mount was noted on the wall. The DON was observed to demonstrate the sturdiness of the mount, which held the chair and stayed on the mount after wiggling and bumping into it. The chairs used by the facility were observed to be foldable wooden chairs weighing approximately 5-6 pounds. During an interview on 6/11/26, at 3:13 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she has taken care of Resident 1 many times before. CNA 1 stated Resident 1 would say no no no and point to the chair on the wall, then request staff remove the chair from the mount, and that she didn't want the chair near her side of the room on the mount. CNA 1 further stated there were no rules or procedures on what to do or not do with the chairs. CNA 1 stated the staff should not just leave the chair leaning against the wall because that is dangerous.A review of Resident 1's care plan reviewed on 6/11/25, care plan indicated no reference to Resident 1's preference of having the chair on off the secure mount, or that Resident 1 was educated on the risks of keeping the chair off the secure mount. Care plan did not instruct staff members to keep the chair off the secure mount prior to the accident.A review of Resident 1's progress notes dated January 2026 to 6/9/26 indicated no reference from staff regarding Resident 1's preference to keep the chair off the secure mount, or any reference to staff educating resident on the risks of keeping the chair off the mount.

Based on interview and record review, the facility failed to ensure the employed social worker met the minimum qualifications of the position as per federal regulations for a census of 143 residents, when the social worker had no bachelor's degree since hiring to meet the required minimum qualifications of the position for a facility with more than 120 beds.This failure decreased the facility's potential to provide social services that meet the residents' individualized needs.Findings:A review of the Social Service Manager's (SSM) undated Employee Information, indicated SSM was hired on 11/10/25 for the Social Services Director (SSD) position.A review of the SSM's Offer Letter for Social Services Leader at [the facility name], dated 10/21/25, indicated SSM was offered a full-time position as a Social Services Lead and anticipated starting on 11/17/25.A review of the facility's undated document for manager key personnel, indicated SSM was in charge of the social services department.A review of the SSM's Application for Employment, dated 10/30/25, indicated the SSM's applied position was SSD and she had an associated of applied science (AAS) degree in medical office administration and medical assisting.During a concurrent interview and record review on 5/5/26 at 11:30 a.m. with SSM, SSM's employee file was reviewed. SSM confirmed she had no bachelor's degree and had an AAS degree from a college. SSM stated her role was to conduct psychosocial assessment and care plan meetings for all residents, coordinate safe and timely discharges, and collaborate care with families and communities. SSM further stated she worked independently and there was no SSD overseeing her social work since she was hired on 11/10/25.During a concurrent interview and record review on 5/5/26 at 11:55 a.m. with the Director of Nursing (DON), SSM's employee file was reviewed. DON confirmed SSM had an AAS degree. DON stated SSM worked independently and no personnel in the facility with a bachelor's in social work nor human services overseed SSM's work. A review of the facility's license, dated 6/30/25 to 6/29/26, indicated the facility's licensed capacity was 148 skilled nursing beds.A review of the facility's job posting titled, Social Services Director, dated 4/7/26, indicated candidates for the SSD job position must have a bachelor's degree in either psychology, sociology, or social work.

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when a care plan for Resident 1's peripheral IV [(PIV) intravenous line-delivers fluids, medications or nutrients directly into a vein] was not developed. This failure had the potential to cause an increased risk of infection and bleeding.Findings:A review of Resident 1's clinical record indicated Resident 1 was admitted in January 2026 with multiple diagnoses which included atrial fibrillation (irregular heart rhythm), malignant neoplasm of esophagus (esophageal cancer), and Parkinson's Disease (progressive movement disorder of the nervous system).A review of Resident 1's Order Details dated 3/20/26 indicated, Place PIV for IV ATB [antibiotic] (medication to treat infection) one time only.A review of Resident 1's Order Details dated 3/20/26 for Ertapenem Sodium Injection Solution Reconstitutes 1 Gm [gram] (unit of measure) .Use 1 gram intravenously one time a day for UTI [urinary tract infection] for 7 days.During a telephone interview on 4/13/26 at 11:28 a.m. with the Director of Nursing (DON), the DON confirmed there was no IV care plan developed for Resident 1. The DON further stated she would expect there to be a care plan regarding the resident's IV.During a review of the facility's policy and procedure (P&P) titled, Goals and Objectives, Care Plans, with a revision date April 2009 indicated, Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence.1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem.

Based on interview and record review, the facility failed to ensure a peripheral IV (PIV- intravenous line-delivers fluids, medications or nutrients directly into a vein) for one of three sampled residents (Resident 1) was discontinued prior to being discharged from the facility. This failure had the potential for inadequate monitoring of Resident 1's PIV and could have resulted in an infection or bleeding for Resident 1.Findings:A review of Resident 1's clinical record indicated Resident 1 was admitted in January 2026 with multiple diagnoses which included atrial fibrillation (irregular heart rhythm), malignant neoplasm of esophagus (esophageal cancer), and Parkinson's Disease (progressive movement disorder of the nervous system).A review of Resident 1's Order Details dated 3/20/26 indicated, Place PIV for IV ATB [antibiotic] (medication to treat infection) one time only.A review of Resident 1's Order Details dated 3/20/26 for Ertapenem Sodium Injection Solution Reconstitutes 1 Gm [gram] (unit of measure) .Use 1 gram intravenously one time a day for UTI [urinary tract infection] for 7 days.During an interview on 4/2/26 at 10:29 a.m. with Licensed Nurse (LN) 1, LN 1 stated he did not know Resident 1 had an IV. LN 1 stated if he had known Resident 1 had an IV, he would have removed the IV before discharge. LN 1 further stated there was no physician's order to discontinue Resident 1's IV. LN 1 stated Resident 's 1 family called him, after being discharged , informing him that the resident still had an IV in her arm.During a concurrent interview and record review on 4/2/26 at 10:41 a.m. with the Director of Nursing (DON), Resident 1's clinical record was reviewed. The DON confirmed there was no documentation that Resident 1's PIV was discontinued prior to being discharged from the facility. During an interview on 4/2/26 at 12:12 p.m. with the DON, the DON stated she would expect Resident 2's PIV to be removed prior to being discharged . The DON further stated the PIV would be at risk for infection or becoming dislodged.During a review of the facility's policy and procedure (P&P) titled, Peripheral IV Catheter Removal, revised October 2024 indicated, The purpose of this procedure is to provide guidelines for safe, aseptic removal of a peripheral IV catheter.The following should be documented in the resident's medical record: 1. Date, time of procedure, and resident tolerance. 2. Location of catheter that was removed. 3. Reason for removal of catheter (end of treatment, complication, rotation of site, etc.). 4. Any complications and interventions taken. 5. Any communication with physician or oncoming shift.

Based on interview and record review, the facility failed to allow one (Resident 1) out of four sampled residents to return to the facility after hospitalization.This failure resulted in the resident remaining in the hospital despite being medically stable for discharge and created the potential for the resident to have no safe discharge location once hospital-level care was no longer required.Findings:During a review of Resident 1's admission Record (AR), indicated, Resident 1 was admitted 4/2025 with the diagnosis including End Stage Renal Disease ( ESRD- kidneys no longer work as they should to meet the body's needs), Diabetes Mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing.)During a review of interdisciplinary Note (IDT - shared record where different professionals [ doctors, nurses, nurse practitioner, social worker] documents their findings together in one place) dated 2/18/26, indicated, .Left big toe infection.Suspected Osteomyelitis (osteomyelitis- inflammation of bone or bone marrow, usually due to infection). IDT recommended sending out Resident 1 to the Emergency department for further evaluation and treatment.During a review of Resident 1's admission Record, indicated a date of discharge 2/25/26 at 10:30 a.m., following expiration of a seven-day bed-hold period while the resident remained hospitalized .During a review of hospital case management correspondence records dated 3/9/26 at 11:22 a.m. indicated, . resident (Resident 1) was medically stable and ready to leave the hospital, and the hospital began planning for the resident to return to the facility. During a review of the intake notes from the complainant sent online to California Department of Health (CDPH) on 3/10/26 at 2:28 p.m. indicated, .Spoke with the facility administrator, and the facility is now refusing to readmit the patient [resident] after hospitalization, citing insurance lapse.During an interview on 3/12/26 at 12:30 p.m. with the Director of Nursing (DON), DON stated, the resident had some insurance issues that was why they did not take her back. DON stated, after 7-day bed hold dated 2/25/26, she was automatically discharged from the facility. DON further stated, there was no 30- day discharge notice, no Appeal Rights provided, and there was no discharge planning provided to the resident prior to hospitalization. The DON confirmed that Resident 1 was still considered a resident of the facility when she was transferred to the hospital. DON confirmed that the facility refused re-admission of Resident 1 due to insurance lapses. DON confirmed there was a bed available for Long Term care.During an interview on 3/12/26 at 1:45 p.m. with Admissions Coordinator (AC), the AC confirmed that the reason why she was not admitted was because of lack of insurance.During a review of the facility's policy and procedure titled, readmission to the Facility, dated 3/2017, indicated, .Residents who have been discharged to the hospital or for therapeutic leave will be given priority in readmission to the facility.1) Resident whose hospitalization exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed.if the resident requires the services provided by the facility.4) readmission procedures apply equally to all residents regardless of race, color, creed, national origin, or payment source.

Based on observation, interview, and record review, the facility failed to ensure safe and effective medication management, when:1. Two of six randomly selected residents' (Resident 12 and Resident 111) controlled medications (those with high potential for abuse and addiction) were not accurately accounted for on the Medication Administration Record (MAR) and the Controlled Drug Record (CDR, an accountability record); and 2. Automated dispensing cabinet (ADC) medication discrepancies, including those involving controlled substances were not identified, reported and resolved in a timely manner for a census of 144 residents.These failures decreased the facility's potential to prevent misuse, loss, or diversion of controlled substances and resulted in three unresolved ADC discrepancies, including a morphine solution (a controlled medication to treat pain) discrepancy that remained unresolved for 21 days.Findings:1. A review of Resident 111's clinical record indicated the following as needed (PRN) orders, dated 2/3/26: (a) Oxycodone (controlled medication for pain) five milligrams (mg; a unit of measure), give one tablet by mouth every four hours as needed for moderate pain and (b) Oxycodone five mg, give two tablets by mouth every four hours as needed for severe pain.During a concurrent interview and record review on 2/24/26 at 2:04 p.m. with the Director of Nursing (DON), DON confirmed two tablets of oxycodone five mg were signed out from the CDR on the following dates and times: 2/4/26 at 1:41 p.m., 2/4/26 at 6:53 p.m., and 2/13/26 at 3:33 p.m. DON also confirmed Resident 111's February 2026 MAR indicated documentation for only one tablet administered at each of the above times. DON acknowledged Resident 111's CDR did not reconcile with the corresponding MAR and stated three oxycodone tablets were signed out but not documented as administered on the MAR, presenting a risk for diversion or misuse of controlled substances.A review of Resident 12's clinical record indicated the following PRN order, dated 8/25/25: Oxycodone five mg, give half tablet by mouth every six hours as needed for moderate-severe painDuring a concurrent interview and record review on 2/24/26 at 2:12 p.m. with DON, DON confirmed on 10/13/25 at 8:16 p.m., half tablet (2.5 mg) of oxycodone was signed out of the CDR with no corresponding administration documented on October 2025 MAR. DON also confirmed October MAR indicated documented administration of half tablet on 10/14/25 at 8:53 a.m. and on 10/17/25 at 2:32 a.m. with no corresponding CDR removals. DON acknowledged Resident 12's CDR did not reconcile with the corresponding MAR and stated there was a risk for diversion and inaccurate charting.A review of the facility's policy and procedure (P&P) titled, Controlled Substances, revised April 2019, indicated, .7. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. The policy further indicated, The nurse administering the medication is responsible for recording: (1) name of the resident receiving the medication; (2) name, strength and dose of the medication; (3) time of administration; (4) method of administration; (5) quantity of the medication remaining; and (6) signature of nurse administering medication. 2. During a concurrent observation and interview on 2/23/26 at 2:06 p.m. with Licensed Nurse (LN) 2 and the Assistant Director of Nursing (ADON) 1, the ADC in the central medication room was inspected. The ADC displayed three active, unresolved discrepancies: (1) gabapentin (used for nerve pain) 100 mg capsules discrepancy created on 11/19/25 at 12:59 p.m., (2) morphine 100 mg/5 ml solution discrepancy created on 2/2/26 at 4:48 a.m., and (3) vancomycin (oral antibiotic) 125 mg capsules discrepancy created on 1/28/26 at 1:56 p.m. Both ADON 1 and LN 2 confirmed the discrepancies were still open in the system at the time of the observation. ADON 1 stated each nurse had an individual login and password to access the ADC and medication orders appeared on the screen for removal. ADON 1 further stated she was not aware of any active discrepancies and the Consultant Pharmacy (CP) checked the ADC monthly and handled the discrepancies. ADON 1 expected nursing staff to contact the pharmacy if a discrepancy occurred.During an interview on 2/24/26 at 1:37 p.m. with the DON, DON stated she had not been notified of the ADC discrepancies and added, they [the pharmacy] are supposed to tell me right away. DON confirmed the morphine discrepancy remained unresolved since 2/2/26, for a total of 21 days. DON also stated on 2/23/26, after being informed of the issue, she contacted the CP and performed a physical count when prompted by the ADC. DON opened the bin, counted the morphine, and resolved the discrepancy in the system. DON acknowledged the discrepancy could have been due to a missing medication.During a phone interview on 2/24/26 at 3:46 p.m. with the CP, CP stated he investigated the ADC discrepancies monthly when he was at the facility and could not resolve a discrepancy unless he performed a physical count. CP confirmed he was not notified by the DON of the controlled substance discrepancies. CP further stated he would only notify the DON of what he considered a true discrepancy, which he defined as a missing medication.A review of the facility's Automated Dispensing Cabinet (Nexsys) Medication List titled, Periodic Automatic Replenishment (PAR) Versus Usage Report, dated May 30, 2024, indicated the ADC contained 15 controlled medications, including morphine sulfate 100 mg/5 ml solution.A review of the facility's P&P titled, Policy & Procedures for use of Capsa Healthcare Nexsys ADC Medication Management System, dated August 21, 2024, indicated, All discrepancies create a report that is generated daily to the pharmacist-in charge and the director of nursing . for review. The P&P further indicated, Designated parties at the pharmacy and facility are notified in real time of any discrepancy. i. Pharmacy will contact Director of Nursing to confirm discrepancy at ADC. ii. Logs are generated of all activity involving the discrepancy in question and the pharmacy and facility will conduct an onsite investigation.

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored, labeled, and maintained according to the facility's policy and/or manufacturer's specifications for a census of 144 residents, when:1. A treatment cart containing supplies and medications was left unlocked and unsupervised; 2. Resident 74 and Resident 12 had expired medications stored in two of four medication carts;3. Resident 54 had one opened and undated foil pouch containing levalbuterol (a medication to relieve shortness of breath) stored in one of five medication rooms; and 4. Resident 32 had a compounded intravenous (IV; administered into a vein) medication, daptomycin (a potent antibiotic) stored in one of five medication refrigerators after being discontinued.These failures decreased the facility's potential to prevent unauthorized access to medication carts, misuse of medications, administration of expired, contaminated, reduced potency, and ineffective medications and medication errors for vulnerable residents.Findings: 1. During a concurrent observation and interview on 2/25/26 at 2:35 p.m. with Licensed Nurse (LN) 10, LN 10 confirmed the treatment cart was unlocked and unattended. LN 10 stated there were residents and staff in the hallway who could get the medications inside the cart. During an interview on 2/26/26 at 10:50 a.m. with the Director of Nursing (DON), DON stated the medication and treatment carts should always be locked and secured when nurses are away from it; otherwise residents, visitors, or staff could get medications inside the open cart. A review of the facility's policy titled, Medication Labeling and Storage, dated 2001, indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. 2. During a concurrent observation and interview on 2/23/26 at 9:19 a.m. with LN 2, Unit D Medication Cart 2 was inspected. One Lantus Solostar (insulin glargine) pen for Resident 74 was observed labeled with 1/13 on the label. LN 2 stated this was the medication's open date and confirmed the pen expired 28 days later, on 2/10/26. During a concurrent interview and record review on 2/26/26 at 12:01 p.m. with DON, Resident 74's February Medication Administration Record (MAR) was reviewed. DON confirmed the insulin pen identified on 2/23/26 had expired on 2/10/26, and acknowledged Resident 74 had the potential to receive ineffective insulin. A review of the manufacturer's prescribing information for Lantus (single patient use Solostar prefilled pen), revised July 2023 and retrieved from DailyMed, indicated, Only use your pen for up to 28 days after its first use. Throw away the Lantus Solostar pen you are using after 28 days, even if it still has insulin left in it. During a concurrent observation and interview on 2/23/26 at 12:05 p.m. with the Assistant Director of Nursing (ADON) 2, Unit A Medication Cart 1 was inspected. An opened fluticasone/salmeterol (Wixela) inhaler (inhaled medication to treat breathing problems) for Resident 12 was observed stored in the cart with an open date of 1/5/26 written on the box. ADON 2 reviewed the manufacturer's product labeling which indicated, Discard the inhaler 1 month after opening the foil pouch or when the counter reads 0 (after all blisters have been used) whichever comes first. ADON 2 confirmed the inhaler in the medication cart was expired. During an interview on 2/24/26 at 2:17 p.m. with the DON, DON confirmed the inhaler expired and acknowledged the medication might not be effective. A review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, revised February 2023, indicated, .3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 3. During a concurrent observation and interview on 2/23/26 at 9:46 a.m. with LN 2 and ADON 1, Unit D Medication room was inspected. One opened, and undated foil pouch containing levalbuterol inhalation solution for nebulization (unit-dose vials used to relieve shortness of breath) for Resident 54 was observed. The pouch contained 21 unit-dose vials. ADON 1 and LN 2 reviewed the manufacturer's instructions printed on foil pouch which indicated, Once the foil pouch is opened, the vials should be used within two weeks. ADON 1 and LN 2 confirmed the pouch had no date opened and acknowledged that without an open date they could not confirm if the medication was expired or safe to use. During an interview on 2/24/26 at 2:17 p.m. with the DON, DON reviewed the pictures of the opened levalbuterol foil pouch observed on 2/23/26. DON confirmed there was no open date on the pouch and stated the medication was light sensitive and its stability could have been compromised. 4. During a concurrent observation and interview on 2/23/26 at 3:01 p.m. with ADON 2, Unit B bottom medication refrigerator was inspected. Two sterile compounded IV preparations of daptomycin 500 milligrams (mg, a unit of measure) in 50 milliliters (ml, a unit of measure) normal saline for Resident 32 were observed stored in a sealed clear bag. ADON 2 reviewed the printed prescription label which indicated, Infuse . every 24 hours until 2/20/2026. ADON2 stated Resident 32 was currently in the hospital and confirmed the two compounded IV preparations were stored in the refrigerator. During a concurrent interview and record review on 2/24/26 at 2:53 p.m. with the DON, pictures of the compounded IV labels and Resident 32's electronic health record were reviewed. DON confirmed the daptomycin label for Resident 32 indicated to infuse until 2/20/26 and stated the antibiotic was discontinued on 2/9/26. DON acknowledged the medication should not have been in the refrigerator and should have been removed after the order was discontinued. A review of the facility's P&P titled, Medication Labeling and Storage, revised February 2023, indicated, .3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to ensure texture modified diets were prepared to the correct texture in accordance with the International Dysphagia Diet Standardization Initiative (IDDSI) guidelines, when pureed and minced and moist trays did not meet required texture standards. This deficient practice placed the 17 residents on the pureed diet and the eight residents on the minced and moist diet at risk for choking and aspiration (food or liquid entering the airway).Findings: During a concurrent observation and interview on 2/24/26 at 10:17 a.m. with [NAME] 1 in the kitchen, [NAME] 1 removed turkey from the oven and added it to the food processor bowl to create texture modified diets. After grinding all the turkey to make the minced and moist texture, [NAME] 1 removed the minced and moist portions and placed it in a steam table pan. The remaining turkey in the processor bowl was mixed with an unmeasured amount of a chicken broth and margarine mixture. [NAME] 1 processed the turkey twice before deciding it was too chunky and proceeded to add additional broth/margarine mixture. When [NAME] 1 finished processing the turkey mixture, it appeared thin. [NAME] 1 stated it would thicken up while on the steam table. During an observation of the lunch meal plating on 2/24/26 at 11:53 a.m., the minced and moist trays and pureed meals were observed. The minced and moist vegetable texture was chunky and did not appear to fit through the prongs of a fork as required under IDDSI Level five standards. The pureed vegetables were liquid in consistency and did not hold their shape on the plate. The pureed vegetables expanded across the plate surface. The pureed roasted turkey was also thin and spread across the plate. During an observation on 2/24/26 at 1:28 p.m., a test tray was conducted. The puree bread item was observed to be thick and sticky. The item failed the spoon tilt test, as the food adhered to the spoon and did not slide off with gentle tilt which might adhere to the palate and increase choking risk for residents with swallowing disorders. A review of the facility's tray tickets for lunch meal, dated 2/24/26, indicated 17 residents were identified as receiving pureed diets and eight residents were identified as receiving minced and moist diets. During an interview on 2/24/26 at 3:38 p.m. with the Speech Language Pathologist (SLP), SLP stated kitchen staff must prepare meals according to IDDSI standards which had tests so staff can ensure the correct texture. SLP acknowledged that incorrectly prepared textures could place residents at risk for aspiration or choking. SLP reviewed the pictures of lunch meal trays taken earlier that day and further stated mashed potatoes and bread appeared too thick for the pureed diet. SLP also stated the minced and moist meat appeared not finely ground enough and needed more moisture added. A review of the facility's provided recipes titled, Pureed (IDSSI Level 4) Meats as well as the Pureed (IDSSI Level 4) Vegetables (Healthcare Menus Direct, LLC. 2025), indicated in bullet five of both recipes, The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm, and should not weep. The finished pureed item must pass IDDSI level #4 testing requirements (i.e. the fork drip, fork pressure and spoon tilt tests). During an interview on 2/24/26 at 3:52 p.m. with the Registered Dietitian (RD), RD reviewed the pictures from lunch and stated the textures of the pureed and minced and moist diets appeared inconsistent and expressed concern that the minced and moist vegetable did not appear to be finely ground enough to fit between the prongs of a fork as required. RD acknowledged there was some work to do by the kitchen staff on preparing textured diets in accordance with IDDSI guidelines. A review of the pureed diet per the IDDSI diet website, indicated these foods were usually eaten with a spoon, do not require chewing . fall off a spoon in a single spoonful when tilted, are not sticky, liquid (like sauces) must not separate from solids. A review of the minced and moist texture per the IDDSI diet website, indicated these foods were soft and moist, but with no liquid leaking/dripping from the food, biting is not required, minimal chewing required, (food) lumps of 4 mm in size .

Based on observation, interview, and record review, the facility failed to maintain the food preparation and storage areas in a sanitary condition for a census of 144 residents, when:Ice buildup was present on a pipe in the walk-in refrigerator and on the ceiling and cooling unit of the freezer;Racks holding food products were found coated with a rust-colored substance;Dirty dishes and mugs were left on clean nourishment room counters;Holes were found in kitchen wall along with chipping paint; andItems in the residents' refrigerator were not labeled and dated. These failures had the potential to allow contamination of food and food-contact surfaces, increasing the risk of bacterial growth and foodborne illness (illness caused by consuming contaminated food) for residents.Findings: 1. During an observation on 2/23/26 at 8:58 a.m. in the walk-in refrigerator, significant ice buildup was observed on an insulated black pipe descending from the ceiling at the back of the refrigerator near the entrance to the freezer. The ice buildup measured approximately eight inches (a unit of measure) in length over the pipe with an inch of thickness surrounding the pipe. During an observation on 2/23/26 at 9:01 a.m. in the freezer, frozen drops of water were observed on the ceiling, each drop was approximately an inch circumference. A large amount of ice buildup was noted on the bottom side of the freezer cooling unit that was approximately four inches circumference and two inches in-depth below the bottom of the freezer cooler unit. During an interview on 2/23/26 at 10:50 a.m. with Plant Operations Director (POD), POD concurred that there was ice buildup in both units. When asked to review the refrigerator/freezer manual, POD stated the facility no longer had one. During an interview on 2/25/26 at 4:26 p.m. with the Registered Dietitian (RD), RD stated they worked at the facility since 5/25 and the ice buildup has been there for a while. A review of the facility's policy titled, Refrigerators and Freezers, revised November 2022, indicated, 10. Supervisors inspect refrigerators and freezers monthly for . excessive condensation and any other damage or maintenance needs. Necessary repairs are initiated immediately. A review of the website www.hellosuper.com, indicated, Frost and ice buildup . can be a sign of faulty sealing and air leaks, or overworked systems. A review of the website www.wikihow.com, indicated five steps to correcting ice buildup including: 3. Tighten the door hinges if they're loose. 4. Wipe down the seals around the inside of each door to remove any residue. 5. Replace a damaged door seal (or gasket) with a new one. 2. During an observation on 2/23/26 at 8:58 a.m., a reddish-brown substance was observed on the interior wall directly beneath the ice-covered pipe. The discoloration was approximately five inches in length. During an observation on 2/23/26 at 9:01 a.m., a metal rack located in the corner of the kitchen next to the ovens and dishwashing sink was observed with a rust-colored substance on the shelving and wheel hubs. During an observation on 2/23/26 at 9:03 a.m., a second metal rack located to the right of the dishwasher machine under the stainless-steel dishwashing deck was observed with a rust-colored substance. During a concurrent observation and interview on 2/23/26 at 10:50 a.m. with POD, POD confirmed the rust-colored substance on the metal rack and acknowledged the discoloration. During a concurrent observation and interview on 2/23/26 at 10:51 a.m. with the Dietary Manager (DM), DM stated the rust-colored substance could serve as a mechanism for bacteria to spread to food, potentially causing foodborne illness.A review of the facility's policy titled, Sanitization, dated 11/2022, indicated, shelves and equipment are to be kept clean and free from breaks or corrosion. A review of the facility's policy titled, Refrigerators and Freezers, revised November 2022, indicated, 10. Supervisors inspect refrigerators and freezers monthly for . presence of rust . and any other damage or maintenance needs. Necessary repairs are initiated immediately. 3. During an observation on 2/23/26 at 9:51 a.m. in C wing nourishment room, two soiled resident coffee cups were on counter left side of the sink. No signage indicated the area was for soiled dishes. During an observation on 2/25/26 at 11:27 a.m. in D wing nourishment room, a soiled meal tray was left on counter right side of the sink under the paper towel dispenser. No signage was noted designating the area for soiled dishes. During an observation on 2/25/26 at 11:25 a.m. in D Wing nourishment room, two soiled resident coffee cups were to the left side of the sink, next to a box of clean straws. No signage designating the area of counter for soiled dishes. During an observation on 2/25/26 at 11:41 a.m. on C wing, two soiled resident meal trays were left on counter to the left of the sink. No signage designating the area of counter for soiled dishes. During an interview on 2/25/26 at 11:27 a.m. with Licensed nurse (LN) 1, LN 1 stated normally the nursing staff would walk the soiled trays and cups to the kitchen if the dirty meal cart had already been returned. During an interview on 2/25/26 at 11:52 a.m. with the Infection Preventionist (IP), IP stated the nourishment rooms should not store dirty dishes and the expectation was that dirty dishes were brought back to the kitchen. IP expressed concern of other residents finding and interacting with the dirty dishes leading to cross contamination. A review of the facility's policy titled, Sanitization (Med-Pass, 2001), indicated in bullet one, All kitchens, kitchen areas . are kept clean and free from garbage and debris, and protected from rodents and insects. 4. During an observation of the lunch meal plating on 2/24/26 at 12:17 p.m., a hole was observed in the wall under the handwashing sink of approximately 4 x 6 inches surrounding two pipes. During a concurrent observation and interview on 2/24/26 at 12:22 p.m. with DM, DM concurred there was a section of the drywall that had been removed and stated the previous sink was replaced and facility had a hole ever since. A circle of drywall was noted to be damaged above the area with an approximately one and a half inches in length section of drywall missing. On the corner, close to the entrance, paint had chipped off exposing the drywall in multiple areas, of up to five inches in length. DM stated the damage was likely from the carts entering the kitchen and hitting the wall. During an interview on 02/25/26 at 4:26 p.m. with RD, RD stated the holes in the drywall were a risk for critters coming into the kitchen as well as for cross contamination. A review of the United States (US) Food and Drug Administration 2022 Food Code, indicated in section 6-501.11 on Repairing, Physical facilities shall be maintained in good repair . Poor repair and maintenance compromises the functionality of the physical facilities. This requirement is intended to ensure that the physical facilities are properly maintained in order to serve their intended purpose. A review of the US Food and Drug Administration 2022 Food Code, indicated in section 6-202.15 on Outer Openings, Protected, indicated, a Food establishment shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings. 5. During a concurrent observation and interview on 2/25/26 at 11:12 a.m. with Certified Nursing Assistant (CNA) 4, B Wing nourishment room was inspected. A bottle of Pedialyte (oral electrolyte solution designed for rapid, effective rehydration in both children and adults by replenishing fluids and minerals) in the refrigerator was found opened and with approximately a cup of the liquid remaining. No resident name or open date was written on the bottle. CNA 4 stated the unlabeled Pedialyte bottle was not correct and staff were expected to write the name of the resident on the bottle (or food) it belonged to. CNA 4 further stated without a name, the item could be given to the wrong resident. During a concurrent observation and interview on 2/25/26 at 11:42 a.m. with Assistant Director of Nursing (ADON) 1, ADON 1 stated nurses managed the labeling of resident foods from home in all nursing units. ADON 1 acknowledged Pedialyte was not labeled. A review of the facility's policy titled, Foods Brought by Family/Visitors, revised March 2022, indicated, 6b . Containers are labeled with the resident's name, the item and the 'use by' date.

Based on observation, interview, and record review, the facility failed to ensure resident food and beverages brought from outside of the facility were consistently stored and managed under sanitary conditions for a census of 144 residents, when staff demonstrated inconsistent knowledge regarding storage timeframes and reheating practices. This failure had the potential for allowing bacterial growth and cross-contamination, consumption of food beyond safe storage timeframes and limiting resident food options.Findings: During a concurrent observation and interview on 2/24/26 at 11 a.m. with the Dietary Manager (DM), the nourishment rooms were inspected. No microwaves were observed on the nursing units. DM stated staff could heat residents' food using the microwave in the dining room. During an interview on 2/24/26 at 8:04 a.m. with Resident 133 on Wing A, Resident 133 stated she and her previous roommate used to order food from an outside delivery source and share the meal; otherwise if she ordered by herself then it was too much food and would be thrown out in 48 hours as per facility's policy. During a concurrent observation and interview on 2/25/26 at 11:03 a.m. with Certified Nursing Assistant (CNA) 5 in the D wing, CNA 5 stated food brought from home could only be eaten for two hours before being discarded, as staff were not allowed to store or reheat food for residents. During a concurrent observation and interview on 2/25/26 at 11:42 a.m. with the Assistant Director of Nursing (ADON) 1, ADON 1 stated residents' food could not be reheated in the dining room microwave. ADON 1 expected staff to bring food to dietary for heating. During an interview on 2/25/26 at 12:12 p.m. with Licensed Nurse (LN) 9 in the B wing, LN 9 stated families could bring food, but they could not reheat it and the facility would store food for 24 hours before discarding it. LN 9 showed the instructions she follow on wing B refrigerator. During an interview on 2/25/26 at 2:39 p.m. with the Director of Nursing (DON), DON encouraged families to bring food for residents and acknowledged there were variations in how different nursing stations managed food from home. DON stated she and the ADONs had provided education to staff on shift regarding Foods Brought by Family/Visitor, dated March 2022. DON showed education pieces for residents' families indicating food would be stored for 72 hours and could be reheated per the section on rewarming. A review of the facility's policy titled, Foods Brought by Family/Visitors (Med-Pass, 2022), indicated, Food brought to the facility by family and visitors is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. The policy gave staff minimal guidance on the specifics of food storage and reheating practices for the facility. In bullet five, the policy further indicated, If staff is assisting family or visitors with reheating . staff must use safe food handling practices. No guidance was given on what this entails, or even where to reheat resident foods. In bullet seven, the policy also indicated, nursing staff will discard perishable foods on or before the 'use by ' date, but does not guide staff on how to determine this date.

Based on observation, interview, and record review, the facility failed to follow proper infection control measures for two of 31 sampled residents (Resident 37 and Resident 157), when:1. Licensed Nurse (LN) 10 did not maintain proper hand hygiene practices during wound care for Resident 37; and2. Two Certified Nurse Assistants (CNAs) did not wear the required personal protective equipment (PPE, protective clothing/gown, gloves, facemasks/face shields designed to protect the wearer from injury or the spread of infection) while providing care to Resident 157 who was on enhanced barrier precaution (EBP, an infection control method).These failures decreased the facility's potential to prevent spreading an infection among vulnerable residents.Findings: 1. A review of Resident 37's admission Record, dated 2/26/26, indicated Resident 37 was admitted to the facility in 2025 with diagnoses including foot ulcer (an open sore) and diabetes (a chronic condition characterized by high blood sugar levels). A review of Resident 37's Medication Review Report, dated 2/26/26, indicated Resident 37 had a sacrum (tail bone) wound treatment order to cleanse with vashe (a wound cleaner), pat dry, triad (zinc oxide based cream) to wound bed, apply silver alginate (a type of wound dressing with silver), cover with foam dressing every evening shift and as needed for wound care. During an observation on 2/25/26 at 2:24 p.m., LN 10 was preparing the wound care materials for Resident 37's sacrum wound: triad in a cup, wound cleaner and gauze in a cup and other wound materials. LN 10 placed the wound materials directly on the bed without any barrier. Next, LN 10 cleaned Resident 37's buttock after a bowel movement and used a wet towel to wipe the buttock. LN 10 then removed the dirty gloves, put on a new pair of gloves and continued to clean the buttock with a wet towel. LN 10 again removed the soiled gloves, put on a new pair of gloves and removed the old dressing of the wound. Next, LN 10 removed the used gloves and put on a new pair of gloves. Three occasions were observed when LN 10 removed used gloves and donned new gloves without hand hygiene. During an observation on 2/25/26 at 2:35 p.m., LN 10 cleaned Resident 37's sacrum wound with gauze and wound cleaner, then removed the gloves and put on a new pair of gloves without hand hygiene. During an interview on 2/25/26 at 2:45 p.m. with LN 10, LN 10 confirmed she did not maintain hand hygiene after removing gloves and putting on new gloves. LN 10 stated good hand hygiene practice was to prevent infection and the spread of bacteria. During an interview on 2/26/26 at 11:03 a.m. with the Director of Nursing (DON), DON expected nurses to maintain hand hygiene standard of practice, to use hand sanitizer or hand washing after removing gloves and donning new gloves. DON also stated hand hygiene practice was good to prevent contamination of the wound. A review of the facility's policy titled, Handwashing/Hand Hygiene, dated 10/2023, indicated, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. The policy further indicated, The use of gloves does not replace hand washing/hand hygiene. Perform hand hygiene before applying non-sterile gloves. 2. A review of Resident 157's admission Record, indicated she was admitted to the facility in February 2026 with multiple diagnoses including end stage renal disease (ESRD-an irreversible kidney failure) on hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). A review of Resident 157's Medication Review Report (MRR), dated 2/20/26, indicated Resident 157 had a hemodialysis access port in the left upper arm and EBP was required. During an observation on 2/23/26 at 4:18 p.m. inside Resident 157's room, CNA 2 and CNA 3 were observed assisting Resident 157 change her clothes and transfer from her wheelchair to the bed. Both CNAs were not wearing a gown. During a concurrent observation and interview on 2/23/26 at 4:25 p.m. with LN 6 inside Resident 157's room, LN 6 confirmed CNA 2 and CNA 3 were not wearing gowns while providing care to Resident 157. LN 6 stated Resident 157 was on EBP and the CNAs should have worn the appropriate PPE while providing care. During an interview on 2/26/26 at 10:45 a.m. with DON, DON stated staff should follow infection control protocols when caring for residents on EBP to prevent the spread of infection and ensure resident safety. A review of the facility's policy titled, Enhanced Barrier Precautions, dated June 2024, indicated, Enhanced Barrier Precautions are used as an infection prevention and control intervention . Gloves and gown are applied prior to performing the high contact resident care activity . Examples of high-contact resident care activities dressing; transferring . EBPs are indicated for residents with . indwelling medical devices . include . dialysis access sites .

Based on interview and record review, the facility failed to ensure a copy of advance directives was obtained for one of 31 sampled residents (Resident 87), when a copy of Resident 87's advance directive was not available in the facility's medical records.This failure decreased the facility's potential to honor the end-of-life wishes of its residents.Findings:A review of Resident 87's admission Record, dated 2/26/26, indicated Resident 87 was admitted to the facility in January 2026 for hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility).A review of Resident 87's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 1/8/26, indicated Resident 87's Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was eight out of 15 with moderate decline in mental capacity.During an interview on 2/23/26 at 10:11 a.m. with Resident 87, Resident 87 was incapable to be interviewed.During an interview on 2/24/26 at 11:30 a.m. with Resident 87's Representative (RR) 1, RR 1 stated Resident 87's advance directive was created in 2014 and the facility never asked for a copy of it.A review of Resident 87's Order Summary Report (OSR), dated 2/26/26, indicated an order to Do Not Resuscitate (DNR- a medical order written by a doctor to instruct health care providers not to do cardiopulmonary resuscitation if breathing stops or the heart stops beating) as per resident/RR's wishes. OSR also indicated Resident 87 did not have the capacity to understand choices and make health care decisions.During a concurrent interview and record review on 2/24/26 at 9:30 a.m. with Licensed Nurse (LN) 3, Resident 87's medical records and Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) were reviewed. LN 3 confirmed Resident 87's advance directive was prepared in March 2014 and a copy was not available.During an interview on 2/26/26 at 9:58 a.m. with the Director of Nursing (DON), DON confirmed a copy of advance directive was not present in Resident 87's medical records. DON expected staff to obtain a copy of advance directive from the RR upon admission and to place it in the medical records. DON stated missing a copy of advance directives posed a risk of not honoring Resident 87's preferences and potentially violating residents' rights.A review of the facility's policy titled, Advance Directives, dated September 2022, indicated, . If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff .

Based on interview and record review, the facility failed to ensure one of 31 sampled residents (Resident 72) was free from abuse, when Resident 91 verbally abused Resident 72 for three nights.This failure decreased the facility's potential to protect Resident 72 from verbal abuse and maintain residents' psychosocial wellbeing.Findings:A review of Resident 72's admission Record, indicated she was admitted to the facility in January 2026 with a diagnosis of obesity (excess body fat that increases the risk of health conditions like heart disease).A review of Resident 72's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/6/26, indicated her Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 out of 15 with intact memory.A review of Resident 91's admission Record, indicated she was admitted to the facility in January 2026 with a diagnosis of cerebral infarction (a stroke caused by blocked blood vessels, leading to brain cell damage).A review of Resident 91's MDS, dated [DATE], indicated her BIMS score was 13 out of 15 with intact memory.During an interview on 2/24/26 at 1:46 p.m. with Resident 72 in her room, Resident 72 stated on the night of 2/3/26 Resident 91 started . calling me a 'big fat b*tch,' and that she didn't know how I got so fat. Resident 91 repeatedly told Resident 72 that she wished she would die a long death and go to h*ll. Resident 72 further stated the verbal abuse happened three nights in a row from 2/3/26 to 2/5/26 and the abuse stressed her to the point it made her cry. Resident 72 added she was worried that Resident 91 would come to her bed and hurt her and felt that staff should have noted her distress and prioritized her safety to move her sooner.During an interview on 2/24/26 at 2:17 p.m. with Resident 91, Resident 91 admitted being verbally abusive to Resident 72 and stated Resident 72 . was a 275-pounds [a unit of measure] b*tch. Resident 91 further stated her hostility toward Resident 72 began when she wanted the door closed for privacy and Resident 72 wanted it open.A review of Resident 72's Progress Notes, dated 2/6/26 at 10:22 a.m., indicated the Social Services Director (SSD) met with Resident 72 on 2/5/26 at 4:30 p.m. because Resident 72 was having difficulties with her roommate and wanted to be moved to a different room. SSD stated a room was not available for a room change, but one would be available the next day.During an interview on 2/24/26 at 2:50 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated he heard Resident 91 on the beginning of night shift on 2/5/26 verbally going hard on Resident 72 regarding her weight and hoped she would die. CNA 1 further stated Resident 72 was transferred to a new room within 10 minutes after the verbal altercation.A review of Resident 72's Progress Notes, dated 2/6/26 at 1:56 a.m., indicated around 11:20 p.m. on 2/5/26, Resident 72 told CNA 1 that her roommate was being verbally abusive. CNA 1 was in the room during the altercation and reported to Licensed Nurse (LN) 8 that Resident 91 called Resident 72 a fat b*tch and a pig, and told her she wanted her to die and go to h*ll. The notes further indicated the verbal abuse had been ongoing for three days, which caused Resident 72 stress and anxiety. LN 8 immediately relocated Resident 72 to a separate room.During an interview on 2/24/26 at 3:05 p.m. with the Director of Nursing (DON), DON confirmed Resident 91 verbally abused Resident 72. DON expected staff to recognize abuse among residents and take measures to ensure the victim felt safe and did not experience ongoing stress from the verbal abuse.A review of the facility's policy and procedures titled, Resident Rights, dated February 2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to . be free from abuse .A review of the facility's policy titled, Identifying Types of Abuse, revised September 2022, indicated, Abuse of any kind against residents is strictly prohibited . The policy further indicated verbal or mental abuse consisted of harassing a resident, in addition or mocking, insulting, ridiculing, or intimidating.A review of the facility's policy titled, Resident-to-Resident Altercations, revised September 2022, indicated, Facility staff monitor residents for aggressive/inappropriate behaviors towards other residents . Behaviors that may provoke a reaction by residents or others include verbally aggressive behavior, such as screaming, cursing . intimidating.

Based on observation, interview, and record review, the facility failed to provide services according to accepted standards of quality for two of six sampled residents (Resident 74 and Resident 148), when: 1. Licensed Nurse (LN) 1 administered Xeljanz (tofacitinib; an immune suppressant medication) to Resident 74 without following the required hazardous drug handling procedures; and 2. LN 1 did not remain with Resident 148 to ensure MiraLAX (a powdered laxative) was taken as prescribed.These failures decreased the facility's potential to prevent hazardous drug exposure, incorrect dosing, wrong ingestion, and adverse effects due to lack of monitoring for residents.Findings: 1. During a medication pass observation on 2/23/26 at 8:28 a.m. on Unit D, LN 1 was observed preparing 13 medications for Resident 74, including Xeljanz without wearing gloves. During an observation on 2/23/26 at 8:40 a.m., LN 1 was observed at Resident 74's beside administering Xeljanz medication with a spoon, without wearing gloves. During a concurrent interview and label review on 2/23/26 at 8:49 a.m. with LN 1 at the medication cart, LN 1 read the Xeljanz bottle label, which indicated, Use gloves when handling. LN 1 confirmed she did not worn gloves during preparation or administration and acknowledged that gloves were required to reduce exposure to hazardous medications. During an interview on 2/24/26 at 2:17 p.m. with the Director of Nursing (DON), DON expected staff to wear gloves when handling hazardous medications to protect themselves from exposure. A review of the facility's policy and procedure (P&P) titled, Hazardous Drugs, revised April 2019, indicated, Hazardous pharmaceutical drugs are handled according to practice standards so as to minimize staff and resident exposure and environmental damage. P&P further indicated, 2. Hazardous drugs classified by National Institute for Occupational Safety and Health -NIOSH (A federal agency that provides guidance to prevent work related injuries and exposures) are drugs that exhibit one or more of the following criteria: a. Carcinogenicity (linked to cancer); b. Teratogenicity (linked to birth defects); c. Developmental toxicity (linked to developmental delay); d. Reproductive toxicity; e. Organ toxicity in low doses (animals or humans); f. Genotoxicity (linked to DNA damage); and g. Any new drugs that mimic existing hazardous drugs in structure or toxicity. A review of the NIOSH publication titled, NIOSH List of Hazardous Drugs in Healthcare Settings, 2024, dated December 2024, indicated, The drugs in Table 2 meet NIOSH definition of a hazardous drug . these drugs may also present an occupational hazard to those workers who are actively trying to conceive, who are pregnant or may become pregnant, and who are breastfeeding. The publication further indicated, tofacitinib listed under Table 2. 2. During a medication pass observation on 2/23/26 at 8:59 a.m. at unit D medication cart 1, LN 1 prepared eight medications for Resident 148, including MiraLAX mixed with eight ounces (measurement of volume) of water. During an observation on 2/23/26 at 9:10 a.m., LN 1 was observed at Resident 148's bedside administering medications. Resident 148 took the oral pills with the MiraLAX solution. Afterwards half of the MiraLAX solution remained on the bedside table after LN 1 finished the medication pass. During a follow-up interview on 2/23/26 at 11:20 a.m. with LN 1, LN 1 confirmed the remaining half-cup of MiraLAX and acknowledged she did not observe Resident 148 taking the rest of the medication. During an interview on 2/24/26 at 2:17 p.m. with DON, DON expected nursing staff to observe the administration of all medications. A review of the facility's P&P titled, Medication Administration Schedule, dated 2001, indicated, The exact time of medication administration is documented on the MAR [Medication Administration Record].

Based on observation, interview, and record review, the facility failed to ensure ancillary services were provided for one of 31 sampled residents (Resident 44), when Resident 44's eyeglasses prescription was not carried out as ordered by the physician and a hearing consultation was not scheduled promptly.These failures had the potential for a delayed delivery of care to help improve Resident 44's vision and hearing.Findings:A review of Resident 44's admission Record, indicated he was admitted to the facility in June 2025 with diagnoses including severe protein-calorie malnutrition and repeated falls.During a concurrent observation and interview on 2/23/26 at 10:54 a.m. with Resident 44 in his room, Resident 44 spoke in a loud voice and stated he had been requesting from staff to see an eye and ear doctor to improve his vision and hearing. Resident 44 also stated he feared to potentially lose vision in one eye if the consultation will be delayed further.A review of Resident 44's optometry (comprehensive primary eye and vision care) consultation notes, dated 10/5/25, indicated Resident 44 had limited vision due to cataracts (clouding of the lens of the eye) and was prescribed new glasses to improve his eyesight.A review of Resident 44's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 1/25/26, indicated Resident 44 did not wear eyeglasses and had difficulty in hearing.During a concurrent interview and record review on 2/26/26 at 9:58 a.m. with the Social Services Director (SSD), Resident 44's MDS, optometry notes, and social services notes, were reviewed. SSD confirmed Resident 44 was prescribed new eyeglasses, but she could not find any documentation indicating Resident 44 had been assisted in obtaining them. SSD stated there was no record of a completed hearing consultation for Resident 44.During a concurrent observation and interview on 2/26/26 at 10:15 a.m. with SSD and Resident 44 in Resident 44's room, SSD searched Resident 44's bedside table drawer and dresser. SSD confirmed no eyeglasses, magnifying devices or amplifiers were found. Resident 44 stated he did not remember wearing eyeglasses at the facility.During an interview on 2/26/26 at 10:45 a.m. with the Director of Nursing (DON), DON expected staff members to assist residents acquire the assistive devices or consultations they need. DON stated assistive devices should be prioritized when medically necessary to ensure residents' safety, comfort and improve overall quality of life.A review of the facility's policy titled, Assistive Devices and Equipment, revised in January 2020, indicated, Our facility maintains the use of assistive devices for the residents . Facility provides the residents with assistance in locating available resources to obtain assistive devices . including glasses/magnifying devices and hearing aids/amplifiers.A review of the facility's policy titled, Care of Hearing-Impaired Residents, revised in February 2018, indicated, Staff will assist hearing impaired residents (or representative) with locating available resources, scheduling appointments and arranging transportation to obtain needed services.

Based on observation, interview, and record review, the facility failed to provide a safe environment for one of 31 sampled residents (Resident 3), when floor mats were not placed beside Resident 3's bed as ordered.This failure increased Resident 3's potential to sustain injury after fall.Findings:A review of an admission record indicated Resident 3 was admitted to the facility in November 2025 with a diagnosis of repeated falls related to right hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body).A review of Resident 3's Care Plan, dated 11/18/25, indicated Resident 3 was at risk for falls due to impaired mobility related to cerebrovascular accident (CVA or stroke; loss of blood flow to a part of the brain) with right hemiplegia.A review of Resident 3's Medication Regimen Review (MRR), dated 11/21/25, indicated Resident 3 was at high risk for falls and staff should ensure floor mats were in place on both sides of Resident 3's bed every shift for fall prevention. During observations on 2/25/26 at 8:07 a.m., 11:15 a.m., and 12:10 p.m. in Resident 3's room, floor mats were not present on either side of Resident 3' bed.A review of Resident 3's Medication Administration Record (MAR), dated 11/21/25, indicated Licensed Nurse (LN) 7 signed on the morning shift of 2/25/26 indicating floor mats were placed beside Resident 3's bed.During a concurrent observation, interview, and record review on 2/25/26 at 12:15 p.m. with LN 7 inside Resident 3's room, Resident 3's MAR and MRR were reviewed. LN 7 confirmed floor mats were not in place and acknowledged her signature on Resident 3's MAR.During an interview on 2/26/26 at 10:45 a.m. with the Director of Nursing (DON), DON expected staff to follow the physician's order for placing floor mats to prevent Resident 3 from sustaining an injury in the event a fall occurred.A review of the facility's policy titled, Managing Falls and Fall Risk, revised in March 2018, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview, and record review, the facility failed to provide pain management for one of 31 sampled residents (Resident 12), when Licensed Nurse (LN) 10 did not assess Resident 12's pain and administer pain medication prior to wound care.This failure decreased the facility's potential to provide Resident 12 with an effective pain management.Findings:A review of Resident 12's admission Record, dated 2/26/26, indicated Resident 12 was admitted to the facility in August 2025 with diagnoses including chronic pain (long term pain) and depression (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and low energy).A review of Resident 12's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/31/25, indicated Resident 12 had some memory impairment.During a concurrent observation and interview on 2/25/26 at 2:56 p.m. with Certified Nursing Assistant (CNA) 5, CNA 5 assisted Resident 12 with turning and repositioning before wound care in bed. CNA 5 confirmed Resident 12 was moaning multiple times when turning on her side.During an observation on 2/25/26 at 3:07 p.m. during wound care treatment, LN 10 cleaned Resident 12's buttock wound while Resident 12 was moaning in pain.During a concurrent observation and interview on 2/25/26 at 3:16 p.m. with Resident 12 inside Resident 12's room, LN 10 assisted Resident 12 with repositioning after the wound care. Resident 12 stated her back was hurting.During an interview on 2/25/26 at 3:30 p.m. with LN 10, LN 10 confirmed Resident 12 was moaning and in pain during wound care. LN 10 acknowledged she did not offer Resident 12 a pain medication before wound care.A review of Resident 12's Medication Administration Record (MAR), dated 2/1/26 to 2/28/26, indicated Resident 12's pain was not assessed every shift in February 2026. The MAR further indicated an order for acetaminophen (a pain medication) 325 milligrams (mg, a unit of measurement), give two tablets by mouth every four hours as needed (PRN; pro re nata) for mild pain and oxycodone (a pain medication) five mg, give half tablet by mouth every six hours PRN for moderate to severe pain before wound care. LN 10 did not administer acetaminophen or oxycodone on 2/25/26 before wound care.During an interview on 2/26/26 at 9 a.m. with LN 11, LN 11 stated nurses should have monitored and assessed Resident 12's pain every shift, administered acetaminophen or stronger pain medication if needed, and assessed the effectiveness of medication. LN 11 further stated nurses should have given the pain medication before Resident 12's wound care, shower or therapy.During a concurrent interview and record review on 2/26/26 at 10:53 a.m. with the Director of Nursing (DON), Resident 12's medication orders and MAR were reviewed. DON confirmed there was no pain assessment in the orders. DON expected nurses to assess the residents' pain level and offer pain medications prior to wound care.A review of the facility's policy titled, Pain Assessment and Management, dated 3/2020, indicated, Observe the resident (during rest and movement) for physiologic and behavior (non-verbal) signs of pain. The policy further indicated during the comprehensive pain assessment to gather information from the resident (or legal representative) of the history of pain, location of pain, intensity of pain, characteristics of pain, pattern of pain, frequency, timing and duration of pain. Documentation of the resident's reported level of pain with adequate detail in the resident's medical record. A review of the facility's policy titled, Wound Care, dated 10/2010, indicated, PRN orders for pain medication to be administered prior to wound care.

Based on observation, interview, and record review, the facility failed to prevent a significant medication error for one resident (Resident 74) of a census of 144, when Resident 74 received 12 doses of insulin (a medication to regulate blood sugar) from a pen used past the manufacturer's opened expiration date. This failure resulted in the administration of expired medication to Resident 74, creating the potential for reduced potency, elevated blood sugar levels, adverse effects, and bacterial contamination.Findings: During a concurrent observation and interview on [DATE] at 9:19 a.m. with Licensed Nurse (LN) 2, Unit D Medication Cart 2 was inspected. One Lantus Solostar (insulin glargine-long-acting insulin) pen assigned to Resident 74 was observed with a hand written date of 1/13 on the prescription label. LN 2 confirmed this was the open date, then calculated 28 days from the open date and stated the insulin pen expired on [DATE]. A review of Resident 74's order report, revised on [DATE], indicated an order for insulin glargine100 unit/milliliter (u/ml; a unit of measure): inject 15 units subcutaneously (under the skin) one time a day for diabetes. During a concurrent follow up interview and record review on [DATE] at 11:08 a.m. with LN 2, Resident 74's Medication Administration Record (MAR) was reviewed. LN 2 stated Resident 74 had only one insulin glargine pen available for administration and that was the same pen observed during the [DATE] medication cart inspection. LN 2 confirmed February 2026 MAR indicated Resident 74 received 12 doses from the pen, which expired on [DATE]. During a concurrent interview and record review on [DATE] at 12:01 p.m. with the Director of Nursing (DON), Resident 74's February MAR was reviewed. DON confirmed the insulin glargine pen found on [DATE] expired on [DATE]. DON stated Resident 74 received 12 doses from the expired pen and might have received ineffective medication or experienced adverse effects due to the administration of expired insulin. A review of the manufacturer's prescribing information for Lantus (single patient use Solostar prefilled pen), revised [DATE], and retrieved from DailyMed (drug information resource), indicated, Only use your pen for up to 28 days after its first use. Throw away the Lantus Solostar pen you are using after 28 days, even if it still has insulin left in it. A review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, revised February 2023, indicated, .3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. P&P further indicated, 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or long date for the open vial.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure safety for one of three sampled residents (Resident 1) when Resident 1 fell when alone and unsupervised outdoors. This failure resulted in Resident 1's fall and subsequent transfer to the acute care hospital for further evaluation. This evaluation indicated that Resident 1 had widespread bleeding on his head and later died in the hospital.Findings:A review of the admission Record indicated Resident 1 was admitted August of 2016 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness) following nontraumatic subarachnoid hemorrhage (bleeding into the spaces around the brain) affecting left dominant side and aphasia (a disorder that makes it difficult to speak) following cerebrovascular disease (loss of blood flow to a part of the brain). The Minimum Data Set (MDS- a standardized resident assessment tool) dated [DATE] indicated, Resident 1 had impairment (functional limitation that interfered with daily function) on both sides of upper extremities and required setup assistance (resident completes activity, helper assists only prior to or following the activity) once in a wheelchair to wheel at least 50 feet and make two turns and to wheel at least 150 feet in a corridor or similar space.Further review of Resident 1's clinical records indicated the following:-Care Plan, initiated [DATE] indicated, Resident 1 has confusion at times and impaired decision making per physician, diagnosis of anoxic brain injury (no oxygen in the brain causing brain cells to die) with cognitive dysfunction (impaired memory). The interventions included Provide cues and supervision as needed.;-Care Plan, initiated [DATE] indicated, Resident 1 had impaired vision and the intervention included Fall prevention/precaution per policy;-Care Plan, initiated [DATE] indicated, Resident 1 was at risk for falls, repeat falls with possible injuries due to impaired mobility, cognition (ability to think, learn, and understand) poor vision related to history of stroke (loss of blood flow to a part of the brain) , hypertension, and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with neuropathy (numbness or weakness in the hands and feet) with contributing risk factors of cardiac (heart condition) and history of falls; and, -Care Plan, initiated [DATE] indicated, Resident 1 had impaired cognitive function/dementia (a progressive state of decline in mental abilities) or impaired thought processes. The interventions included to Cue, reorient and supervise as needed.During a review of Resident 1's Weekly Nursing Summary (WNS) dated [DATE], the WNS indicated, Resident 1 required supervision or touching assistance for LOCOMOTION ON [ability to move within the unit]/OFF Unit [ability to move to and from locations outside the unit such as outside the facility]- Wheel 50 feet with two turns; Wheel 150 feet. The WNS further indicated Resident 1 was alert/oriented with forgetfulness at baseline (usual or expected) and was able to self-propel around facility with little to no assistance and to continue with current plan of care. During a review of Resident 1's Social Services Note (SSN) dated [DATE], the SSN indicated, Resident 1 was alert and oriented x 3 (awareness to person, place, and time) and the Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 12/15 which indicated Resident 1 had moderate cognitive impairment (noticeable memory problem). The SS Note further indicated Resident 1 will remain in the facility due to Resident 1 requiring 24-hour care and supervision.During a review of Resident 1's Progress Note dated [DATE] indicated, [Resident1] had unwitnessed fall on 11/8 around 1120 AM in garden area between A wing & D wing.was found on floor on side walk [sic] on wheelchair with feet in air and back on sidewalk and head on the side walk [sic] and hit head on concrete sidewalk. [Resident 1] verbalized hitting head.Unable to assess any injuries due to resident stating pain and not medically safe to turn resident or get resident off ground.noted resident on floor when sitting out in patio during lunch.had BP [blood pressure] elevated 219/87 [normal BP is below 120/80]. 911 [emergency services] was called d/t [due to] medically not safe to transfer resident off sidewalk onto wheelchair.A review of Resident 1's Discharge Summary on [DATE] from the acute care hospital indicated the discharge diagnosis was Fall, initial encounter. The reason for admission indicated Resident 1 was status post (after or following) ground level fall (person's feet are on the same level as the ground before a fall) with diffuse intracranial hemorrhage (widespread bleeding inside the skull increasing the pressure in the brain, cutting off oxygen flow and causing cells to die) and was admitted for comfort care. Resident 1 passed away on [DATE] at 6:55 a.m. During a concurrent interview and record review with the Director of Nursing (DON) on [DATE] at 10:22 a.m., the DON showed the list of residents with incidences of falls for the past 2 months. The DON stated Resident 1 had a fall on [DATE], resident was sent out, and he died in the hospital. A follow up interview was conducted on [DATE] at 11:50 a.m. with the DON, the DON stated Resident 1 was able to exit the building by himself. The DON further stated Resident 1 was found with wheelchair tipped backwards, a nurse was there taking a break, when the nurse saw Resident 1, he was already on the ground. During an interview with the Licensed Nurse 1(LN 1) on [DATE] starting at 1:03 p.m., the LN 1 stated she was the desk nurse when Resident 1 fell, and it was a weekend. The LN 1 described Resident 1 as alert and oriented to self, place and situation with slow slurred speech, and wheelchair bound. The LN 1 stated Resident 1 would be up in his wheelchair, he would sit in the hallway a little bit then he goes to breezeway, and he makes his way to the garden.In a subsequent observation and interview on [DATE] at 1:10 p.m., the LN 1 with the state surveyor went out in the garden area located between A and D wing. The LN 1 showed the actual spot where Resident 1 was found with his back and head on the concrete floor. The LN 1 stated Resident 1's front two wheels were up in the air, the back wheels on the ground and Resident 1's legs were up with the two front wheels. The LN 1 confirmed the A wing nurses' station had glass windows with vertical blinds and the garden area was not visible from the said nurses' station. During a concurrent observation and interview on [DATE] at 1:14 p.m., LN 1 showed the state surveyor where she was sitting in the dining room/activity room when she was informed Resident 1 had a fall. LN 1 stated she saw Resident 1 on the ground from the dining room glass window. LN 1 further stated when she went to check on Resident 1 outside, there were licensed staff on the scene, and she was the one who called 911. LN 1 stated Resident 1 was by himself in the patio area when he had a fall. LN 1 further stated Resident 1 required supervision to some extent, at least twice a day during the day when resident was outside (patio). LN 1 confirmed there was no supervision provided to Resident 1 when the fall incident occurred in the patio.During a telephone interview with the Certified Nursing Assistant 1 (CNA 1) on [DATE] at 2:20 p.m., CNA 1 stated Resident 1 was active, and he would go out in the patio by himself every day. CNA 1 further stated Resident 1 goes out around 9 a.m., CNA 1 was unable to recall the last time she saw Resident 1 before the fall on [DATE]. During an interview with the DON on [DATE] at 3:10 p.m., the DON stated she could not find documented evidence indicating Resident 1 was safe by himself in the patio. During a telephone interview with CNA 2 on [DATE] at 12:34 p.m., CNA 2 stated sometimes Resident 1 would allow staff to push his wheelchair sometimes he would say no. CNA 2 further stated when Resident 1 was outside (patio) she was monitoring him often, because anything can happen. CNA 2 added falls can be prevented when CNAs checked on residents more frequently and Resident 1 would be safe in the patio by himself if a CNA was watching him. During a telephone interview with LN 2 on [DATE] at 1:23 p.m., LN 2 stated Resident 1 was up in his wheelchair inside his room between 10-11 a.m. on [DATE]. LN 2 further stated she was on break between 11:30 to 12 noon and she informed her CNAs she was going for a break. When LN 2 came back from her break she was informed Resident 1 had a fall in the patio. LN 2 was asked if Resident 1 was a fall risk, LN 2 responded, not that I know, and LN 2 stated Resident 1 was alert, he can press the call light and he can verbalize his needs.During a telephone interview with the DON on [DATE] at 4:29 p.m., the DON stated Resident 1's Fall Risk Evaluation dated [DATE] indicated Resident 1 was at high risk for falls with a score of 14. The DON further stated whenever a resident was at high risk for falls an individualized plan of care would be initiated. The DON added since Resident 1 was a high risk for falls, he needed close supervision from direct care staff which included the LNs and CNAs. The DON further added if Resident 1 was provided with close supervision or frequent checks Resident 1's fall was avoidable.A review of the facility's policy and Procedure ( P & P) revised [DATE] and titled, Safety and Supervision of Residents indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.The care team shall target interventions to reduce individual risks.including adequate supervision.Implementing interventions .Ensuring that interventions are implemented.Resident supervision is a core component of the system approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs.certain resident risk factors.are addressed.These risk factors.include.Falls.A review of the facility's P & P revised [DATE] and titled, Falls and Fall Risk, Managing indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on interview and record review, the facility failed to ensure physician orders were followed in accordance with professional standards of care and per facility policy for Resident 1, when Resident 1's physician ordered a CT scan (medical imaging technique used to obtain detailed internal images of the body) that was not implemented timely. This failure had the potential to negatively affect Resident 1's health and their ability to achieve their highest practical well-being by delaying ordered care. Findings:Resident 1 was admitted to the facility in January 2025 with multiple diagnoses which included traumatic hemorrhage of cerebrum (bleeding within the brain caused by a traumatic injury). A review of Minimum Data Set (MDS, an assessment tool), dated 7/2/25, indicated Resident 1 had severe cognitive impairment. A review of Resident 1's discharge document titled, SNF ORDERS, with faxed date of 1/8/2025, indicated, Lab/Imagining Orders.CT head without contrast in two weeks (around 1/20/2025).A Review of Resident 1's physician order, with order date 1/23/2025, indicated, Office Visit with: C T SCAN on 1/24/25.During an interview on 9/17/25, at 12:54 p.m., with the Director of Nursing (DON), the DON stated the expectation was for nursing staff to enter all orders and follow up appointments on day of admission for new admits. During a concurrent interview and record review on 9/17/25, at 2:20 p.m., with the Unit Secretary (US), the US reviewed Resident 1's admission documents and CT scan order summary. The US confirmed Resident 1 was admitted on [DATE] and had orders for a CT scan listed on his admission documents. The US further confirmed the CT scan order was not entered until 15 days after the admission date. The US stated the expectation was for the CT scan order to be entered on the day of admission. The US further stated she did not know why the CT scan order was entered late and not entering orders on time could potentially result in delayed care for residents.A review of the facility's policies and procedures (P&P) titled, admission Assessment and Follow Up: Role of the Nurse, revision date 9/12, indicated, .procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident.14. Contact outside services, such as laboratory or diagnostic services.