Every finding on record at Guardian Care and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to provide the services of a full-time Director of Nursing (DON) to lead, guide, and direct nursing care for a census of 104.This failure decreased the facility's potential to provide accurate and safe nursing care and lead to confusion among nursing staff regarding leadership for resident needs.Findings:A review of the facility provided, STATION 2 DAILY ASSIGNMENT SHEET, dated 8/17/26, indicated a line for the DON's name and signature. Review of the assignment sheet for the DON name was blank. Further review of the daily assignment sheet revealed the names of staff for the Director of Staff Development (DSD) as well as other heads of department names and titles listed.During the entrance conference interview on 8/17/26 at 9:05 AM, with the Administrator (ADM), the ADM stated they had a full-time DON and gave the name of the DON. The ADM added that the DON was not coming in today due to calling in sick. The DON confirmed the facility did not have an Assistant Director of Nursing (ADON) and the facility did not have an acting or interim (filling-in) DON.During an interview on 8/20/26 at 10:13 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated there had been a lot of changes with the management and that they currently did not have a DON. CNA 1 stated this had caused confusion with resident care and who the staff should go to with questions.During an interview on 8/20/26 at 10:46 AM with Non-Nursing Staff (NNS) 1, NNS 1 stated the facility had many recent changes in staffing. NNS 1 stated they were concerned about the facility closing due to a foreclosure notice that was placed on the door last week. NNS 1 stated that the previous DON was fired last Monday (8/10/26) and had not heard that the DON position had been replaced.During an interview on 8/17/26 at 10:53 AM with NNS 2, NNS 2 stated that multiple staff had voiced concerns about the previous DON and other staff being fired. NNS 2 further stated the facility had run short on supplies like oxygen concentrators (medical device that pulls in room air and delivers oxygen to people who have trouble breathing) and had nursing staffing concerns and the lack of a DON worried the staff due to a lack of guidance.During an interview on 8/17/26 at 11:19 AM with Licensed Nurse (LN) 1, LN 1 stated the previous DON was fired on 8/10/26 and a new DON had not been hired. LN 1 stated they had concerns due to the lack of leadership for nursing staff in the facility, including the uncertainty of the future of the facility. LN 1 added staff were concerned about the safety of the residents. LN 1 stated there was confusion with nursing staff who to go to when problems arose due to the lack of clinical leadership.During a concurrent interview and record review with the ADM on 8/17/26 at 12:01 PM, the DON's employee file was reviewed. The ADM stated the DON was hired on 8/11/26 and started last week. During a review of the employee file the ADM confirmed the file lacked an application, resume, employee references, background check, references check, and other common items needed for hiring a DON. The employee file reviewed only contained a form dated 8/12/26 to validate the DON's eligibility to work in the United States, as well a copy of the printout from the Board of Registered Nursing, that indicated the DON had a license to practice as a registered nurse. The ADM confirmed the missing items from the employee file like the health examination, background, reference checks and other hiring paperwork were pending completion from the DSD. The ADM further stated she did not advertise the DON position because she had already planned to hire this DON who she had previously worked with and was a friend.During a concurrent interview on 8/17/26 at 1:59 PM with the ADM and the DSD, the DSD stated she met the new DON on 8/14/26. The DSD stated she was unable to finish the DON's hiring process because the new DON had not provided an application, resume, references, or information to conduct a background check. The DSD further stated the DON came on 8/14/26, looked around the facility and took a list of employee names, phone numbers, and schedules. The DSD stated it was not an orientation. The ADM then stated that the DON had not officially started. The ADM further stated the last time they had a full-time DON was on 8/10/26 when the position became vacant. The ADM stated it was important to have the background checked, and references checked for all employees that worked with residents. The ADM added that it was important for the facility to have a full-time DON or designee so that staff had someone to consult. The ADM stated the risk to the residents for the lack of DON was not being able to be guided or led. The ADM confirmed prior to being hired, the DON needed to have a completed hiring package with application, resume, health examination, and screenings as required by regulations.On 8/18/26 at 10:53 AM the Department called the new DON and left a voice mail to call back. The call was not returned.During a telephone call from the ADM on 8/18/26 at 5:01 PM, the ADM stated that the new DON was upset that she had received a call from the Department and wanted to know what questions the new DON would be asked. The ADM further stated that the new DON had not been hired yet and did not believe the Department needed to interview potential staff.A review of the facility provided policy and procedure (P&P) titled, Hiring, undated, indicated, .7. The administrator will determine how to seek applicants from outside the facility (e.g. [for example] through an employment agency, advertisement, word-of-mouth, etc.) .8. The following steps will be followed when accepting applications from outside the facility: a. An applicant must complete and sign a job application form.e. The department director in question will decide, subject to the administrators approval, which applicant, if any should be hired.g. The HR director will then conduct any applicable investigations.10. Where appropriate, background investigations may be conducted.A review of the facility provided P&P titled, Orientation Program for Newly Hired Employees, Transfers, Volunteers, undated, indicated, .An orientation program shall be conducted for all newly hired employees, transfers.under contractual arrangements, and volunteers.1. All newly hired personnel/volunteers/transfers/contractors must attend a 10-hour orientation program within their first five (5) days of hire.5. Our orientation program is an in-depth review of our facility.A checklist is used to record materials reviewed.8. Records of orientation are filed in the personnel file.

Based on interview and record review, the facility failed to demonstrate that they developed, maintained and implemented a training program for an existing Social Services Designee/Assistant (SSA, a support professional who works under the direction of a licensed social workers to help individuals and families in need, connecting them with the resources and services they need to improve their lives), as the facility was unable to provide documentation verifying that the SSA had completed the required training. This failure had the potential to result in the SSA lacking the knowledge and skills necessary to safely and effectively provide social services and meet the needs of residents residing in the facility.Findings: During concurrent interview and record review on 6/30/26, at 3:23 PM with the Director of Staff Development (DSD), the Social Services Designee/Assistant's (SSA) employee file was reviewed. Review of the employee file revealed that the SSA was hired on 6/16/26. However, there was no documentation of competency validation, or job-specific training in the employee's file. During an interview the DSD stated that all staff were expected to receive appropriate orientation and training before performing their job duties, and documentation of the training and competency validation should be maintained in the employee's personnel file. The DSD further stated that the SSA should have completed orientation and had documentation of the required training in the employee's file. The DSD verified that, at the time of the review, the facility was unable to provide documentation of the SSA's competency and, or job-specific training. The DSD further added that she would attempt to locate the records by contacting the Administrator (ADMN), who was the direct supervisor of the SSA and responsible for training. During a concurrent interview and record review on 6/30/26, at 3:40 PM with the ADMN, the SSA employee's file was reviewed. The ADMN stated that the facility was currently without a Social Services Director and added that the SSA was the only staff member assigned to the Social Services Department and that the ADMN was providing oversight of the department during the vacancy. The ADMN added that the facility was in the process of interviewing possible candidates for the Social Services Director position. The ADMN verified that there was currently no documentation of facility competency job-specific training for the SSA in the employees' file. The ADMN confirmed the findings and stated that training should be documented and available in the employees' records. The ADMN stated that she was responsible for training the SSA as a direct supervisor and should document the training that he was receiving. The ADMN further stated that no evidence of documentation signified that no job-specific training was provided to the SSA. During an interview on 6/30/26, at 4:10 PM, the SSA stated that he had very limited knowledge of his job duties and responsibilities as a Social Services Designee/ Assistant. The SSA stated that he was willing to learn and viewed each challenge as an opportunity to gain knowledge and experience in social services. The SSA further stated that social services staff served as resident advocates by providing essential services and support to residents residing in the facility. The SSA explained that having a thorough understanding of his duties and responsibilities, along with receiving appropriate job-specific training, would help him perform his responsibilities effectively and achieve the highest level of performance in his role. The SSA further added that failure to receive proper training could negatively affect the quality of social services provided and potentially negatively impact residents' social service needs and overall well-being. During a subsequent interview and record review on 6/30/26, at 5:18 PM with the ADMN, the facility provided document titled Social Service Designee, that was signed by the ADMN and the SSA on 6/16/26 was reviewed. Review indicated, .The primary purpose of your job position is to assist in planning, developing, organizing, implementing, evaluating, and directing our facility's social service program in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis.As Social Service Designee, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. The ADMN stated that the SSA received only verbal training, and no documentation of the job-specific training was maintained in the employee's personnel file. The ADMN stated that Social Services staff were playing an essential role in residents' psychosocial well-being. The ADMN confirmed that the SSA had not received the training to perform the duties and responsibilities which was listed as duties and responsibilities assigned to the position. The ADMN added that she did not anticipate the SSA to have knowledge of all aspects of the Social Services Designee/Assistant job duties and responsibilities. The ADMN stated that, moving forward, she would begin providing training on the SSA's job duties one task at a time and would ensure that all training was documented. The ADMN also acknowledged that the facility did not have a formal training plan for the SSA and stated that she would develop and implement one to ensure the employee receives the training necessary to competently perform the assigned duties and responsibilities. Review of an undated facility provided policy and procedure (P&P) titled Staff Development In-Service Training-General Policies indicated, .The primary purpose of our facility's .training program is to provide our employees with an in-depth review of our established operational policies and procedures, their positions, methods and procedures to follow in implementing assigned duties, and to provide up-to-date information that will assist in providing quality care.Review of an undated facility provided documents titled Staff training/education and competencies indicated, .Staff training/education and competencies that are necessary to provide the level and types of support and care needed by its resident population.The Director of Staff Development reviews current regulations and list all staff training and competencies needed by type of staff, including managers, nursing, and other direct care staff.to ensure competencies are reviewed at the time the staff member is hired, and cadence of subsequent reviews.

Based on observation, interview, and record review, the facility failed to provide adequate assistance with activities of daily living (ADLs-normal daily functions required to meet basic needs such as bathing, toileting, eating, dressing, and including nail care) for one of three sampled residents (Resident 1) when, Resident 1's fingernails were untrimmed with a brown substance found underneath the nails on 6/23/26.This failure had the potential to cause discomfort, skin impairment, infection, and could negatively affect Resident 1's self-esteem and psychosocial well-being.Findings:During a review of Resident 1's admission RECORD, dated 6/23/26, the record indicated Resident 1 was admitted to the facility with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with agitation.During a review of Resident 1's Minimum Data Set (MDS-an assessment tool), dated 5/5/26, the MDS revealed a BIMS (Brief Interview for Mental Status) score of 7 out of 15 indicating Resident 1 had severe cognitive (how the brain takes in, understands and uses information) impairment.During a review of Resident 1's Order Summary Report, active orders as of 6/23/26, the report indicated, .Monitor cognitive status (orientation, memory, judgment, and behavior changes) and assess for safety risks related to confusion and impaired thinking.During a review of Resident 1's Care Plan Report (a form where you can summarize a person's health condition, specific care needs, and current treatments), dated 1/29/26, the ADL care plan indicated, .Activity of Daily Living Self-care deficit r/t [related to] Dementia.Will be assisted by staff in performing ADLs which cannot be met by resident. The skin care plan indicated, .FRAGILE SKIN: Risk for Impaired Skin Integrity. Discoloration, Skin Tear, Skin irritation.Keep fingernails short.During an interview on 6/23/26, at 1:54 p.m. with Certified Nurse Assistant (CNA) 1, at the East Nurses' station, CNA 1 stated residents' fingernails were trimmed and cleaned during shower days and on Sundays.During an interview on 6/23/26, at 2:14 p.m. with Licensed Nurse (LN) 1, at the East Nurses' station, LN 1 stated one of her responsibilities was to check residents for adequate grooming and hygiene and to follow up when ADLs were not done including checking for trimmed and cleaned fingernails.During a concurrent observation and interview on 6/23/26, at 2:37 p.m. with the Infection Preventionist (IP) and Resident 1, in Resident 1's room, Resident 1 had untrimmed fingernails on both hands with a brown substance underneath the nails. Resident 1 stated I have long and dirty nails. The IP confirmed the appearance of Resident 1's fingernails and responded to Resident 1's statement and stated to have someone take care of her nails.During a concurrent interview and record review on 6/23/26, at 3:35 p.m. with the Director of Staff Development (DSD-a licensed nurse who coordinates education, training and state regulatory compliance for nursing staff in long-term care facilities), the facility's training record titled, Lesson Plan, dated 5/13/26, the record indicated, .Importance of good proper nail care in daily living.How providing good nail care plays an important role in resident dignity. The DSD stated nail care should be provided to prevent infections from spreading to different parts of the body with unclean and untrimmed fingernails. The DSD also stated untrimmed and unclean fingernails could become a dignity issue affecting residents' well-being.During a concurrent interview and record review on 6/23/26, at 4:15 pm with the IP, Resident 1's care plan was reviewed. The IP stated the nail care was not addressed in the ADL care plan, but it was addressed in the skin care plan. The IP stated keeping Resident 1's fingernails short would promote skin integrity since Resident 1 had fragile skin and long fingernails could potentially cause skin tears or cuts.During an interview on 6/23/26, at 4:39 p.m. with the Director of Nursing (DON) and Administrator (ADM), the DON stated she expected that nail care should have been done every Saturdays or as scheduled. The DON stated she expected nails were trimmed and cleaned especially for those residents with fragile skin or residents on anticoagulant (prevent blood clots from forming in the bloodstream) medications because it could increase the risk for bleeding and/or infection, skin bruising and skin tears, and could be a danger to other residents if Resident 1 would accidentally scratch another resident. The ADM stated the facility would implement a process to ensure residents' nail care would be provided regularly.During a review of the facility's undated Policy and Procedure (P&P) titled, Nail Care, the P&P indicated, .To assist the resident to maintain clean and trimmed nails.To prevent infection and possible damage to the skin resulting from long jagged nails.All residents who are unable to do so for themselves will receive proper care of fingernails.on an ongoing basis.Providing nail care to those residents who are unable to take care of their own nails.During a review of the facility's undated P&P titled, Dignity, the P&P indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on observation, and interview, the facility failed to ensure a clean, comfortable, and home-like environment for a census of 99 when: 1. Shower room [ROOM NUMBER] contained black discoloration on the flooring tiles and in the cracks where the floor met the wall, the shower head and handle contained areas of white discoloration, the emergency call light string had brown and pink discoloration and was stuck to the wall, the metal container that held the soap had orange rust on the right side, 2. The baseboard on the hallway shared by station 1, station 2 and the kitchen, was pulling away from the wall and was compacted with dust and debris, the baseboard appeared water damaged; and, 3. The plastic protective covering on the wall in room [ROOM NUMBER] behind bed B, was peeling away from the wall with gaps containing dust. The vinyl baseboard was cracked and peeling away from the wall and contained dust and debris. These failures had the potential to negatively affect the residents' physical and psychosocial well-being.Findings: 1. During a concurrent observation and interview on 3/19/26, at 11:50 AM, in shower room [ROOM NUMBER], with certified nurse assistant (CNA) 1, CNA 1 confirmed the shower room was used to bathe residents. CNA 1 further confirmed there were dark black stains on the flooring, the grout, and in the cracks where the wall and floor met. CNA 1 confirmed there were white stains on the shower head and the shower handle, brown/pink discoloration on the string connected to the call light, and rust on the soap container holder. CNA 1 stated the shower room was dirty, and it should not be. During a concurrent observation and interview on 3/19/26, at 1:26 PM, in shower room [ROOM NUMBER] with the Director of Maintenance (DOM) the DOM scraped the black substance on the floor and between the flooring cracks with a knife. The DOM stated the substance appeared to be mildew. The DOM further stated the white stains on the shower head and handle appeared to be hard water stains. The DOM confirmed there appeared to be rust on the soap holder and it should be replaced. The DOM stated the call light string appeared to be mildewed and stuck to the wall and should be replaced. The DOM further stated the mildew in the shower room was not good for the residents' health. 2. During a concurrent observation and interview on 3/19/26, at 1:16 PM, in the hallway shared by station 1, station 2 and the kitchen with the Maintenance Assistant (MA), the MA stated due to budget constraints the facility had been waiting on materials to fix the baseboard. The MA further stated the kitchen's dish room was behind the wall and a leak in the garbage disposal caused moisture to get into the wood. The MA confirmed there was an accumulation of dust and cobwebs where the baseboard was pulling away from the wall and that the area was difficult to clean. During a concurrent observation and interview on 3/19/26, at 1:20 PM, in the hallway shared by station 1 and 2 and the kitchen with the DOM, the DOM stated the wall and baseboard had been like that for approximately 6 months. The DOM further stated they would replace the whole lower section of the wall and the baseboard. The DOM stated it was not good for the residents to breath in the dust and debris. 3. During a concurrent observation and interview on 3/19/26, at 1:30 PM, in room [ROOM NUMBER] with the DOM, the DOM confirmed the protective wall covering and the baseboard behind bed B were pulling away from the wall and accumulating dust and debris. The DOM stated the dust accumulation was not good for the resident. During an interview on 3/19/26, at 2:42 PM, with the DOM, the DOM stated the maintenance department provided books at each station for staff to indicate needed repairs. The DOM further stated maintenance staff checked the books three times per day. The DOM stated his staff performed weekly rounds in the resident rooms to determine if repairs were needed. The DOM further stated the area in room [ROOM NUMBER] behind bed B may have been missed due to the resident being in bed when his room was checked. During an interview on 3/19/26, at 3:03 PM, with the Infection Preventionist (IP), the IP stated the mildew in shower room [ROOM NUMBER] could get residents sick. TH IP further stated there was risk of residents getting sick from breathing dust and debris in the hallway and in room [ROOM NUMBER]. During an interview on 3/19/26, at 4:09 PM, with the Administrator (ADM), the ADM acknowledged the findings that were observed earlier in the facility with the DOM. During a review of an undated facility policy titled, Homelike Environment, the policy indicated, .Residents are provided with a safe, clean, comfortable and homelike environment.The facility and staff management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.clean, sanitary and orderly environment. During a review of an undated facility policy titled, Maintenance Service, the policy indicated, .Functions of the maintenance personnel include.maintaining the building in good repair and free from hazards.The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1)'s Responsible Party (RP, person responsible for making health care decisions), was informed and consented to the use of psychotropic medication (medication that alters perception, mood, consciousness and behavior) prior to administration of the medication. This failure deprived Resident 1's responsible party RP of the right to make an informed decision regarding Resident 1's care and resulted in Resident 1 receiving seven doses of a psychotropic medication against the RP's wishes.Findings: A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses which included unspecified intellectual disabilities (condition that limits intelligence and disrupts abilities necessary for independent living). A review of Resident 1's clinical document titled, Nurse Note, dated 2/27/26, at 5:16 PM, indicated, .Resident was seen by psych NP [mental health nurse practitioner]. Orders below were noted & carried out by author.Start Buspirone [psychotropic medication for anxiety].BID [twice daily] for anxiety disorder. A review of Resident 1's electronic health record (EHR) did not indicate informed consent was obtained for the medication. A review of Resident 1's clinical document titled, MEDICATION ADMINISTRATION RECORD [MAR], dated 2/1/26-2/28/26, indicated, .busPIRone [sic].Give 1 tablet by mouth two times a day for anxiety m/b [manifested by] repetitive physical movement. The MAR further indicated that the medication had been administered on 2/28/26 at 9 AM and 9 PM. A review of Resident 1's MAR dated 3/1/26-3/31/26, indicated, Resident 1 received doses of buspirone as follows:3/2/26 at 9 AM3/9/26 at 9 PM3/10/26 at 9 AM and 9 PM3/11/26 at 9 AM During an interview on 3/19/26, at 1:58 PM, with Licensed Nurse (LN) 2, LN 2 stated informed consent was required prior to administering buspirone to Resident 1 due to the nature of the medication and all the side effects it could cause. LN 2 confirmed informed consent had not been obtained from Resident 1's RP prior to administering the medication. LN 2 stated when the facility did contact the RP, the RP stated they did not want Resident 1 to receive the medication. During an interview on 3/19/26, at 2:57 PM, with the Director of Staff Development (DSD), the DSD stated when an order was received for a psychotropic medication that staff were required to obtain informed consent from the resident or their RP before the medication was added to the MAR. The DSD further stated the resident, and their RP had the right to make informed decisions about their care. During a review of an undated facility policy titled, Resident Rights, the policy indicated, .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.be notified of his or her medical condition and of any changes in his or her condition.be informed of, and participate in, his or her care planning and treatment. During a review of an undated facility policy titled, Psychotropic Medication Use, the policy indicated, .Residents will not receive medications that are not clinically indicated to treat a specific condition.Residents, families and/or the representative are involved in the medication management process .The IDT [interdisciplinary team, healthcare team who assess and coordinate care] must obtain a resident/representative written informed consent for treatment using psychotherapeutic drugs.

Based on observation, interview, and record review, the facility failed to provide infection prevention and control measures to prevent the possible spread of Clostridioides difficile (C. diff- a bacterium causing severe, often hospital-acquired, diarrhea, and colitis, frequently triggered by antibiotics disrupting normal gut flora) for a census of 93; when staff failed to perform appropriate hand hygiene (act of cleaning one's hands to remove harmful and unwanted substances) between residents.This failure put residents at risk of contracting C. diff, with the potential of causing illness or death.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in February of 2026 with diagnoses that included, .ENTEROCOLITIS [inflammation of the digestive tract] DUE TO CLOSTRIDIUM DIFFICILE, NOT SPECIFIED AS RECURRENT.URINARY TRACT INFECTION, SITE NOT SPECIFIED.A review of Resident 1's orders indicated, .Resident is on contact precaution. Use gown and gloves when entering the room. Ensure proper hand hygiene before and after contact with the resident or their environment .During an interview on 2/20/26, at 10:40 a.m., with the Infection Preventionist (IP), the IP stated, Resident 1 was recently admitted with a C. diff infection and was placed in Hall 400 with contact precautions (infection control steps used in healthcare settings to prevent the spread of germs that are passed by direct contact with a patient or their environment [surfaces, equipment]). During an observation on 12/20/26, at 12:38 p.m., in Hall 400, Certified Nursing Assistant (CNA) 1 was observed entering Resident 1's room with the appropriate Personal Protective Equipment (PPE- protective clothing, helmets, goggles, or other garments/gear designed to protect the wearer's body from injury or infection in industrial, medical, or emergency settings).During an observation on 12/20/26, at 12:40 p.m., in Hall 400, CNA 1 exited Resident 1's room, removed her PPE, performed hand hygiene with alcohol based gel located outside the room, and walked down the hall and entered another resident's room. During an interview on 12/20/26, at 12:42 p.m., with CNA 1, CNA 1 confirmed she performed hand hygiene using an alcohol-based sanitizing gel located outside the Resident 1's room. CNA 1 stated Resident 1 had C. diff and she had done appropriate hand hygiene before moving on to the next resident. During an interview on 12/20/26, at 12:59 p.m., with the IP, the IP stated she expected the staff to use proper contact precautions when caring for a resident with C. diff. The IP nurse further stated the proper hand hygiene for C. diff was to use soap and water. CNA 1 explained that alcohol-based sanitizing gel was not enough as it would not kill the C. diff bacteria. During an interview on 12/20/26, at 1:07 p.m., with the Director of Nursing (DON), the DON stated she expected staff to perform hand hygiene with soap and water when providing care to a C. diff resident. The DON further stated the risk was the spread of infection to other residents. The DON explained the importance of handwashing with soap and water was so that the C. diff infection could not spread.Review of an undated facility document titled, Clostridium Difficile, indicated, .5. Steps toward prevention and early intervention include.d. frequent hand washing with soap and water by staff and residents.Review of an online document posted by the Centers of Disease Control and Prevention (CDC) titled, Preventing C. diff, dated 12/18/24, indicated, Washing hands with soap and water is the best way to prevent the spread of C. Diff from person to person . https://www.cdc.gov/c-diff/prevention/index.html

Based on observation, interview, and record review, the facility failed to ensure professional standards of quality care were met for one of three sampled residents ( Resident 1) when Resident 1 did not receive care for her urinary incontinence (lack of bladder control) in a timely manner. This failure placed Resident 1 at risk for skin breakdown and infection.Findings: A review of Resident 1's admission RECORD, indicated, Resident 1 was admitted to the facility with diagnoses which included paraplegia (inability to voluntarily move the lower half of the body). During a concurrent observation and interview on 2/6/26 at 11:48 AM in Resident 1's bedroom, Resident 1 stated she had not received care since 6:30 AM. Resident 1 further stated she had asked to be cleaned and dressed at 11 AM. Resident 1 pulled down her blanket and asked the department to observe her incontinence brief. The brief indicated a blue line which signified wetness and appeared to be heavily saturated with urine. Resident 1 stated it was almost noon, and she would not be able to go to the dining room for lunch since she had not been cleaned up yet. Resident 1 further stated she was at risk of a urinary tract infection (UTI, infection of kidneys and/or bladder) if she was not changed when she needed to be. During an interview on 2/6/26 at 11:52 AM with Certified Nurse Assistant (CNA) 1, CNA 1 stated she attempted to provide care to Resident 1 at 7 AM, but Resident 1 told her to come back at 11 AM. CNA 1 stated she did not provide care to Resident 1 at 11 AM because she had to go to lunch. CNA 1 further stated CNA 2 had changed Resident 1 instead. CNA 1 stated it was important not to leave residents when they had been incontinent because they were at risk for infections and bed sores, especially Resident 1 as she had a history of infections. During an interview on 2/6/26 at 12:33 PM with CNA 2, CNA 2 stated he did not provide care to Resident 1 at 11 AM or at any other time during the shift. During an interview on 2/6/26 at 12:25 PM with Licensed Nurse (LN) 2, LN 2 stated it was her expectation that Resident 1 would have received incontinence care in a timely manner, or the CNAs should have informed her if they were unable to provide care. LN 2 further stated if Resident 1 had to wait a long period of time to be changed, she was at risk of skin issues or infection. During a concurrent interview and record review, on 2/6/26 at 1:49 PM, Resident 1's care plans were reviewed with the Director of Nursing (DON). The DON stated residents were usually changed every 2 hours and the facility would care plan frequent refusals by residents. The DON stated the CNA should continue to try to change the resident and let nurse know if the resident continued to refuse. The DON reviewed Resident 1's care plans and confirmed the risk to Resident 1 for untimely incontinence care was skin breakdown and the potential for a UTI, per the care plan. During a review of Resident 1's clinical document titled, Care Plan [a working document that indicates a person's health conditions, specific care needs, and current treatments] Report, revised on 6/23/25, the document indicated, .Focus.Bladder/Bowel Incontinence.The resident is always bowel and bladder incontinence [sic].Goal.The resident will remain free from skin breakdown due to incontinence and brief use.Interventions.Clean peri area [area between legs] with each incontinence episode.Check q2-3 H [every 2-3 hours] and as required for incontinence.Monitor/document for s/sx [signs and symptoms] UTI. During a review of an undated facility policy titled, Incontinence Care, the policy indicated, .Residents will be provided with timely, appropriate, and individualized incontinent care in accordance with each residents' assessed needs, care plan, and current standards of nursing practice.Incontinent care will be provided.In a timely manner or as needed.At routine intervals per care plan.As requested by the resident.Staff will monitor skin for redness, breakdown, rashes or pressure injuries during care.

Based on observation, interview, and record review, the facility failed to implement preventative measures to discourage drug seeking behavior/drug use for one of three sampled residents (Resident 1) when Resident 1's urine test results was positive for Cocaine (an addictive drug used as an illegal stimulant) on 7/18/25, and Cannabis (commonly known as marijuana, weed, and pot, which is a psychoactive drug that produces effects, ranging from relaxation to altered perception) on 7/18/25, 8/21/25, 9/25/25 and 12/6/25. These failures posed potential risks to Resident 1's safety, risked potential drug interactions with prescribed medications, and risked changes in level of consciousness for Resident 1 which put Resident 1, and other residents at the facility, at risk for accidents/injuries.Findings:Review of Resident 1 ' s admission RECORD indicated Resident 1 was admitted to the facility in 2013 with diagnoses including paraplegia, chronic pain syndrome, and major depressive disorder (a serious mood illness causing persistent sadness, loss of interest, and significant impairment in daily life, affecting sleep, appetite, energy, and concentration).During an interview on 1/6/26 at 11:03 a.m., in Resident 1's room, Resident 1 stated he got stressed and he made a mistake by sniffing cocaine (inhaling powdered or crushed illicit drugs (like cocaine) through the nose so they are absorbed rapidly which results in quick intoxication). Resident 1 stated he was aware that his urine tested positive for cocaine and cannabis. Resident 1 stated the doctor had decreased his pain medication (methadone) from 60mg (milligram, a unit of measure) to 40mg because he tested positive for marijuana. Resident 1 stated he had used marijuana for the last 12 years while residing at the facility. Resident 1 further stated the doctor notified him that his fourth drug test, which was done in December 2025, tested positive for marijuana. Resident 1 stated he went to the nearby park by himself and that was where he met a friend who supplied him with cocaine and marijuana. Resident 1 stated he had notified the facility staff that a friend had given him cocaine. Resident 1 stated he was never supervised by a facility staff member when he left the facility's premises and was allowed to go to the park by himself. Resident 1 further stated the risk of taking methadone and cocaine was he could have had difficulty breathing and he could have passed out (to become unconscious; faint) and no one would have known. Resident 1 stated he brought one marijuana cartridge (small, pre-filled container holding concentrated cannabis oil designed for use with a compatible vaporizer or vape pen, offering a discreet, portable, and convenient way to inhale cannabis vapor) inside the facility but staff told him he could not smoke marijuana in the facility. Resident 1 stated after his positive drug test in July 2025 he stopped going to the park following a doctor's order not allowing any more day passes. Resident 1 further stated a visitor came into the facility to see him in August 2025, September 2025 and December 2025 and gave him marijuana brownies (brownies a food item made with marijuana or marijuana oils which can be used as an alternative to smoking or vaporizing marijuana). Resident 1 further stated no one at the facility had talked to him about substance use treatment services (such as behavioral health services (treatment for mental health and substance use disorders), medication-assisted treatment (MAT- Medications for Addiction Treatment), alcoholic/narcotics anonymous meetings (drug and alcohol addiction treatment )).During an interview on 1/6/26 at 12:53 p.m., CNA 2 stated residents were not allowed to take drugs in the facility. CNA 2 stated Resident 1 was independent and when Resident 1 got up from his bed she did not know where he went. CNA 2 stated residents signed a log before they went outside of the facility. CNA 2 stated being unsupervised, a resident with drug seeking behavior could go outside and consume some bad stuff and visitors could be a bad influence on the resident. CNA 2 stated when a resident had a history of drug seeking behavior, they should be monitored regularly.During a concurrent interview and record review of Resident 1's medical record on 1/6/26 at 1:04 p.m., Licensed Nurse (LN) 1 stated Resident 1 tested positive for cocaine and cannabis on 7/18/25, and positive for cannabis on 7/18/25, 8/20/25, 9/24/25 and 12/5/25. LN 1 stated a care plan was initiated on 7/24/25 for Resident 1's drug seeking behavior. LN 1 further stated after 7/24/25 until 1/6/26 there were no care plan revisions or new interventions for Resident 1's additional positive drug tests. LN 1 stated there was no drug behavior monitoring (a healthcare document for tracking patient behavior) done regularly for Resident 1's continued drug use.During a concurrent interview and record review of Resident 1's medical record on 1/6/26 at 1:45 p.m., LN 2 stated Resident 1 did not attend drug treatment meetings and there were no psychological evaluations of Resident 1 for drug use in his medical record. LN 2 stated Resident 1 did not have a behavioral monitoring log for drug use. LN 2 stated facility staff did not know Resident 1 was using cocaine and cannabis because there were no psychological evaluations and no behavior monitoring log.During a concurrent interview and record review of Resident 1's medical record on 1/6/26 at 2:03 p.m., LN 3 stated when a resident who used drugs took marijuana with other drugs the Resident could have a drug overdose and/or interaction with his prescribed medications. LN 2 stated Resident 1 did not have a behavior monitoring log to track drowsiness, changes in behavior, or if Resident 1 had taken drugs.During an interview on 1/6/26 at 4:32 p.m., LN 4 stated when a Resident with a history of drug use did not have a behavior tracking log, the facility would not have a way of tracking when that resident used drugs. LN 4 stated the risk of not monitoring Resident 1's drug seeking behavior/drug use was Resident 1 could have respiratory distress (trouble breathing) caused by an overdose and interactions between narcotics and illicit drugs. LN 4 further stated drug seeking behavior monitoring should have been done for Resident 1 to avoid the recurrence of positive drug tests and track who brought drugs to the facility for Resident 1.During an interview on 1/6/26 at 4:45 p.m., the Director of Nursing (DON) stated behavior monitoring was documented on Resident 1's progress notes for 72 hours after Resident 1 tested positive for cocaine and cannabis on 7/18/25. The DON stated there was no daily behavior tracking implemented for drug seeking behavior/drug use for Resident. The DON stated the risk of not having a log for Resident 1 was the new staff at the facility would not be aware of Resident 1's drug seeking behavior/drug use. The DON stated a care plan for drug seeking behavior for Resident 1 was implemented on 7/23/25 and the care plan was not revised after Resident 1 tested positive for cannabis on 8/20/25, 9/24/25 and 12/5/25. The DON stated visitor monitoring could have helped stop drugs being brought to Resident 1 in the facility.During a phone interview on 1/7/26 at 2:14 p.m., the Medical Doctor (MD) stated Resident 1 had a diagnosis of paraplegia (paralysis affecting the lower half of the body, typically the legs, due to damage to the spinal cord, leading to loss of motor function, sensation, and sometimes bowel/bladder control) and Resident 1 was prescribed methadone for his pain. The MD stated Resident 1 was offered to go to a pain management clinic and recommended psychiatric evaluation. The MD stated Resident 1 was educated to not use recreational drugs (a loose term that refers to legal and illegal drugs that are used without medical supervision). The MD stated the risk of using recreational drugs with methadone was it could have caused Resident 1 to have a seizure (disruptions in muscle control and movement), QT prolongation (a heart condition causing the heart's electrical recharging cycle to take too long, increasing the risk for dangerous, irregular heart rhythms which can lead to fainting, seizures, or sudden cardiac arrest), and central nervous system depression (the slowing down of brain activity).Review of Resident 1's urine lab test result indicated a positive result for cocaine on 7/18/25 and positive results for cannabis on 7/18/25, 8/21/25, 9/25/25 and 12/6/25.Review of Resident 1's Office Visit, dated 12/26/25, indicated, .Office Visit.Plan of Care.If drug screen is neg [negative] and pain is still present will consider change, Refer to pain management.Monitor behavior.Continue with methadone 10mg 2 tab [tablets] twice daily.Review of Resident 1's Office Visit, dated 12/11/25, indicated, .Office Visit.HPI [history of present illness] at admission.h/o [history of] polysubstance abuse [mixing of different drugs],.per staff [Resident 1] has had severe behavior issues, possibly ongoing drug use.does leave on own when he wants.Has behavior out burst and anger issues.Opiate dependence [the chronic use of opioids [pain medication] that causes clinically significant distress or impairment].Polysubstance abuse.Patient on chronic [long term] methadone use instructed regarding contraindication.Psych [psychiatric] eval.Monitor behavior.No more day pass.Record review of Resident 1's Change in Condition (CIC) evaluation, dated 6/7/25, indicated, .Aggressive behavior.Review of Resident 1's Office Visit, dated 7/16/25, indicated, .Polysubstance abuse.Refer to Psych eval.Monitor behavior.Supportive care.Review of Resident 1's Office Visit, dated 9/17/25, indicated, .Office Visit.Pending Psych eval.Monitor behavior.Drug screen ordered.Review of Resident 1's Office Visit, dated 10/28/25, indicated, .Office Visit.Monitor behavior.Review of Resident 1's Office Visit, dated 11/3/25, indicated, .Office Visit.Opiate dependence.Pending Psych eval.Monitor behavior.Review of Resident 1's Office Visit, dated 11/4/25, indicated, .Office Visit.Monitor behavior.Rash possible allergic reaction.Review of Resident 1's Office Visit, dated 12/4/25, indicated, .Office Visit.Monitor behavior.Monitor Vitals.fall precautions.Record review of Resident 1's IDT Team Investigation, dated 7/21/25, indicated, .Resident tested positive on UDS [urine drug screen] reported on 7/18/2025.attempted to ask resident where he got his illicit drugs, resident immediately became agitated, started yelling for staffs to get out of his room. Resident stated he only did cocaine once and has been taking cannabis for a long time and will not stop taking cannabis.Record review of Resident 1's IDT Team Investigation, dated 8/20/25, indicated, .Resident tested positive again for cannabis on 8/20/25.Per resident he has been taking cannabis for 13 yrs. and will not stop just because a doctor told him to.Record review of Resident 1's IDT Team Investigation, dated 9/26/25, indicated, .resident tested positive for cannabis on 9/24/25.Per resident, he does not want to stop cannabis.Behavior remains the same, agitated at times and yells at the staffs during care.Record review of Resident 1's IDT Team Investigation, dated 12/8/25, indicated, .team started investigation on positive cannabis UDS result on 12/5/25.Resident stated he does not even smoke the cannabis, he only eats it through edibles [edible forms of cannabis].Record review of Resident 1's Progress Notes, dated 7/21/25 at, indicated, .IDT NOTE.Positive lab results for Narcotics (cocaine, cannabinoids) .Resident agreed to follow facility protocol and policy.IDT RECOMMENDATIONS.Drug test as needed upon suspicion of being under the influence. Monitoring of suspicious behavior.Record review of Resident 1's Progress Notes, dated 7/24/25, indicated, .Resident was seen by MD for PRN [as needed] visit following resident & family member's request to see MD regarding pain medication [discontinued due to] positive UDS result for cocaine & cannabis. Patient teaching was done by MD regarding risk of overdose if resident continues to take illicit drugs.Record review of Resident 1's Progress Notes, dated 12/26/25, indicated, .Resident was seen by MD during routine visit following resident's positive UDS for cannabis on 12/5/25.MD explained to resident that taking recreational drugs might impose a risk to resident if taken alongside methadone. MD stated he will refer resident to pain specialist for pain management but before finishing his sentence, resident cut MD off by stating I don't want to hear anything.During a record review of Resident 1's Care Plan, in the section titled focus initiated on 6/7/25, indicated, .The resident has a behavior problem (aggressive). The section titled Interventions, indicated, .Refer to psych services as needed per MD.During a record review of Resident 1's Care Plan, in the section titled focus initiated on 7/21/25, indicated, .Resident is a long-term resident in the facility. The section titled Interventions, indicated, .Possible referral for psychological services to assist in adjustment to change in functional abilities and assist staff with appropriate behavioral intervention.During a record review of Resident 1's Care Plan, in the section titled focus initiated on 7/23/25, indicated, .History of substance use disorder and drug seeking behaviors. The section titled Interventions, indicated, .Discuss the risks of substance misuse and overdose, use a clear consistent approach from all staff, avoid confrontation, remain calm and nonjudgemental, inform MD for any S/S of overdose, perform urine drug screen for suspected use of illegal substances.During a record review of Resident 1's Care Plan, in the section titled focus initiated on 12/27/25, indicated, .Resident has ep. [episode] Of non-compliance w/UDS. The section titled Interventions, indicated, .Document each refusals for urine drug screen.Provide patient teaching about importance of UDS.A review of facility's undated policy titled, Pain Assessment and Management, indicated, .When opioids are used for pain management, the resident is monitored for medication effectiveness.Any resident who uses opioids for long-term management of chronic pain is at risk for opioid overdose.A review of facility's undated policy titled, Visitation, indicated, .Our facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility.Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security and/or rights of the facility's residents such as.denying access or providing supervised visitation to individuals who have a history of bringing illegal substances into the facility which places residents health and safety at risk.

Based on observation, interview, and record review, the facility failed to accommodate the needs for one out of three sampled residents (Resident 1), when Resident 1's call light (device used to contact staff for assistance) was not within Resident 1's reach.This deficient practice placed Resident 1 at increased risk for unmet care needs, delayed staff response, and potential for accidents or injury.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including senile degeneration of the brain (age-related changes in the brain that cause memory and thinking problems), parkinson's disease with dyskinesia (a brain condition that causes shaking, slow movement, stiffness, and balance problems, along with extra, uncontrolled movements that are often caused by Parkinson's medications), unspecified dementia (memory and thinking problems that interfere with daily life), chronic obstructive pulmonary disease (a long term lung disease that makes it hard to breathe), palliative care (care focused on comfort and relief from pain or symptoms during serious illness), depressive disorder, fracture right femur (break in the right thigh bone).During a concurrent observation and interview on 1/2/26, at 10:30 AM, with Resident 1, in Resident 1's room, Resident 1's call light was observed hanging from the left-side of the bed rail down to the floor. Resident 1 stated that she could not find her call light and that without the call light, staff would not be able to come right away if help was needed.During a concurrent observation and interview on 1/2/26, at 10:45 AM, with Certified Nurse Assistant (CNA) 1, in Resident 1's room, CNA 1 confirmed the call light was not in the proper place because it was hanging from the left side of the bed rail to the floor. CNA 1 stated that if Resident 1 tried to reach the call light, Resident 1 could fall. During a concurrent observation and interview on 1/2/26 at, 10:52 AM, with Licensed Nurse (LN) 1, in Resident 1's room, LN 1 confirmed the call light was not within Resident 1's reach because it was hanging from the left side of the bed rail to the floor. LN 1 stated that Resident 1 would not be able to get help right away if the call light was not within reach, which created a safety risk and could result in a fall.During an interview on 1/2/26, at 4:23 PM, with the Director of Nursing (DON), the DON stated that residents' call lights should always be within a resident's reach. The DON further stated that if a call light was not within reach, the resident was at risk for a fall. Review of Resident 1's Care Plan, revised on 12/12/25, in the section titled, Focus, indicated, .Unwitnessed fall. In the section titled, Interventions, indicated, .Keep call light within reach.Review of Resident 1's Care Plan, initiated on 12/17/25, in the section titled, Focus, indicated, .Fracture to right femur. In the section titled, Interventions, indicated, .Keep call light within reach.Review of the facility policy and procedure (P&P) titled, Answering the Call Light, revised 9/2022, indicated, .Ensure the call light is accessible to the resident when in bed.

Based on interview, and record review, the facility failed to submit a summary of investigation of an alleged unusual incident/injury report to the Department within five (5) working days, as required, following a fracture incident for one of three sampled residents (Resident 1).This failure placed Resident 1 at potential risk for further injury. Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 under hospice care (comfort focused care for people who are seriously ill) with diagnoses including senile degeneration of the brain (age-related changes in the brain that cause memory and thinking problems), parkinson's disease with dyskinesia (a brain condition that causes shaking, slow movement, stiffness, and balance problems, along with extra, uncontrolled movements that are often caused by Parkinson's medications), unspecified dementia (memory and thinking problems that interfere with daily life), chronic obstructive pulmonary disease (a long term lung disease that makes it hard to breathe), palliative care (care focused on comfort and relief from pain or symptoms during serious illness), depressive disorder, fracture right femur (a break in the right thigh bone).Review of Resident 1's UNUSUAL INCIDENT/INJURY REPORT, dated and submitted to the Department on 12/16/25 by the Director of Nursing (DON), indicated that on 12/12/25 at 1:40 AM, Resident 1 was found sitting on the floor with no visible injury noted upon assessment. The UNUSUAL INCIDENT/INJURY REPORT, further indicated that on 12/15/25, Resident 1 underwent an X-ray (an imaging test that takes pictures of bones) due to right hip pain, which revealed a subacute fracture of the right femoral neck (healing or not new break in the upper part of the thigh bone near the hip).Review of Resident 1's X-ray results, dated 12/15/25, indicated, .SIGNIFICANT FINDINGS.RIGHT Hip X-Ray.Subacute fracture of the right femoral neck.During an interview on 1/2/26, at 9:38 AM, with the DON, the DON stated that she forgot to submit the summary of investigation of an alleged unusual incident/injury involving Resident 1 to the Department. The DON further stated that she was aware of the requirement to submit the report within five (5) working days.During a subsequent interview on 1/2/26, at 4:23 PM, with the DON, the DON stated that the purpose of the summary of the investigation for an alleged unusual incident or injury was to identify the root cause of the incident, share findings with staff through in-service education, and plan and implement appropriate interventions. The DON further stated that without the summary of investigation, interventions for the reported incident would not be implemented. Review of an undated facility policy and procedure (P&P) titled, Accidents and Incidents-Investigating and Reporting, indicated, .The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.

Based on observation, interview, and record review the facility failed to provide food storage, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 93 residents who ate facility prepared meals when:1. Four sheet pans (sheet pan, a flat, rectangular metal pan with a raised rim on all four sides, used in ovens for baking, roasting, and broiling foods) were found with dark brown build-up; and,2. A food item (pie) in the freezer was not labeled with a use-by date and expiration date.These failures had the potential to expose 93 residents to foodborne illnesses (illnesses caused by the ingestion of contaminated food or beverages).Findings: 1. During a concurrent observation and interview conducted during the initial tour of the kitchen with the Dietary Supervisor (DS) on 12/19/25 at 10:47 a.m., a stack of four large sheet pans was observed stored in the clean rack, stacked on top of one another. Dark brown buildup was noted on the raised rims of all four sheet pans. The DS confirmed the finding. The DS stated that some of the sheet pans were old and required more thorough scrubbing. The DS further stated it was not acceptable when sheet pans were not washed properly, as residents consuming food prepared on those sheet pans could potentially be exposed to foodborne illness. The DS stated that he expected staff to scrub the sheet pans properly; however, his expectations were not met by dietary staff.During an interview on 12/19/25 at 12:16 p.m., the Dietary Aide (DA) stated that if dishes and pans were not completely cleaned, old food particles could come off into food, and residents could become ill from consuming contaminated food.During a concurrent observation and interview of the sheet pans conducted on 12/19/25 at 12:49 PM the Dietary Supervisor Assistant (DSA) stated that bacteria and mold could grow on those sheet pans and that anyone consuming food cooked on those pans could potentially develop foodborne illnesses. The DSA also stated that she checked all dishes, including sheet pans, and she did not know how she missed those items.During an interview on 12/19/25 at 1:07 p.m., the Dietary [NAME] (DC) explained the dishwashing process, and stated that all remaining food items were first removed from dishes, including sheet pans. The DC stated all dishes and pans were then scrubbed thoroughly with soap and water to ensure no food build up remains, rinsed with water, and placed in the dishwasher, and after washing, dishes were air-dried and then placed on the clean racks. The DC stated that when sheet pans were noticed to not be properly clean, the entire process would be repeated to ensure the items were clean and safe for use. The DC further stated that if food particles remain on dishes or pans, it would be unsafe for residents to consume food prepared and cooked in those items and could cause residents to become ill. During an interview on 12/23/25 at 2:26 p.m., the Assistant Director of Nursing (ADON) stated that it was not acceptable for dishes to be inadequately cleaned and that there was a risk of foodborne illness associated with consuming food prepared using improperly cleaned dishes.Review of the facility provided policy and procedure (P&P) titled, Sanitation, dated 2023 indicated, .The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food. PROCEDURE. 11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair. The facility's P&P was not followed. According to the Food and Drug Administration (FDA) Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces required, . EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. 2. During a concurrent observation and interview conducted on 12/19/25 at 10:42 a.m., during the initial kitchen tour with the Dietary Supervisor (DS), an opened box of (brand name) pie was observed with an open date of 12/11/25; however, it did not have a use-by ( the last day a food is recommended for consumption, meaning you should not eat it after this date) date, or expiration date. The item was located on the left side shelf inside the freezer near the door. The DS confirmed the finding and stated the pie had been left over from Christmas dinner held several days prior. The DS acknowledged that the pie should have been labeled with a use-by date and that the date was missing. The DS further stated that serving food past its use-by date was unsafe and could result in foodborne illness, posing a risk to residents and anyone consuming the product.During an interview on 12/19/25 at 1:07 p.m., the Dietary [NAME] (DC) stated that all food items stored in kitchen storage areas and other food preparation locations were required to be labeled with an open date, preparation date, use-by date, and expiration date to ensure residents' safety.During an interview on 12/23/25 at 2:26 PM, the Assistant Director of Nursing (ADON) stated food items should be labeled properly with all dates. ADON added residents might get foodborne illnesses from eating unlabeled foods. Review of the facility provided policy and procedure (P&P) titled, LABELING AND DATING OF FOODS, dated 2023, indicated, POLICY: All food items in the storeroom, refrigerator and freezer need to be labeled and dated. PROCEDURE. Newly opened food items will need to be closed and labeled with an open date and used by date that flows the. Freezer Guidelines. Food items will be dated with receive date, open date and use by date. The facility P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure the use of supplemental oxygen was provided in accordance with professional standards of practice for two out of three sampled residents who received oxygen therapy (Resident 2, and Resident 3) when, oxygen in use signage was not posted at Resident 2's, and Resident 3's doorway.This failure had the potential to result in negative impacts on the health and safety of Resident 2, Resident 3, other residents in the facility, staff, and visitors.Findings:a. Review of Resident 2's admission RECORD indicated Resident 2 was admitted to the facility with diagnoses which included chronic atrial fibrillation (a persistent, long term irregular heart rhythm with symptoms including shortness of breath).Review of Resident 2's current order summary report indicated an active physician order dated 12/17/25 for oxygen therapy at 2 L/min (liter per minute, a unit of measure) via nasal cannula (two prongs that fit into the nostrils to deliver supplemental oxygen), to be administered as needed for shortness of breath, labored breathing.During an interview on 12/19/25 at 3:16 p.m., Licensed Nurse (LN) 3 stated Resident 2 was prescribed oxygen at 2 liters per minute via concentrator (a medical device that delivers concentrated, purified oxygen) as needed for shortness of breath. LN 3 further stated Resident 2 had diagnosis of atrial fibrillation and orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down), which required oxygen use for episodes of shortness of breath.During an observation on 12/19/25 at 3:11 p.m., Resident 2 was observed in a lying position in bed with an oxygen concentrator positioned on the floor to the right side of his bed; however, no Oxygen in Use signage was observed posted on Resident 2's doorway.During an observation on 12/23/25 at 8:40 a.m., Resident 2 was observed in his room receiving oxygen without Oxygen in Use signage posted on Resident 2's doorway.During a concurrent observation and interview at Resident 2's room on 12/23/25 at 8:50 a.m., Certified Nurse Assistant (CNA) 3 confirmed Resident 2 was receiving oxygen at 2 liters per minute via concentrator and confirmed that no oxygen in use signage was posted on his doorway. CNA 3 explained the importance of oxygen in use signage, stating it was necessary to prevent fire hazards and to alert staff, residents, and visitors that oxygen was being used in the room.During an interview on 12/23/25 at 10:26 a.m., LN 2 stated the purpose of posting oxygen in use signage was to alert nursing staff that the resident was receiving oxygen, to ensure resident safety and prevent fire hazards. LN 2 stated it was the responsibility of nursing staff to post oxygen in use signage when there was an active physician order for oxygen therapy. LN 2 further stated that nursing staff were expected to ensure oxygen in use signage was posted on the doorway of any resident receiving oxygen at the facility.b. Review of Resident 3's admission RECORD indicated Resident 3 was admitted to the facility with diagnoses which included unspecified combined systolic and diastolic congestive heart failure (a condition where the heart struggles to pump blood effectively, affecting both its ability to squeeze and relax), and chronic total occlusion of coronary artery (a complete blockage of a heart artery caused by severe buildup, leading to reduced blood flow, shortness of breath, chest pain, and fatigue.Review of Resident 3's current order summary report indicated an active physician order dated 11/24/25 for oxygen therapy at 2 L/min via nasal cannula, to be administered as needed for shortness of breath and/or comfort.During an observation in Resident 3's room on 12/19/25 at 3:14 PM Resident 3 was noted lying in his bed while receiving oxygen therapy at 2 L/min via an oxygen concentrator. No oxygen in use signage was observed posted on Resident 3's doorway.During a concurrent observation and interview on 12/19/25 at 3:16 p.m., in Resident 3's room Licensed Nurse (LN) 3 confirmed that Resident 3 was receiving oxygen at 2 L/min via an oxygen concentrator for shortness of breath.During a subsequent observation on 12/23/25 at 8:40 a.m., no oxygen in use signage was observed posted on Resident 3's doorway.During a concurrent observation and interview at Resident 3's room on 12/23/25 at 8:50 a.m., Certified Nurse Assistant (CNA) 3 confirmed that no Oxygen in Use signage was posted on Resident 3's room doorway. CNA 3 also confirmed that Resident 3 was receiving oxygen via an oxygen concentrator. CNA 3 explained that Oxygen in Use signage should be posted to alert staff, visitors, and residents that oxygen was in use in the room to maintain safety and prevent potential fire hazards.During an interview on 12/23/25 at 10:49 a.m., the Director of Staff Development (DSD) confirmed that nurses were responsible for posting oxygen in use signage on residents' doorways when oxygen was being used to prevent fire hazards and to meet residents' needs.During a concurrent interview and record review on 12/23/25 at 2:26 p.m., with the Assistant Director of Nursing (ADON) the facility provided policy and procedure (P&P) titled Oxygen Administration, revised September 2022, was reviewed. The ADON explained the purpose of oxygen in use signage, stating it was important to post signage on the doorway of rooms where residents were receiving oxygen as a safety precautions. The ADON stated that when there was an order for oxygen therapy, nurses were responsible to ensure oxygen in use signage was posted on the resident's doorway. The ADON stated it was necessary to post oxygen in use signage on Resident 2's and Resident 3's doorway to alert staff, residents, and visitors that oxygen was being used in the room to prevent fire hazards. The ADON further stated she expected nurses to post oxygen in use signage immediately upon receiving and implementing an order for oxygen therapy, and stated this expectation was not met by nursing staff.Review of the facility's P&P for oxygen administration indicated, . The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation. 3. Assemble the equipment and supplies as needed. Equipment and Supplies. 4. No Smoking/Oxygen in Use signs. Steps in the Procedure. 2. Place an Oxygen in Use sign on the outside of the room entrance door. The ADON acknowledged that the facility's P&P was not followed.

Based on interview, and record review, the facility failed to provide adequate supervision and ensure an accident-free environment for one of three sampled residents (Resident 103) when, Resident 103 fell while left unsupervised and partially secured in her gurney, in a transportation vehicle during transportation to a dialysis clinic (outpatient facility that provides dialysis treatment to residents with end-stage renal disease (ESRD) or chronic kidney failure, helping to clean their blood of waste and excess fluid when their kidneys cannot) on 7/3/25.This failure potentially resulted in Resident 103 sustaining a mild compression fracture (when the bone is crushed or compressed but not completely broken) in the L3 (the third lumbar vertebra (bone) in the spine located in the lower back that supports body weight).Findings:A review of Resident 103's admission RECORD, indicated Resident 103 was admitted to the facility in 2021 with diagnoses which included chronic pain, hemiplegia and hemiparesis (weakness or paralysis on one side of the body) following cerebral infarction (a medical condition where blood flow to the brain is interrupted, leading to tissue damage or death) affecting the left non-dominant side, dependence on renal dialysis (a person's life relies on regular dialysis treatments to sustain life because their kidneys have lost most or all of their function), functional quadriplegia (a person is unable to move all four limbs due to severe disability or frailty, but without any underlying physical injury or damage to the spinal cord), and aphasia (a language disorder that affects a person's ability to communicate effectively due to damage to the area in the brain responsible for language processing).A review of Resident 103's nursing care plan, .ADLS [Activities of Daily Living; tasks necessary for basic personal care and independent living ] . dated 10/21/21, indicated, .Focus: Resident has self-care deficit d/t [due to] left sided weakness .Requires 1-2-person dependent assistance [require total physical assistance from another person].Goal: Will be assisted by staff in performing ADLs which cannot be met by resident.Interventions: Monitor for any decline in ADL function.A review of Resident 103's nursing care plan, dated 6/15/25, indicated, .Focus: Resident requires safe and coordinated transport to/from medical appointments.Goal: Resident will be transported safely with no injury or adverse event.Interventions: Provide safety belts, positioning devices, and blankets as needed .A review of Resident 103's Progress Notes with the following dates and times indicated the following:1. 7/3/25, at 1 p.m., .VS WNL [vital signs such as blood pressure, heart rate, respiratory rate and temperature are within normal limits]. No new skin changes noted. Resident left to dialysis.2. 7/3/25, at 2:03 p.m., .Received call from dialysis that resident was sent to [name of hospital] due to resident having a fall in van and running a fever of 105.3. 7/3/25, at 6:36 p.m., .resident in hospital.4. 7/4/25, at 1:54 a.m., .Spoke to ER [emergency room] nurse.as per nurse resident on ATB [antibiotic; a medication used to fight off bad bacteria] for UTI [urinary tract infection; an infection in any part of the urinary system which includes the kidneys, ureters, bladder and urethra].5. 7/6/25 at 8:16 a.m.hospitalized .6. 7/7/25, at 1:28 p.m., .[General Manager (TRM 2)] expressed his plan of correction and apologized for the driver not following protocol.[name of transportation company] informed that the driver will be terminated [fired] and not following procedure of securing resident in the transport van.7. 7/18/25, at 7:14 p.m., Resident arrived at the facility around 16:22 [4:22 p.m.] via Stretcher from [hospital].DX [diagnosis] of UTI with sepsis [a serious condition in which the body responds improperly to an infection].8. 7/22/25, at 7:48 p.m., .Results received via fax. Resident is noted [with] mild compression [fracture] in L3.A review of Resident 103's emergency department (ED) records titled, ED Note - Physician, dated 7/3/25, the record indicated, .CHIEF COMPLAINT: BIBA [brought in from ambulance] from [name redacted] dialysis center. Pt [patient] resides at [name of skilled nursing facility]. Fever. HISTORY OF PRESENT ILLNESS: Patient.with history of chronic kidney disease on dialysis, nonverbal from previous CVA [cerebral vascular accident; also known as a stroke which is a medical condition where blood flow to the brain is disrupted, causing brain tissue damage] brought in by ambulance from [name of skilled nursing facility] for evaluation of fever, per report from EMS [Emergency Medical Services] patient had a maximum temperature of 102 at the facility.Patient unable to give adequate history because she is nonverbal [unable to speak] from previous CVA. There was no mention of Resident 103's fall from the gurney in the ED Note.A review of Resident 103's clinical record written by Resident 103's primary physician titled, Office Visit, dated 7/22/25, indicated .Family requesting Xray.Recent gurney [a medical stretcher on wheels for transporting residents] fall to ground patient complaining of increase pain in hip knee.Plan of care.Xray ordered.A review of Resident 103's clinical record titled, Radiology [specializes in the use of imaging techniques to diagnose and treat diseases] Interpretation, dated 7/22/25, indicated .LUMBER SPINE 2-3 View [an X-ray (imaging that takes pictures of the inside of your body) study of the lower back that includes two to three different images taken from specific angles]: Mild compression fracture in L3.Review of Resident 103's Nurses Note, dated 7/23/25, the record indicated, .Resident was see by MD [medical doctor] on 7/22. X-ray reviewed, resident was noted w/ [with] compression fx [fracture] on L3.MD instructed writer to f/u [follow-up] w/ [name of doctor redacted, Resident 103's primary physician] on treatment secondary to L3 compression fx findings.During an interview on 7/27/25, at 11:29 a.m., Certified Nursing Assistant (CNA) 5 stated Resident 103 was on total care (resident reliant on staff to meet all needs) on 7/3/25. CNA 5 stated during the transport to the dialysis clinic on 7/3/25, Resident 103 was secured on the gurney with two out of three safety belts. CNA 5 explained, Resident 103 was secured by two safety belts; one was around the hip and the second one around the legs. CNA 5 stated Resident 103 was not secured by the safety belt around the chest area. CNA 5 stated she did not know if Resident 103 needed to have a safety belt secured in place around the chest area. CNA 5 stated instead of sitting in the back seat of the transportation van she sat in the front seat next to the driver. CNA 5 stated during transportation inside the transportation van Resident 103 was sitting upright in the gurney with her head elevated. CNA 5 stated on the way to the dialysis clinic, when the van made a left turn, she heard a sound. CNA 5 stated she turned around to look at the back of the van and saw Resident 103's upper body was out of the gurney while Resident 103's leg was still secured in the gurney. CNA 5 stated Resident 103 had rolled halfway from the gurney to the van floor. CNA 5 stated the driver of the transportation van stopped the vehicle and both the driver and CNA 5 went to the back of the van and put Resident 103 back in the gurney. CNA 5 stated when she placed Resident 103 back in the gurney Resident 103 had no safety belt secured around her chest area. CNA 5 further stated that upon arrival at the dialysis clinic she notified Licensed Nurse (LN) 9 (nurse whom worked at the dialysis clinic) that Resident 103 fell from the gurney inside the transportation van on the way to the dialysis clinic. CNA 5 stated LN 9 took Resident 103's temperature and notified CNA 5 that Resident 103 had to go to the emergency room due to a high temperature and the fall from the gurney. CNA 5 stated she should have checked that Resident 103 had a safety belt secured in the chest area. CNA 5 stated since she sat in front of the transportation van she did not have direct visual of Resident 103. CNA 5 stated she should have had visual of Resident 103 the whole-time during transportation. CNA stated the risk of not checking the safety belts fastened resulted in Resident 103 falling from the gurney. CNA 5 stated Resident 103 could have injured her head from the fall.During an interview on 8/27/25, at 12:07 p.m., the Staffing Coordinator (SC) stated CNA 5 had notified her that Resident 103 fell out of the gurney inside the transportation van during transportation to dialysis clinic on 7/3/25. The SC stated she had transported residents on a gurney in the past and there was a seat in the back of the van next to the gurney for the staff to sit. The SC stated she had sat in the back seat of the van next to the gurney to make sure residents were safe during transportation. The SC stated she had made sure that all safety belts were properly fastened around the resident and prevented residents from falling. The SC stated in the past she would have a licensed nurse check with her that all safety belts were fastened.During an interview on 8/27/25, at 12:48 p.m., Transportation Driver (TR, from a contracted transportation company) 1 stated nurses did a safety check before he took residents out for appointments in the transportation van.During a phone interview on 8/27/25, at 1:31 p.m., Responsible Party (RP) 1 stated the facility notified him that Resident 103 had a back fracture from a fall that happened during transfer to Dialysis Clinic on 7/3/25. RP 1 stated Resident 103 was in pain and crying and grimacing more after the fall. RP 1 stated the expectation that all the safety belts were safely secured in the gurney during Resident 103's transportation in the van. RP 1 stated he felt frustrated that a staff member was not sitting next to Resident 103 during transfer since Resident 103 was immobile. RP 1 stated if all safety belts were fastened and a staff member sat next to Resident 103 then she would not have fallen and got injured.During an interview on 8/28/25, at 8:49 a.m., LN 7 stated before a resident left for appointments the LN took residents vital sign and made sure all three safety belts were properly secured. LN 7 stated the CNA assisted with transferring residents to the gurney from their bed. LN 7 stated there were three safety belts on the gurney, one for the chest area, one for the hip and the third for the leg. LN 7 stated she did not let the residents transport in the van if one of the safety belts was missing. LN 7 stated the resident could fall and get injured if one of the three safety belts was not secured. LN 7 stated the Director of Nursing (DON) had given in-service to staff to take precautions and safe transfer of residents for appointments.During an interview on 8/28/25, at 9:08 p.m., LN 6 stated the LN and CNA transferred residents from their bed to the wheelchair or gurney. LN 6 stated the LN made sure that all three safety belts were properly secured before a resident left facility for appointment. LN 6 stated there were three safety belts on the gurney, one for chest, one for hip area and one for legs. LN 6 stated residents could fall and get injured if safety belts were missing or not properly secured.During a phone interview on 8/28/25, at 10:05 a.m., the Office Manager (TRM, from a contracted transportation company) 1 stated the transportation van that was used to transfer Resident 103 had a gurney with three safety belts, one for the chest area, one for the hip and one for the legs. TRM 1 stated the transportation van driver was trained to safely secure all three safety belts when transferring residents on a gurney. TRM 1 stated the risk of not having all safety belts secured is resident could fall and get injured.During a phone interview on 8/28/25, at 10:46 a.m., the General Manager (TRM, from a contracted transportation company) 2 stated the driver of the transportation van was fired because the driver did not make sure the aid (CNA 5) sat in the back seat of the van with Resident 103. TRM 2 stated there was a seat at the back of the transport van for a staff member to sit close to Resident 103 for safety. TRM 2 stated CNA 5 sat in the front passenger seat next to the driver of the van during transportation. TRM 2 stated the camera from the van showed when the van made a left turn, Resident 103 rolled from the gurney over to her left side and landed on the floor. TRM 2 stated the driver of the van should have insisted CNA 5 to sit in the back seat with Resident 103 to make sure Resident 103 was safe and secured and did not fall.During an interview on 8/28/25, at 1:23 p.m., Transportation Driver (TR, from a contracted transportation company) 2 stated facility staff always checked and made sure residents were secured in their wheelchair before they were picked up for appointments.During an interview on 8/28/25, at 1:26 p.m., LN 4 stated before a resident left for appointment the LN made sure all three safety belts on the gurney were fully secured. LN 4 stated there were three safety belts, one on the chest, one on the hip and one on the leg. LN 4 stated the LN stayed with the resident until the resident got into the transportation van. LN 4 stated a CNA accompanied residents for the appointments to make sure residents were taken care of. LN 4 stated residents could fall when safety belt was not secured.During an interview on 8/28/25, at 1:26 p.m. and 2:22 p.m., CNA 6 stated she had gone to appointments in a transportation van with a resident who was on a gurney. CNA 6 stated she made sure that all three safety belts on the gurney were secured. CNA stated there were three safety belts, one for the chest area, one for the hip and one for the leg. CNA 6 stated to make sure residents did not fall she sat on the back seat in the transportation van so she could visually see the resident during transportation. During an interview on 8/29/25, at 8:42 a.m., the Social Services Director (SSD) stated CNA 5 had gone to an appointment with Resident 103 in a transportation van. The SSD stated there was a seat on the back of the vehicle next to the gurney. The SSD stated CNA 5 had to sit on the back seat of the van next to Resident 103 and had to make sure Resident 103 was safe and her needs were taken care of. The SSD stated CNA 5 did not sit on the back seat and did not make sure all three safety belts were secured. The SSD stated Resident 103 fell inside the transportation van and was sent to the hospital.During an interview on 8/29/25, at 10:42 a.m., the Director of Nursing (DON) stated a CNA from the facility was with Resident 103 when Resident 103 fell during transportation in the transportation van. The DON stated instead of sitting in front passenger seat, the CNA was supposed to sit in the back seat and always have visual on Resident 103. The DON stated the expectation was for the staff to make sure Resident 103 was safe and secured in the gurney. The DON stated when staff did not always have visual of the resident during transportation accidents could happen and residents could fall. The DON stated the facility staff were responsible for ensuring all three safety belts were fastened on the gurney to prevent any fall or injuries.During an interview and concurrent record review on 8/29/25, at 10:58 a.m., LN 1 stated Resident 103 had a chest x-ray done on 7/3/25 while in the hospital. LN 1 stated Resident 103 came back to the facility from the hospital on 7/18/25. LN 1 stated the x-ray for chest showed Resident had an infection. LN 1 stated on 7/22/25 the facility received x-ray results for Resident 103's lumbar spine and the x-ray result showed mild compression fracture of L3. LN 1 stated Resident was given pain medication for pain.During an interview on 8/29/25, at 11:43 a.m., LN 5 stated Resident 103's baseline vital sign was stable on 7/3/25 and she had double checked to make sure all three safety belts were secured before resident 103 left facility in transportation van for her appointment. LN 5 stated the transportation van driver, and the CNA had transferred Resident 103 from her bed to the gurney under LN 5's supervision. LN 5 stated that after all safety belts were secured, she walked to the front of the facility building with the CNA. LN 5 stated she waited outside the facility until the transportation van left. LN 5 stated CNA 5 went with Resident 103. LN 5 stated she did not remember where CNA 5 sat. LN 5 stated Resident 103's hands and legs were contracted, and Resident 103 could not take safety straps off by herself. LN 5 stated Resident 103 was totally dependent on care including needing assistance to eat. LN 5 stated an hour after Resident 103 left the facility she received a call from the dialysis clinic that Resident 103 was being sent to the hospital because Resident 103 fell in the transportation van and she was running a fever.During an interview on 8/29/25, at 12:11 p.m., the Medical Doctor (MD) stated the expectation was to have the CNA to always have visual on Resident 103 during transportation. The MD stated anything could have happened when the CNA did not have visual on the resident.During an interview on 9/2/25, at 3:20 p.m., LN 9 (nurse employed at the dialysis clinic) stated on 7/3/25 CNA 5 had notified her that Resident 103 had a fall during transportation to the Dialysis clinic. LN 9 stated Resident 103 ‘s skin was warm to touch, and her temperature was 100.2 F (Fahrenheit, a unit of temperature measurement). LN 9 stated she tried to call the doctor, and the doctor did not answer so she called 911 and had the paramedics (highly trained prehospital care providers who assess, stabilize, and treat patients experiencing medical emergencies or traumatic injuries before they reach a hospital) take Resident 103 to the hospital.During a concurrent interview and record review, on 9/12/25, at 4:28 p.m., Resident 103's hospital electronic medical record was reviewed with the Quality Assurance Director (QAD, employed by the hospital Resident 103 went to after the incident). The QAD confirmed Resident 103 did not have a fall while in the hospital from the date of admittance of 7/3/25 through the discharge date of 7/18/25. The QAD stated Resident 103's emergency room visit notes and ambulance report did not contain documentation regarding Resident 103's fall from the gurney prior to arrival at the emergency room. Review of an undated facility policy titled, Safety and Supervision of Residents, the policy indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Resident supervision is a core component of the systems approach to safety.risk factors and environmental hazards include the following: a. Bed safety.falls.Review of an undated facility policy titled, Fall Risk Assessment, the policy indicated, .The staff will seek to identify factors that may contribute to falling .Review of an undated facility policy titled, Transportation, Diagnostic Services [medical tests, examinations, and procedures used to identify or diagnose a health condition], the policy indicated, .A member of the nursing staff, or social services, will accompany the resident to the diagnostic center when the resident's family is not available. The nursing staff must always monitor and seat next to the residents .The nursing staff must check if residents are strapped in their seats, safe and secure.Review of the facility staff job descriptions titled, Certified Nursing Assistant, dated 2003, the document indicated, .Make resident comfortable.Assist in transporting residents to/from appointments.Assist with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, bathtubs, wheelchairs, lifts etc.Ensure that residents who are unable to call for help are checked frequently.Assist with the application of slings, elastic bandages, binders, etc. [et cetera; and other similar things].Follow established safety precautions in the performance of all duties.

Based on interview and record review, the facility failed to implement and maintain a comprehensive QAPI (QAPI- a data driven and proactive approach to improvement used to ensure services are meeting quality standards) program and plan when the facility did not adhere to its QAPI policy and did not provide documentation or evidence of ongoing QAPI activities.These failures had the potential to impede the facility's ability to identify and correct quality of care issues which could place the residents at risk for unmet physical, psychosocial, and overall health needs.Findings:During a concurrent interview and record review on 8/29/25, at 1:55 PM, the Administrator (ADM) reviewed the QAPI program and confirmed that they did not have an appropriate monitoring and documentation portion of the QAPI program. Review of the QAPI binder showed no evidence of detailed monitoring, follow-up, or documentation of QAPI activities. The ADM acknowledged that documentation of the QAPI program should have been completed and confirmed the program lacked sufficient details and follow-through. The ADM also acknowledged that the QAPI policy was not comprehensive, required revision, and lacked clear guidelines for implementation. Furthermore, the ADM confirmed that while the committee had been meeting on a quarterly basis, the facility was not following its QAPI policy.During a review of an undated facility policy and procedure titled, Quality Assurance and performance Improvement (QAPI) Program, indicated, .Key components of this process include: a. tracking and measuring performance.f. monitoring or evaluating the effectiveness of corrective actions/performance improvement activities, and revising as needed. 3. The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan when:A care plan was not developed for Resident 62's face and neck swelling; and,Resident 102's care plan intervention for two person assist with activities of daily living (ADL, skills required for self-care and independent living, including bathing, dressing, toileting, transferring, continence, and feeding) care was not followed.These failures resulted in Resident 62 not having interventions and goals for his face and neck swelling and the potential for injury to Resident 102, negatively impacting Resident 62 and Resident 102's health, safety, and well-being.Findings: 1. Review of Resident 62's admission RECORD, indicated Resident 62 was admitted to the facility with diagnoses which included chronic pain (persistent pain that lasts for more than three months) and abdominal pain. During an interview on 8/27/25, at 11:25 AM, with Resident 62, Resident 62 stated he was not happy with the care he received for his face and neck swelling. Resident 62 explained staff did not do anything for the face and neck swelling. Resident 62 further explained he had to tell staff what to do, stating he directed them to get him some ice so he could put it on his face and neck. A review of Resident 62's clinical document titled, Care Plans, indicated Resident 62 did not have a care plan for his face and neck swelling. A review of Resident 62's clinical document titled, Progress Notes, dated 8/16/25, indicated, .@ [at] 0530 [5:30 AM] [Resident 62] complained of swelling with a burning sensation 3/10 [pain level on a 1-10 scale with 10 being the worst pain] to the right side of face and neck. Assessed the site. Skin color normal for ethnicity .Plan of care ongoing . During an interview on 8/28/25, at 11:11 AM, with the Director of Nursing (DON), the DON acknowledged there was not a care plan in place for Resident 62's face and neck swelling. The DON explained care plans were important so residents could get the proper treatment and a plan to resolve the issue. A review of an undated facility policy titled, Care Plans, Comprehensive Person-Centered, indicated, .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 . 2. A review of Resident 102's MDS (Minimum Data Set- a resident assessment and screening tool) Section GG (focusing on functional abilities and goals), dated 8/14/25, indicated Resident 102 required assistance of two (2) or more helpers to roll left and right. A review of Resident 102’s Care Plan initiated on 10/3/18, under the section, Focus, indicated, .the resident has Multiple Sclerosis [MS, a disease that causes breakdown of the protective covering of nerves. Multiple sclerosis can cause numbness, weakness, trouble walking, vision changes and other symptoms] affecting lower extremities. Further review of the document under the section, Interventions, indicated Resident 102 required 2 persons to assist with her ADLs. During an interview on 8/26/25, at 2:16 PM, with Resident 102, Resident 102 stated she was not happy with the care she received while being turned by staff. Resident 102 explained there was only one nursing aide who turned her while providing care. During a phone interview on 8/27/25, at 2:42 PM, with Certified Nursing Assistant (CNA) 3, CNA 3 confirmed that she had turned Resident 102 alone, without the assistance of another staff. During a concurrent interview and record review on 08/28/25, at 10:55 AM, with the Director of Staff Development (DSD), the DSD confirmed that CNA 3 had turned Resident 102 alone, when there should have been two CNAs providing care. The DSD stated it was important to follow Resident 102's care plan to ensure that the resident was receiving proper care, using the correct interventions, and to achieve goals for health conditions. Review of an undated facility policy titled, Repositioning, indicated, .Repositioning the Resident in Bed 1. Check the care plan…to determine resident’s specific positioning needs…and the number of staff required to complete the procedure .

Based on observation, interview, and record review, the facility failed to ensure professional standards of quality care were met for 2 of 32 sampled residents (Resident 83 and Resident 10), with the potential to affect the full census of 92 when: 1. Resident 83's bilateral foot pain was not assessed for over 24 hours after the licensed nurse (LN) was notified,2. Wounds on Resident 10's right forearm were not assessed for over 48 hours; and,3. Staff providing resident care could not communicate in English.These failures resulted in a delayed assessment, treatment, and pain control for Resident 83 and delayed assessment and treatment for Resident 10. In addition, these failures had the potential to negatively affect Resident 83 and Resident 10's health and well-being and had the potential for all residents in the care of non-English speaking staff to have unmet care needs.Findings: 1. A review of Resident 83's admission RECORD, indicated Resident 83 was admitted to the facility with diagnoses which included type 2 diabetes (a disease in which the blood glucose or blood sugar levels are too high) with foot ulcer (an open sore or wound on the foot that results from the breakdown of skin and underlying tissues). During a concurrent observation and interview on 8/26/25, at 10:25 AM, with Resident 83, in Resident 83's room. Resident 83 stated he was concerned about his toes. Resident 83 further stated he had his toenails trimmed on 8/19/25. Resident 83 explained his toenails had been long prior to his appointment and he was starting to get feeling back in his toes. Resident 83 further explained his toes 'really hurt' and the bottom of his feet hurt also. Observation of Resident 83's feet showed two blackened nickel sized areas on each of Resident 83's great toes. Resident 83 stated he had not informed his nurse and stated it was okay for the Department to inform his nurse. During an interview on 8/26/25, at 10:30 AM, with LN 10 (Resident 83's day shift [work hours 6:30 AM to 3 PM] nurse), LN 10 was informed that Resident 83 was experiencing pain in his feet and had blackened areas on his great toes. LN 10 stated she would follow up with Resident 83. During a subsequent interview on 8/27/25, at 9:40 AM, with Resident 83, Resident 83 stated LN 10 never came in to ask him about the pain in his feet and had not spoken to him about his toes. Resident 83 explained his feet and toes were causing him constant pain, at a pain level of 7 (pain scale 1-10 with 10 being the worst pain). Resident 7 further explained the pain, especially in his great toes was keeping him awake at night. During a concurrent observation and interview on 8/27/25, at 9:46 AM, with LN 11 (Resident 83's day shift nurse), LN 11 stated if she had been informed a resident was experiencing pain she would do an assessment. LN 11 explained she would assess the site of pain, do a skin assessment and notify the physician if there were any issues. LN 11 further explained if there were any issues she would carry out any physician orders. LN 11 performed a skin and pain assessment on Resident 83 in Resident 83's room. Resident 83 informed LN 11 that he had a constant pain level of 7 and the bottom of his feet and great toes hurt. LN 11 asked Resident 83 if she could look at his feet, Resident 83 stated yes. LN 11 donned (put on) gloves, lifted the blanket and observed the blackened areas on Resident 83's great toes. LN 11 stated Resident 83 was prone to diabetic ulcers (an open sore or wound, often on the feet, that fails to heal properly due to complications of diabetes). LN 11 further stated LN's did full assessments daily and the blackened areas on Resident 83's great toes should have been noted. LN 11 stated the blackened areas looked like diabetic ulcers. During an interview on 8/27/25, at 9:58AM, with the Director of Nursing (DON), the DON stated her expectations were if a resident had a complaint of pain, it was the LN's responsibility to assess the resident and notify the physician if it was a new onset of pain. The DON explained the certified nursing assistants (CNA) needed to report any skin issues to the LN. During an interview on 8/27/25, at 9:59 AM, with LN 10, LN 10 stated she had not written a progress note regarding Resident 83's foot and toe pain. LN 10 stated she had not looked at Resident 83's toes on 8/26/25. A review of Resident 83's untitled clinical document from the podiatrist's (foot doctor) office, dated 8/19/25, indicated, .Plan .Check feet daily . During a joint interview on 8/27/25, at 2:54 PM, with both LN 11 and LN 12, LN 11 and LN 12 stated they should have known about the podiatry consult from 8/19/25 and should have put in the 'check feet daily' as an order and had not. During an interview, on 8/27/25, at 3:10 PM, with LN 13 (Resident 83's PM shift [work hours 2:30 PM to 11 pm] nurse on 8/26/25), LN 13 stated LN 10 had not informed her of Resident 83's new onset of pain in his feet on 8/26/25, during change of shift. During an interview on 8/27/25, at 3:14 PM, with LN 1, LN 1 stated Resident 83's new onset of pain in his feet should have been reported to the oncoming shift. LN 1 stated informing the oncoming shift was important because Resident 83's feet could have been assessed to rule out infection. LN 1 explained the risk to Resident 83 was his toes could have been infected and could have caused sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection). LN 1 stated since Resident 83's pain and blackened great toes had not been assessed and reported to anyone that there was a delay in care for Resident 83. LN 1 further stated the physician would have wanted to be informed of Resident 83's change in condition. During an interview on 8/27/25, at 3:37 PM, with the DON, the DON stated the process for getting the podiatry notes if the packet did not come back with the resident, was to call podiatry to get the report. The DON explained LNs should have followed up with the podiatry office when Resident 83's packet was not available to carry out physician's orders. The DON further explained when LN 10 was informed of Resident 83's new onset of pain and the blackened areas on his great toes, she should have assessed Resident 83 right away. The DON stated the importance was to prevent pain and infection. The DON stated Resident 83 was at high risk for infection. A review of an undated facility policy titled, Pain Assessment and Management, indicated, .The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain.Acute [sudden] pain (or significant worsening of chronic [long-term] pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. 2. A review of Resident 10's admission RECORD, indicated Resident 10 was admitted to the facility with diagnoses which included depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest). During an observation on 8/26/25, at 10:28 AM, with Resident 10, in resident 10's room, Resident 10 was in bed, appeared to be sleeping, wearing a short-sleeved shirt. Nine dime sized scabs were visible on Resident 10's right forearm. During a record review of Resident 10's Electronic Health Record (EHR), there was no documented evidence of the nine dime sized scabs on Resident 10's forearm being assessed. Further review of the record did not show any progress notes, change in condition, or care plans regarding the nine dime sized scabs on Resident 10's forearm. During a concurrent observation and interview on 8/28/25, at 2:07 PM, with Resident 10, in Resident 10's room, Resident 10 was lying in bed, wearing a short-sleeved shirt, with the nine dime sized scabs on his right forearm with noted red raised areas around the scabs. Resident 10 stated the scabs did not itch but were a little painful. Resident 10 further stated he had had the scabs for about 2 months. During an interview on 8/28/25, at 2:13 PM, with LN 13, LN 13 stated she had not asked Resident 10 about the scabs on his right forearm. During an interview on 8/28/25, at 2:14 PM, with LN 14, LN 14 stated she had observed the scabs but did not ask Resident 10 about the scabs. During a concurrent observation and interview on 8/28/25, at 2:16 PM, with the DON, in Resident 10's room, the DON confirmed the presence of the nine dime sized scabs on Resident 10's right forearm. The DON stated her expectation was for the LNs to write a progress note, do a change in condition, care plan it, and notify the physician and resident representative. The DON further stated the importance was to prevent infection and complications before the areas got worse. A review of an undated facility policy titled, Change in a Resident's Condition or Status, indicated, .Our facility promptly notifies the resident, his or her attending physician.of changes in the resident's [NAME]/mental condition and/or status.The nurse will notify the resident's attending physician.when.discovery of injuries of unknown source.significant change in the resident's physical.condition.A significant change of condition is a major decline or improvement in the resident's status that.will not normally resolve itself without intervention by staff.Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the [physician]. 3. A review of Resident 48's admission RECORD, indicated, he was admitted to the facility in late 2024. A review of Resident 48's minimum data set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) dated 7/18/25, indicated, .Section C-Cognitive Patterns.Brief Interview for Mental Status (BIMS) [a tool used to screen for cognitive impairment]. indicated, a score of 15 points which suggested that cognition was intact. During an interview on 8/26/25, at 10:01 AM, with Resident 48, Resident 48 stated not all of the CNAs who cared for him spoke English or understood what was said to them. Resident 48 stated he could not name the CNAs who did not speak English because there were too many of them. A review of Resident 36's admission RECORD, indicated, she was admitted to the facility in late 2022 with diagnoses which included chronic obstructive pulmonary disease (COPD, lung condition that causes long-term breathing difficulties). A review of Resident 36's MDS dated [DATE], indicated, .Section C-Cognitive Patterns.Brief Interview for Mental Status (BIMS). indicated, a score of 12 points which suggested a moderate cognitive impairment. During an interview on 8/26/25, at 1:06 PM, with Resident 36, Resident 36 stated the staff did not speak English and did not understand her needs. Resident 36 further stated when she required her nebulizer (machine that delivers medication in a fine mist to improve breathing status) the non-English speaking staff just looked at her and did not understand her request. A review of Resident 6's admission RECORD, indicated, he was admitted to the facility in early 2023. A review of Resident 6's MDS dated [DATE], indicated, .Section C-Cognitive Patterns.Brief Interview for Mental Status (BIMS). indicated, a score of 15 points which suggested that cognition was intact. During an interview on 8/26/25, at 3:17 PM, with Resident 6, Resident 6 stated a lot of the staff did not speak English. Resident 6 further stated the non-English speaking staff did not understand his needs. A review of a facility provided document titled, RESIDENTS COUNCIL MEETING, dated 7/29/25, indicated, .Residents had said the CNA's and Nurses continue to talk in their Language and that they can't understand the English residents what they are asking for and that the residents can't understand them. During a telephone interview on 8/27/25, at 12:32 PM, with CNA 3, CNA 3 stated, via [NAME] translator, she worked the night shift because she did not speak English. During a concurrent interview and employee file review on 8/28/25, at 10:55 AM, with the Director of Staff Development (DSD), The DSD stated CNA 3 spoke only basic English. The DSD further stated CNA 3 required a staff member to interpret for her when she had received her orientation and subsequent trainings. During a concurrent interview and record review on 8/29/25, at 8:54 AM, with the Director of Nurses (DON), the DON stated it was her expectation that all staff would be able to communicate with the residents and speak in English. The DON further stated there was a risk to the residents of unmet care needs if the staff could not communicate with them. The DON confirmed the facility's CNA job description indicated staff should be able to speak and read in English. A review of a facility job description titled, Certified Nursing Assistant, dated 2023, indicated, .The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and plan of care.Specific Requirements.Must be able to read, write, speak, and understand the English language. A review of an undated facility policy titled, STAFF COMMUNICATION, indicated, .All nursing staff must adhere to standardized communication practices that support resident safety, continuity of care, and compliance with federal, state, and facility guidelines.

Based on interview, and record review, the facility failed to ensure that physician-ordered weekly weights were completed for 1 out of 3 sampled residents (Resident 43) when Resident 43's weekly weight order was not carried out by staff.This failure resulted in Resident 43 experiencing an unmonitored 10-pound weight loss over one month (from 132 pounds on July 3, 2025, to 122 pounds on August 3, 2025), placing the resident at risk for further nutritional compromise and decline.Findings:Review of Resident 43's admission RECORD, indicated Resident 43 was admitted to the facility with multiple diagnoses including type 2 diabetes mellitus with other specified complication (high levels of sugar in the blood) and paraplegia, unspecified (inability to voluntarily move the lower parts of the body).Review of Resident 43's clinical record titled, .Order Recap Report, (summary listing of a resident's order by the physician), indicated that Resident 43's weight should be monitored weekly as ordered by the physician on 7/1/25 with a start date of 7/7/25. During a concurrent interview and record review on 8/28/25, at 10:38 a.m., with the Restorative Nurse Assistant (RNA 1), Resident 43's medical records were reviewed. RNA 1 confirmed that staff did not follow the doctors' order of monitoring and documenting Resident 43's weight every week.During a concurrent interview and record review on 8/28/25, at 11:22 a.m., with Licensed Nurse (LN 6), Resident 43's Physician orders were reviewed. LN 6 confirmed that Resident 43's medical records contained a physician's order directing staff to check the resident's weight weekly; however, there was no documentation showing the orders were completed by the staff. LN 6 stated that Resident 43's weight loss would have been prevented if the order was followed. During a concurrent interview and record review on 8/28/25, at 10:54 a.m., with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), the ADON and the DON reviewed Resident 43's medical record and validated that staff had not been checking Resident 43's weight weekly as ordered. The ADON and the DON both agreed that Resident 43's weight loss could have been prevented if the order to weigh the resident weekly was carried out by staff. Review of Resident 43's undated clinical record titled, Care Plan Report, (document that outlines a person's specific needs, goals, and the services or interventions required to meet them, ensuring consistent and coordinated care from various providers and caregivers), indicated that .Weekly Weights x 4 weeks. Review of an undated facility policy titled, Following Physician Orders, indicated, .It is the policy of this facility that all clinical staff shall carry out physician orders as prescribed. 2. Implementation. Orders must be carried out as prescribed and within the timeframe indicated.

Based on interview, and record review, the facility failed to ensure allegations of abuse were thoroughly investigated for one resident (Resident 72) in a census of 92. This failure had the potential for Resident 72 to experience further abuse, negatively affecting their physical and psychosocial well-being. Findings:A review of Resident 72's admission RECORD, indicated Resident 72 was admitted to the facility with diagnoses which included palliative care (a specialized form of medical care that focuses on improving the quality of life for people with serious or life-limiting illnesses).During a concurrent observation and interview on 8/26/25, at 2:44 PM, with Resident 72, in Resident 72's room, Resident 72 was seated in her wheelchair. Resident 72 further stated a staff member used foul language when caring for her and slapped me around a little. Resident 72 explained it had occurred recently.A review of Resident 72's clinical document titled, Progress Notes, dated 6/27/25, indicated, .resident [Resident 72] reported .that she was slapped by CNA [Certified Nursing Assistant] after 2pm on 06/25/25 .will monitor closely for physical or mental distress .During a concurrent interview and record review on 8/28/25, at 10:08 AM, with the Director of Staff Development (DSD), CNA 8's (the alleged perpetrator) employee file was reviewed. The DSD stated there were three incidents where CNA 8 was in-serviced on communication skills. The DSD explained one of the incidents was a verbal counseling on poor communication skills. The DSD reviewed CNA 8's document titled, Employee Progressive Counseling, dated 10/27/20, and 11/2/20, which indicated, .Type of Offense .Standards of Conduct .Description of Infraction .FAILURE TO PROPERLY COMMUNICATE WITH A RESIDENT. STAFF USED INAPPROPRIATE WORDS WHILE PROVIDING CARE FOR A RESIDENT .Type of Offense Quality of Work .Description of Infractions .Failure to provide the quality of care to residents as required under job descriptions for CNA per facility protocol with multiple warnings and write-ups. Staff will be suspended for 3 days for further investigation . The DSD explained following the incidents in October and November 2020, CNA 8 was placed on a Performance Improvement Plan, which indicated, .The purpose of this Performance Improvement Plan (PIP) is to define serious areas of concern, gaps in your work performance .Consequences of Further Infractions .Termination . The DSD reviewed CNA 8's third incident, which occurred 4/3/24. CNA 8's document titled, Employee Progress Counseling, dated 4/3/24, was reviewed. The document indicated, .Type of Counseling .Verbal .Description of Infraction .Poor communication skills .During an interview on 8/27/25, at 3:58 PM, with the Social Services Director (SSD), the SSD stated the investigative interviews for Resident 72's alleged abuse were all conducted by her. During a concurrent interview and policy review on 8/28/25, at 10:15 AM, with the SSD, the SSD stated Resident 72 was the only resident she interviewed. The SSD explained the staff member she interviewed on the day and shift when the alleged abuse occurred was CNA 8, the alleged perpetrator. Following review of an undated facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, the SSD stated she should have interviewed other residents and other staff members that were working on the day and shift of the alleged abuse. The SSD explained she did not feel it was a good investigation. The SSD stated she had not reviewed CNA 8's employee file. The SSD further stated she should have partnered with the DSD to review CNA 8's employee file. The SSD stated the risk to Resident 72 was further abuse. During an interview on 8/28/25, at 11:19 AM, with the Director of Nursing (DON), the DON stated other staff members on shift of the day of the alleged abuse should have been interviewed. The DON further stated other residents, in the care of CNA 8, should have been interviewed. The DON explained the importance of interviewing staff on shift from the day of the alleged abuse and other residents was to ensure a complete investigation and to prevent further incidents. The DON explained it was important to look at employee records to help in the investigation and to find out if there were similar complaints.A review of an undated facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, indicated, .All reports of resident abuse (including injuries of unknown origin) .are reported .and thoroughly investigated .The individual conducting the investigation as a minimum .interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .interviews the resident's roommate, family members, and visitors .interviews other residents to whom the accused employee provides care or services .reviews all events leading up to the alleged incident .

Based on interview, and record review, the facility failed to ensure medications were administered to meet professional standards of practice for 1 out of 32 sampled residents (Resident 7), when Resident 7's medication Midodrine (a blood pressure medication used to treat low blood pressure) was administered outside of physician ordered parameters (standard guidelines from the physician, used to categorize a patient's blood pressure reading and determine the proper course of treatment). This failure had the potential for Resident 7 to experience hypertension (high blood pressure, can damage the arteries and increase the risk of heart disease, and other health problems). Findings: A review of Resident 7's admission RECORD, indicated Resident 7 was admitted to the facility with diagnoses which included hypotension (low blood pressure). A review of Resident 7's clinical document containing physician orders, indicated, .Order Date .12/18/24 .Midodrine .by mouth .1 tablet .two times a day .hold if SBP [systolic blood pressure - the upper number on a blood pressure reading] > [greater than] 120 . A review of Resident 7's clinical document titled, Care Plan Report, revised 7/2/25, indicated, .Focus .Resident [7] has Hypotension .On Midodrine . Goal .The resident will maintain BP [blood pressure] within acceptable range as determined by [physician] .Give medications as ordered . A record review of Resident 7's clinical document titled, Medication Administration Record, (MAR) dated 8/1/25 through 8/31/25, indicated Resident 7's medication Midodrine was administered outside of the physician ordered parameters on 16 out of 53 opportunities for the month of August 2025. During an interview on 8/29/25, at 8:23 AM, with licensed nurse (LN) 5, LN 5 stated she would administer the medication midodrine for low blood pressure. LN 5 explained the parameters for midodrine were in the physician's order. During a concurrent interview and record review on 8/29/25, at 9:32 PM, with the Director of Nursing (DON), the DON stated the order for Resident 7's medication midodrine was to be held for a SBP greater than 120. The DON reviewed the following dates of administration on Resident 7's August 2025 MAR as follows: August 2025, 9 AM administration: 8/3 122/608/10 126/788/24 124/768/25 124/728/26 128/77 August 2025, 5 PM administration: 8/10 124/728/11 126/708/13 126/628/14 122/708/15 122/808/16 134/898/17 128/768/18 122/708/19 124/688/22 126/708/24 128/78 The DON confirmed midodrine was administered to Resident 7 with the above BPs and were outside of the physician ordered parameters. The DON explained the midodrine should not have been administered for the above BP's. The DON further explained it could have caused hypertension. A review of the facility policy titled, Administration Procedures For All Medications, revised 8/2014, indicated, .Prior removing the medication package/container from the cart/drawer .Check for vital signs .prior to medication administration .Notification of Physician .Held medications for pulse, blood pressure .resulting in medications being held .

Based on observation, interview, and record review, the facility failed to ensure the provision of care and services to ensure 1 of 32 sampled residents ( Resident 80) maintained his highest level of function when staff did not provide range of motion (ROM, the full movement of a joint) exercises to his extremities or hand hygiene to his contracted (shortening or hardening of muscles, tendons, or other tissue leading to a deformity and rigidity of joints) right hand.This failure had the potential for Resident 80 to experience a physical decline, worsening of right arm and hand contractures, and infection to his right hand.Findings:A review of Resident 80's admission RECORD, indicated he was admitted to the facility in early 2024.A review of Resident 80's clinical document titled, Care Plan Report, indicated, .Focus.Resident has a self care deficit. Requires 1-2 person extensive total assistance in ADL's [Activities of Daily Living, personal care tasks which include bathing, dressing, eating, and transferring in and out of bed].RUE [right upper extremity] contracture [A permanent tightening of the muscles, tendons, skin] .Goal.risk of complications due to self care deficit will be minimized with interventions.Interventions.Incorporate ROM exercises during care.Monitor/document/report.any s/sx [signs/symptoms] of immobility: contractures forming or worsening.skin breakdown.A review of Resident 80's minimum data set (MDS, a federally mandated resident assessment and screening tool which identifies care needs) Section GG-Functional Abilities, indicated, .Functional Limitation in Range of Motion.Upper extremity (shoulder, elbow, wrist, hand).1. Impairment on one side.A review of Resident 80's clinical documentation of care provided titled, Task: Incorporate ROM exercise during care every AM [morning] & PM [evening] Shift, indicated, .Amount of time spent providing Range of Motion. the document indicated: .Not Applicable. for the following dates and shifts: AM and PM shift for the dates of 8/4/25, 8/13/25, 8/15/25, 8/18/25, and 8/24/25.AM shift for the dates of 8/17/25, 8/19/25, 8/21/25, 8/22/25, and 8/23/25.PM shift for the dates of 8/6/25, 8/7/25, 8/8/25, 8/9/25, 8/10/25, 8/11/25, 8/12/25, 8/14/25, and 8/16/25.During an interview on 8/28/25, at 3:23 PM, with Certified Nurse Assistant (CNA) 10, CNA 10 stated, when she provided ROM for Resident 80, she documented the number of minutes the care was provided. CNA 10 further stated if Resident 80 refused ROM she documented Resident Refused. CNA 10 stated she documented not applicable if she did not perform ROM with Resident 80 or if he was asleep when she went in the room.During a concurrent observation and interview on 8/29/25, at 8:35 AM, with the Assistant Director of Nurses (ADON), in Resident 80's room, the ADON confirmed Resident 80's contracted right hand had a strong odor. The ADON further confirmed Resident 80's fingers were curled tightly into the palm of his hand. The ADON stated Resident 80's right hand should be clean, and a hand roll should have been in place to prevent his fingers from digging into his hand. The ADON provided hand hygiene to Resident 80, which resulted in a brown, crusty residue on the washcloth. During a concurrent interview and record review on 8/29/25, at 8:47 AM, with the ADON, the ADON confirmed Resident 80's clinical document indicated, Not Applicable for ROM over multiple days and shifts for the month of August 2025. The ADON stated that without ROM care, Resident 80 was at increased risk of contracture and limited mobility. The ADON further stated staff should have provided daily care to Resident 80's right hand, including using a splint or rolled washcloth to prevent his fingers from digging into his palm. The ADON stated Resident 80 was at risk of skin breakdown and infection if the care was not provided.A review of a facility policy titled, Activities of Daily Living (ADLs), Supporting, revised 3/18, indicated, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently.including.hygiene.mobility.Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs.A review of an undated facility policy and procedure titled, Range of Motion Exercises, indicated, .The purpose of this procedure is to exercise the resident's joints and muscles.The following information should be recorded in the resident's medical record.The date and time that the exercises were performed.If the resident refused the treatment, the reason(s) why and the intervention taken.Notify the supervisor if resident refuses the exercises.

Based on observation, resident and staff interview, and facility policy review, the facility failed to ensure facility residents, staff and visitors were protected from the danger of fire and/or an explosion due to residents smoking around oxygen tanks, and accidental needle sticks, for a census of 131 residents when: 1a. Random Resident 48, who required continuous supplemental oxygen, was smoking in the designated smoking area while sitting in a wheelchair with a portable oxygen tank attached to it; 1b. Random Resident 47 was assisted to the designated smoking area in a wheelchair while on continuous supplemental oxygen via nasal cannula that was attached to a portable oxygen tank on the back of their wheelchair; and, 2. A crash cart in Station 1 that contained syringes with needles was not locked and was accessible to residents. These failures had the potential to cause a fire and put all residents (census of 131) in the facility at risk for serious harm and even death, and also put residents at risk for accidental needle sticks. Findings: 1a. On 11/2/16 at 7:55 a.m. Random Resident 48 was observed, along with two residents, smoking in the designated smoking area while sitting in their wheelchairs. A CNA (certified nursing assistant) was sitting on a bench by an ashtray. Random Resident 48 was observed with a nasal cannula beside them on the seat of their wheelchair; the nasal cannula was attached to a portable oxygen tank hanging on the back of the resident's wheelchair with the oxygen tank remained on. During an interview with the three residents, they stated there was no formal smoking time in the facility. They stated they smoke whenever staff was available to go out to the smoking area with them. Random Resident 48 stated they need supplemental oxygen on at all times and that they were able to propel their wheelchair on their own. In a subsequent observation on 11/2/16, at 8:20 a.m., the CNA went inside the building with one of the residents and left the two random residents smoking without staff supervision. At 8:30 a.m., another CNA came out and assisted Random Resident 47 to the designated smoking area in a wheelchair while on continuous supplemental oxygen via nasal cannula that was attached to a portable oxygen tank on the back of their wheelchair. The CNA wheeled Random Resident 47 next to Random Resident 48 then went behind Random Resident 47's wheelchair to turn the oxygen off. CNA 2 sat down on the bench by the ashtray to monitor the residents while they smoked. Random Resident 48 took a cigarette and a lighter out from under their lap blanket and handed them to Random Resident 47. Random Resident 47 took their oxygen nasal cannula off, set the nasal cannula on their wheelchair seat, and then started smoking. At 8:40 a.m., another staff member came out to the smoking area and removed the oxygen tanks attached to Random Resident 47's and 48's wheelchair and set them by the door to the building. She told CNA 2 Oxygen tanks are not supposed to go past this line while pointing to a demarcation on the ground. CNA 2 responded, I didn't know that. AA 2 replied, There's a sign here but it got wet so it's not clear. AA 2 went inside the building. Random Resident 47 turned to the surveyor and said, Their (staff) practice change when you guys (surveyors) are not here. It changes so we (residents) don't know the rules. The residents nodded their heads in agreement. Multiple staff were interviewed on 11/2/16, from 7:20 a.m. to 7:50 a.m. Licensed Nurses (LNs) 5, 10, and 11, and CNAs 1 and 4 stated staff had to be present in the smoking area at all times while residents are smoking. CNA 4 stated oxygen tanks had to be turned off when residents are in the smoking area. The undated facility policy and procedure titled Smoking Assignment Procedure indicated, 1. Smoke breaks are at 8:30 a.m., 11 a.m., 3 p.m. and 7 p.m .4. The box containing the resident's smoking materials is located at Station 1 in the med room .7. Collect the smoking materials from the residents at the end of the smoking break .8. Return the smoking box back to Station 1 .9 .you must monitor or supervise the non-independent resident smokers . Oxygen safety was not addressed in the policy and procedure. An Immediate Jeopardy (IJ - a situation that has threatened or is likely to threaten the health and safety of a resident) was identified by the Department for the facility's failure to ensure the oxygen nasal cannulas and tanks were moved away from the residents who smoked prior to allowing them to light their cigarettes and smoke. The facility's Administrator and the Director of Nursing were informed of the IJ, and an interim plan of correction was presented by the facility and put into place. The plan of correction that was in place was an inservice to staff regarding the removal of oxygen tanks before allowing residents to smoke. The plan of correction was accepted by the Department. The IJ was lifted on 11/2/16 at 4:20 p.m. 2. An observation on 11/7/16, at 10 a.m., of a crash cart (cart stocked with emergency medical equipment and supplies for use by medical personnel particularly during efforts to resuscitate a patient) which was located in front of Nurses Station 1 was observed to be unlocked. When drawers of crash cart were opened, 6 syringes with needles were found in the third drawer of the crash cart. During an interview on 11/7/16, at 10:15 a.m., with the Facility Nurse Consultant (NC), she acknowledged the crash cart was unlocked and stated it should have been locked for safety reasons because residents that were cognitively impaired could have access to sharp objects and harm themselves and others. A review of the undated facility document titled, Manteca Care and Rehabilitation Crash Cart, it indicated .Cart must be cleaned and completed after every use for completeness. A plastic seal must be used to secure after completed and inspected by licensed nurse daily .