Every finding on record at Harbor Villa Care Center

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for two of three final sampled residents (Residents 10 and104) reviewed for pressure injuries. * The facility failed to offload Resident 10's heels, as ordered by the physician and failed to provide a pressure relieving mattress with a pump as ordered by the physician. * The facility failed to offload Resident 104's heels as ordered by the physician. These failures had the potential for the residents to result in new pressure injuries, worsening of existing wounds, or other complications.Findings: Review of the facility's P&P titled Prevention of Pressure Injuries (undated) showed in part in the prevention skin care section to do not rub or otherwise cause friction on skin that is at risk of pressure injuries. Provide support devices and assistance as needed. Remind and encourage to change positions. Select appropriate support surfaces based the resident's risk factors, in accordance with current clinical practice. 1. Medical record review for Resident 10 was initiated on 4/7/26. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10' MDS assessment dated [DATE], showed the resident had intact cognition. Resident 10 was dependent on the staff with toilet hygiene, bathing, lower body dressing, sit to stand, and chair to bed or bed to chair transfer. In addition, Resident 10 required substantial to maximal assistance with bed mobility, rolling from left to right and sit to lying. Review of Resident 10's Order Summary Report showed the following physician's orders:- dated 1/4/26, to provide pressure-relieving mattress with a pump. Monitor for device function every shift for skin management. - dated 1/11/26, to offload or float bilateral heels at all times for skin management. - dated 4/1/26, to paint left and right heel diabetic ulcer (open sore, caused by nerve damage and poor circulation) with povidone iodine (antiseptic) and wrap with rolled gauze every day shift for wound care for 30 days. On 4/8/26 at 0745 hours, an observation of Resident 10 was conducted in the resident's room. Resident 10 was observed lying on the bed with a mattress without a pump, and both heels covered with dressings, which were resting directly on the mattress and not floated or offloaded. On 4/8/26 at 0923 hours, an interview and concurrent observation of Resident 10 was conducted with LVN 6 inside the resident's room. LVN 6 verified the resident did not have a pump equipped mattress and the heels were not floated. LVN 6 stated Resident 10 had a pump on the mattress previously, however, another resident needed the pressure relieving mattress with a pump. LVN 6 verified Resident 10's physician's orders above. LVN 6 stated she could contact the physician to clarify the orders for skin management. LVN 6 further stated Resident 10 was at high risk for pressure injuries. On 4/9/26 at 0759 hours, an observation of Resident 10 was conducted inside the resident's room. Resident 10 was observed lying on the bed with both heels resting directly on the mattress without offloading. On 4/9/26 at 0822 hours, an interview and concurrent observation of Resident 10 was conducted with CNA 1. CNA 1 verified the heels were touching the mattress and stated she would reposition the resident and offload the heels. On 4/10/26 at 1408 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings as above. 2. Medical record review for Resident 104 was initiated on 4/7/26. Resident 104 was admitted to the facility on [DATE]. Review of Resident 104's Order Summary Report showed the following physician's orders: - dated 4/6/26, apply A&D (topical skin protectant used to treat and prevent minor skin irritations) ointment to the right and left heel blanchable redness every day shift for skin management for 30 days. - dated 4/6/26, to offload/float bilateral heels every shift for skin management. On 4/8/26 at 0807 hours, an observation of Resident 104 was conducted inside the resident's room. Resident 104 was observed lying in bed with both heels resting directly on the mattress and not floated. On 4/8/26 at 0912 hours, an interview and concurrent observation of Resident 104 was conducted with LVN 6. LVN 6 verified resident's heels were touching the bed mattress. LVN 6 stated she had not yet assessed the resident since the start of the shift. LVN 6 stated the resident was at risk for pressure injury and had a blanchable redness on both heels. On 4/8/26 at 1515 hours, an interview and concurrent observation of Resident 104 was conducted with RNA 1. RNA 1 verified Resident 104's heels were directly touching the mattress and not offloaded. RNA 1 stated she would reposition the resident. On 4/10/26 at 1310 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings as above.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one two of four residents (Residents 6 and 44) observe for the medication administration were free from the significant medication errors. * LVN 1 administered the furosemide (medication to treat fluid retention) medication outside the physician's ordered parameter for Resident 6. * LVN 3 administered the heparin (blood thinner) medication without a physician's order for Resident 44. These failures posed the risk of adverse complication to the residents.Findings: Review of the facility's P&P titled Administering Medications (undated) showed the medications are administered in accordance with prescriber orders, including any required time frame. The P&P also showed the individual administering the medications checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. On 4/8/26 at 0938 hours, a medication administration observation for Resident 6 was conducted with LVN 1. Prior to administering the medications for Resident 6, LVN 1 obtained the resident's BP reading using an automatic BP machine and the resident's BP reading was 103/68 mmHg. LVN 1 was then observed preparing and administering the following medications to Resident 6:- digoxin (used to increase the force of the heart contractions and slowing the heart) 125 mcg one tablet;- Drizalma sprinkle (antidepressant) 40 mg one capsule by mouth;- potassium chloride ER (supplement) 10 mEq one tablet by mouth;- furosemide 40 mg one tablet by mouth;- multivitamin with minerals (supplement) one tablet by mouth;- iron sulfate (supplement) 325 mg one tablet by mouth;-docusate sodium (stool softener) 100 mg one soft gel by mouth;- fluticasone propionate (used to prevent and treat seasonal allergies) 50 mcg nasal spray, one spray to each nostril;- ciclesonide (used to treat persistent asthma and allergic rhinitis) 80 mcg/inhalation, one puff orally; and- dabigatran etexilate (blood thinner) 110 mg one capsule by mouth. Medical record review for Resident 6 was conducted 4/7/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 2/1/26, showed the resident had the capacity to understand and make decisions. Review of Resident 6's Order Summary Report dated 4/8/26, showed a physician's order dated 4/5/26, to administer furosemide 40 mg one tablet by mouth one time a day for BLE edema (swelling); hold if SBP was less than 110 mmHg. On 4/8/26 at 1102 hours, an interview and concurrent medical record review for Resident 6 was conducted with LVN 1. LVN 1 verified he administered the furosemide medication to Resident 6 during the medication administration observation. LVN 1 further verified Resident 6's physician's order for the furosemide medication showed an ordered parameter to hold the medication if the SBP was less than 110 mmHg. LVN 1 stated he should not have administered the furosemide medication to Resident 6 because the resident's BP reading was 103 mmHg. On 4/8/26 at 1138 hours, a follow-up interview was conducted with LVN 1. LVN 1 stated he notified Resident 6's physician regarding the furosemide medication that was administered outside of the ordered parameter. LVN 1 stated the physician ordered to monitor the resident [NAME] hypotension (low blood pressure). On 4/8/26 at 1240 hours, an interview was conducted with the DON. The DON was informed of the above findings and stated the change of condition assessment was completed for Resident 6 and the resident's physician was notified. 2. On 4/9/26 at 0927 hours, an interview and concurrent medication administration observation for Resident 44 was conducted with LVN 3. LVN 3 was observed administering the heparin injection solution on the RUQ of Resident 44's abdomen. LVN 3 stated he would administer the heparin injection solution to the RUQ of the resident's abdomen because the previous dose was administered on the LUQ of the abdomen on 4/8/26. Medical record review for Resident 44 was conducted on 4/7/26. Resident 44 was readmitted to the facility on [DATE]. Review of Resident 44's H&P examination dated 3/30/26, showed Resident 44 had capacity to make medical decisions. Review of Resident 44's MAR for April failed to show a physician's order to administer the heparin injection solution to Resident 44. Review of Resident 44's Order Summary Report dated 4/9/26, failed to show a physician's order to administer the heparin injection solution to Resident 44. On 4/9/26 at 0950 hours, an interview and concurrent medical record review for Resident 44 was conducted with LVN 3. LVN 3 verified Resident 44 had no physician's order for the heparin injection solution. LVN 3 stated he made a mistake and administered the heparin injection solution to the wrong resident. On 4/9/26 at 1034 hours, a follow-up interview was conducted with LVN 3. LVN 3 stated Resident 44 was previously receiving the heparin injection solution, and he did not check the resident's MAR thoroughly prior to administering the heparin injection solution. LVN 3 stated when he checked for the last injection site for the heparin injection solution on the resident's MAR, he checked the last injection site for the Retacrit (used to treat low red blood cell count) injection instead. LVN 3 further stated he would check the resident's MAR to see what medications were due for the resident on his shift prior to administering the resident's medications. LVN 3 stated Resident 44's physician was notified the resident mistakenly received the heparin injection solution and the physician recommended to continue monitoring the resident. On 4/9/26 at 1051 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. On 4/9/26 at 1426 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure to prepare food by methods that conserve nutritive value and at safe and appetizing temperature for 11 residents that consumed pureed food and 45 residents on Regular Diet Texture. * The prepared pureed vegetables were left in the oven for more than one hour before the lunch food tray line. * The ham temperature was at 98 degrees Fahrenheit. These failures had the potential for the residents not to eat the food served and could affect the residents nutritional status. Findings: Review of the facility's P&P titled Food Preparation and Service (not dated) showed food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Proper hot and cold temperatures are maintained during food distribution and service. 1. Review of the facility's Diet Type Report dated 4/7/26, showed 11 residents consumed pureed food prepared in the kitchen. On 4/8/26 at 1004 hours, an observation of puree food preparation was conducted with [NAME] 1. [NAME] 1 was observed preparing pureed sweet potato yam. [NAME] 1 placed the sweet potato yam in the oven at 1007 hours. [NAME] 1 prepared the pureed ham and placed in the oven at 1011 hours. [NAME] 1 prepared the pureed braised cabbage and placed in the oven at 1016 hours. The oven was observed set at 200 degrees Fahrenheit. On 4/8/26 at 1120 hours, an observation and concurrent interview was conducted with [NAME] 2. [NAME] 2 verified the prepared pureed food was in the oven. [NAME] 2 verified the oven temperature was set at 200 degrees Fahrenheit. [NAME] 2 stated temperature could be lowered. On 4/8/26 at 1123 hours, an interview was conducted with the DSS. The DSS stated the food tray line would start at 1200 hours. The DSS stated the food temperatures need to be maintained and food should not been prepared more than one hour before tray line to prevent it from losing nutritional value. On 4/10/26 at 1302 hours, the DSS and Administrator were informed and acknowledged the above findings. 2. Review of the facility's Diet Type Report dated 4/7/26, showed 45 residents consumed Regular Diet Texture prepared in the kitchen. Medical record review for Resident 39 was initiated on 4/8/26. Resident 39 was admitted to the facility on [DATE]. Review of Resident 39's H&P examination dated 10/19/25, showed the resident was competent and was able to make decisions. Review of Resident 39's Order Summary Report showed a physician's order dated 8/27/25, for Resident 39 to have a fortified high protein no added salt regular texture, thin consistency diet with large portions at breakfast to increase caloric intake. On 4/7/26 at 0830 hours, an observation and concurrent interview was conducted with Resident 39. Resident 39 stated the facility food did not taste good and was served cold. On 4/8/26 at 1255 hours, a test tray inspection and concurrent interview was conducted with the DSS. The regular diet tray included ham. The ham temperature was observed at 98 degrees Fahrenheit. The DSS verified the temperature of the ham. The DSS stated the ham was not warm enough. On 4/10/26 at 1302 hours, the DSS and the Administrator was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed for 81 of 87 residents who eat in the kitchen. * Food items used for residents' food were not properly stored, labeled and dated. * One expired bottle of opened ground ginger spice was not discarded. * The kitchen equipment and utensils were not maintained in a sanitary condition. * One cutting board was observed heavily marred and fuzzy with knife marks. * The pitchers were stored wet. * The hair restraint was not worn by one staff member preparing food in the kitchen. * Nonfood contact surfaces were not clean or in a cleanable condition. These failures had the potential to contaminate the food which could lead to foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.Findings: 1. Review of the facility's Diet Type Report dated 4/7/26, showed 81 of 87 residents consumed the food prepared in the kitchen. On 4/7/26 at 0615 hours, during the initial tour of the kitchen with the DSS, the following was observed:- Oatmeal was observed in an aluminum container. The aluminum container lid was broken and would not close properly. The plastic liner of the container was torn; and- Ground cinnamon had no open date. The DSS verified the above findings. The DSS stated the oatmeal should have been stored in a sealed container and the cinnamon should have been stored, dated, and labeled accordingly. 2. On 4/7/26 at 0619 hours, during the initial tour of the kitchen with the DSS, an opened ground ginger spice was observed with a use by date of 3/27/26. The DSS verified the above finding and stated the above item should have been expired items and should have been discarded. 3. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils (C), nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. On 4/7/26 at 0625 hours, during the initial tour of the kitchen with the DSS, the following was observed:- two spatulas with red handle with chipped part;- a food strainer with brownish orange material resembling rust; and- one frying pan with inner deep scratches had lost the non-stick surface exposing the underlying metal. The DSS verified the above findings. The DSS stated the frying pan and the utensils will be replaced. 4. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, showed surfaces such as cutting blocks that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. On 4/7/26 at 0628 hours, during the initial tour of the kitchen with the DSS, one cutting board was observed heavily marred and fuzzy with knife marks. The DSS verified the findings. 5. According to USDA Food Code 2022, Section 4-901.11, equipment and utensils, air drying required, items must be allowed to drain and to air-dry before stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganisms can grow. On 4/7/26 at 0630 hours, during the initial tour of the kitchen with the DSS, eight water pitchers were observed stored wet. The surface of the shelf were the pitchers were stored were also wet. The DSS verified the observation and stated staff should have air dried the pitchers before storing. 6. According to the USDA Food Code 2022, Section 2-402.11 Effectiveness (A), Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils. Review of the facility's P&P titled Foodborne Illness - Employee hygiene and Sanitary Practices not dated, showed food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Hair nets or caps and/ or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. On 4/7/26 at 0645 hours, an observation of Dietary Aide 1 and concurrent interview was conducted with the DSS. Dietary Aide 1 was observed with hairy arms with no covering preparing pancake syrup in the kitchen. The DSS verified the observation of Dietary Aide 1's arms. The DSS stated Dietary Aide 1 should wear arm sleeves to keep hair from contacting the food. 7. According to the USDA Food Code 2022, Section 4-601.11 Food Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A) Equipment, food contact surfaces and utensils shall be clean to sight and touch, (C) Nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. On 4/7/26 at 1002 hours, an observation of the water pipe in the kitchen behind the dishwasher and concurrent interview was conducted with the Maintenance Director. The water pipe in the was observed peeling off with brownish orange material resembling rust. The Maintenance Director confirmed the findings. On 4/10/26 at 1302 hours, the DSS and Administrator was informed and acknowledged the above findings.

Based on interview, medical record review, and facility's P&P review, the facility failed to ensure the residents or their representatives were informed in advance of the proposed treatment regarding the use of psychotropic medications (medications affecting brain activity) for two of five residents (Residents 3 and 4) reviewed for unnecessary medications. * The facility failed to have separate informed consent and nonpharmacological interventions for Resident 4's use of the clonazepam (a prescription medication used to treat seizure disorders and panic disorder by acting as a central nervous system depressant), lorazepam (a medication used for short-term management of anxiety disorders, insomnia, acute seizures (status epilepticus), and pre-anesthetic sedation) and aripiprazole (medication used to treat mental health conditions by balancing dopamine (critical neurotransmitter and chemical messenger in the brain that regulates pleasure, reward, motivation, memory, and motor control). In addition, the aripiprazole medication was classified as antidepressant in the resident's informed consent. * The facility failed to ensure the informed consents for the olanzapine (a medication for mental disorders including schizophrenia and bipolar disorder) and mirtazapine (antidepressant medication) medications were signed by Resident 3's physician. In addition, the facility failed to have separate informed consent and nonpharmacological intervention for Resident 3's use of the mirtazapine and olanzapine medications. These failures had the potential to compromise the residents' and/or their designated representatives' right to be fully informed regarding the psychotropic medication and its possible nonpharmacological interventions in order to make an informed decision.Findings: 1. Medical record review for Resident 4 was initiated on 4/7/26. Resident 4 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 4's MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. Review of Resident 4's Informed Consent-Psychoactive Medication – V3 dated 3/4/26 showed the facility used one informed consent form for the aripiprazole, clonazepam, and lorazepam medications. In addition, the aripiprazole was classified as an antidepressant medication. There was no documented evidence a separate informed consents and nonpharmacological interventions for Resident 4's use of the aripiprazole, clonazepam, and lorazepam medications were completed. Review of Resident 4's Order Summary Report dated 4/9/26, showed the following physician's orders: - dated 9/30/25, to administer clonazepam 1 mg tablet by mouth every 12 hours for anxiety manifested by undirectable verbal aggressive behavior. Institute nonpharmacological approach prior to administration of pain medication: (1) Repositioning, (2) Dim lights/quiet environment (3) Hot/cold applications and (4) Relaxation techniques; - dated 1/6/26, to administer lorazepam 1 mg tablet mouth every 12 hours as needed for anxiety manifested by verbalization of anxiety/ post-traumatic stress for 90 days not to exceed 2 grams per day. Institute nonpharmacological approach prior to administration: (1) Reorientation, (2) Music/TV, (3) Re-direction/ Diversion, (4) Reassurance, (5) Quiet environment, (6) Encourage vent feelings, (7) food/drink; and - dated 1/12/26, to administer aripiprazole 10 mg tablet by mouth at bedtime for Bipolar Disorder (a chronic mental health condition characterized by extreme mood swings, alternating between intense highs -mania/hypomania- and lows - depression) manifested by loose and disorganize thoughts. Institute nonpharmacological approach prior to administration: (1) Reorientation, (2) Music/TV, (3) Re-direction/Diversion, (4) Reassurance, (5) Quiet environment, (6) Encourage vent feelings, (7) food/drink. On 4/9/26 at 1600 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 4's Informed Consent-Psychoactive Medication – V3 dated 3/4/26, showed the facility used one informed consent form for the aripiprazole, clonazepam, and lorazepam medications. In addition, RN 1 verified the aripiprazole was classified as an antidepressant medication on the informed consent. On 4/10/26 at 0900 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD stated she was not aware the informed consent should have only one medication listed. The SSD further stated she would implement the use of one informed consent per each medication. On 4/10/26 at 1324 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 3 was initiated on 4/7/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed the resident had severe cognitive impairment. Review of Resident 3's Informed Consent-Psychoactive Medication – V2 dated 11/14/25, and Informed Consent-Psychoactive Medication – V3 dated 2/12/26, failed to show documented evidence the informed consents for the mirtazapine and olanzapine medications were signed by Resident 3's physician. In addition, the facility failed to have a separate informed consent and nonpharmacological interventions for Resident 3's use of mirtazapine and olanzapine medications. Review of Resident 3's Order Summary Report dated 4/9/26, showed the following physician's order: - dated 1/12/26, to administer mirtazapine oral tablet 30 mg, give one tablet by mouth at bedtime for depression manifested by poor oral intake less 50%. Institute nonpharmacological approach prior to administration: 1. Reorientation, 2. Music/TV, 3. Re-direction/Diversion, 4. Reassurance, 5. Quiet environment, 6. Encourage vent feelings, 7. food/drink; and - dated 1/12/26, to administer olanzapine oral tablet 5 mg, give one tablet by mouth at bedtime for schizoaffective episodes manifested by outburst without reason. Institute nonpharmacological approach prior to administration: 1. Reorientation, 2. Music/TV, 3. Re-direction/Diversion, 4. Reassurance, 5. Quiet environment, 6. Encourage vent feelings, 7. food/drink. On 4/10/26 at 0903 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 3's Informed Consent-Psychoactive Medication -V2 dated 11/14/25, and the Informed Consent-Psychoactive Medication V-3 dated 2/12/26, had two psychotropic medications in each informed consent. RN 2 acknowledged both informed consents were not signed by Resident 3's physician and the nonpharmacological approach for the mirtazapine and olanzapine medications were not separated. RN 2 stated there should have been separate informed consent and nonpharmacological approaches to make sure it was clear which nonpharmacological approach was specific for each medication. RN 2 stated the licensed nurses should make sure Resident 3's physician signed the informed consent. On 4/10/26 at 1317 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 87 residents (nonsampled resident, Resident 91) was assessed to self-administer of medication. The facility failed to ensure there was a physician's order and self-administration assessment for the Vicks VapoRub (cough suppressant and topical analgesic) ointment medication found at the resident's bedside. This failure had the potential to impact Resident 91's safety and well-being and an increased risk of improper medication use. Findings: Review of the facility's P&P titled Self-Administration of Medications (undated) showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. On 4/7/26 at 0816 hours, during the initial tour of the facility, Resident 91 was observed sitting in bed and watching TV. A container of Vicks VapoRub ointment was observed inside an open drawer of the resident's bedside cabinet. Medical record review for Resident 91 was initiated on 4/7/26. Resident 91 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 91's MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident 91's Order Summary Report for April 2026 failed to show a physician's order for the Vicks VapoRub ointment medication. Further review of Resident 91's medical record did not show Resident 91 had been assessed to self-administer the Vicks VapoRub ointment medication. On 4/7/26 at 0843 hours, an observation and concurrent interview was conducted with Resident 91. A Vicks VapoRub ointment was observed inside the resident's opened bedside drawer. Resident 91 stated she used the Vicks VapoRub ointment two days ago. On 4/7/26 at 0849 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 verified the Vicks VapoRub ointment was inside the opened drawer of Resident 91's bedside drawer. CNA 3 stated Resident 91 was not allowed to have medication in her cabinet and/or bedside table. On 4/7/26 at 0853 hours, an observation and concurrent interview was conducted with RN 3. RN 3 verified the Vicks VapoRub ointment was present at Resident 91's bedside. RN 3 stated the ointment should not be at the bedside because it was considered a medication. On 4/7/26 at 0917 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified there was no physician's order and no self-administration assessment for Resident 91's Vicks VapoRub ointment. LVN 1 stated Resident 91's drawers should have been checked and the facility staff or the resident should have notified the charge nurse if there was medication kept at the bedside. LVN 1 further stated there should have been a physician's order and self-administration assessment for Resident 91's Vicks VapoRub ointment in place. On 4/10/26 at 1317 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation and interview, the facility failed to ensure a safe environment for the residents, staff, and visitor was provided in one of four hallways. * One of four hallways was observed with a handrail that was sharp to the touch. This failure posed the risk of injury to the residents, staff, and visitors.Findings: On 4/7/26 at 0709 hours, the handrail in Hallway A was observed with an uneven surface. The paint on the handrail was peeling, exposing the wooden surface underneath. The handrail felt sharp to the touch. On 04/7/2026 at 1346 hours, an observation and concurrent interview was conducted with the Maintenance Director. The Maintenance Director verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 3 and 4) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 3 was properly monitored for orthostatic blood pressures (measure the blood pressure while laying down or sitting and again upon standing up) as ordered by the physician. * The facility failed to ensure Resident 3's monthly behavior summary for the use of olanzapine (a medication for mental disorders including schizophrenia and bipolar disorder) and mirtazapine (antidepressant medication) were completed. * The facility failed to ensure a gradual dose reduction (GDR) was attempted for Resident 4 when the facility failed to follow the psychiatrist's order to discontinue the clonazepam medication. These failures had the potential for adverse health outcomes to the residents related to the effects of psychotropic medications.Findings: Review of the facility's P&P titled Psychotropic Medication Use (undated) showed residents will not receive medications that are not clinically indicated to treat a specific condition. The P&P further showed: - Use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. - Residents on the psychotropic medications receive gradual dose reductions (coupled with nonpharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications. - Residents receiving psychotropic medications are monitored for adverse consequences, including cardiovascular effects: irregular heart rate or pulse, palpitations, lightheadedness, shortness of breath, diaphoresis, chest/arm pain, increased blood pressure and orthostatic hypotension. Review of the facility's P&P titled Charting and Documentation (undated) showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Under the Policy Interpretation and Implementation section showed documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1. Medical record review for Resident 3 was initiated on 4/7/26. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MDS assessment dated [DATE], showed the resident had severe cognitive impairment. a. Review of Resident 3's Order Summary Report dated 4/9/26, showed the following physician's orders: - dated 11/14/25, to monitor orthostatic BP when laying every Sunday; and - dated 11/14/25, to monitor orthostatic BP when sitting every Sunday. Review of Resident 3's MARs for February and March 2026 showed orthostatic BP (lying and sitting) were scheduled to be monitored every Sunday. However, Resident 3's BP readings for lying and sitting were identical on multiple dates: - On 2/1/26, the BP readings were 125/67 mmHg for lying position and 125/67 mmHg for sitting position. - On 3/8/26, the BP readings were 122/65 mmHg for lying position and 122/65 mmHg for sitting position. - On 3/15/26, the BP readings were 125/67 mmHg for lying position and 125/67 mmHg for sitting position. - On 3/22/36, the BP readings were 133/72 mmHg for lying position and 133/72 mmHg for sitting position. - On 3/29/26, the BP readings were 119/72 mmHg for lying position and 119/72 mmHg for sitting position. On 4/9/26 at 1130 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 3's orthostatic BP were the same for laying and sitting position on the above dates. RN 1 stated Resident 3's BP should have been checked in correct positions. RN 1 stated accurate orthostatic readings were necessary to identify hypotension and report concerns to the physician. RN 1 stated the psychotropic medication could affect Resident 3's BP and required monitoring. b. Review of Resident 3's Order Summary Report dated 4/9/26, showed the following physician's orders: - dated 1/12/26, to administer mirtazapine 30 mg oral tablet, give one tablet at bedtime for depression manifested by poor oral intake less than 50%. -dated 1/12/26, to administer olanzapine 5 mg oral tablet, give one tablet by mouth at bedtime for schizoaffective episodes manifested by outburst without reason. However, further review of Resident 3's medical record showed no monthly behavior summary reports for January through March 2026 were completed for the olanzapine and mirtazapine medications. On 4/9/26 at 1339 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified no monthly behavior summary reports from January to March 2026 for the use of the olanzapine medication were completed for Resident 3. RN 1 stated the monthly summaries were needed to assess behavioral response and determine whether medication adjustments were needed. On 4/9/26 at 1422 hours, a follow-up interview and concurrent medical record review was conducted with RN 1. RN 1 no monthly behavior summary reports from January to March 2026 for the use of mirtazapine for Resident 3 were completed. RN 1 stated the reports were necessary to determine medication effectiveness and whether dose reduction was appropriate. On 4/10/26 at 1317 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 4 was initiated on 4/7/26. Resident 4 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 4's MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. Review of Resident 4's Order Summary Report dated 4/9/26, showed the following physician's order: - dated 9/30/25, to administer clonazepam 1 mg tablet by mouth every 12 hours for anxiety manifested by undirectable verbal aggressive behavior. - dated 1/6/26, to administer lorazepam 1 mg tablet mouth every 12 hours as needed for Anxiety manifested by verbalization of anxiety/ post-traumatic stress for 90 days. - dated 1/12/26, to administer aripiprazole 10 mg tablet by mouth at bedtime for Bipolar Disorder (a chronic mental health condition characterized by extreme mood swings, alternating between intense highs -mania/hypomania- and lows - depression) manifested by loose and disorganize thoughts. Review of Resident 4's Consultant Pharmacist's Recommendation to Inter-Disciplinary Team (IDT) dated 2/18/26, showed the need to assess if clinically appropriate to consider a GDR for either one or both of the agents. Review of Resident 4's Psych Progress Notes dated 3/3/26, showed GDR would be attempted. The physician documented to discontinue the clonazepam 1 mg in the progress notes. However, further review of Resident 4's Order Summary Report failed to show the clonazepam 1 mg was discontinued. On 4/9/26 at 0816 hours, an interview was conducted with Resident 4. Resident 4 stated her medications made her sleepy sometimes. However, she needed to take the medications and her pain medication to control her pain. On 4/9/26 at 1530 hours, an interview and concurrent record review was conducted with the SSD. The SSD verified Resident 4's Psych Progress Notes dated 3/3/26, showed GDR would be attempted and the physician's order to discontinue the clonazepam. The SSD stated she did not know why the psychiatrist order was not carried out and that the RN in charge of the psychotherapeutic medication lead the GDR meetings and the SSD supervised. On 4/9/26 at 1545 hours, a telephone interview was conducted with the Psychiatrist. The Psychiatrist verified he discontinued the clonazepam 1 mg on 3/3/26, as per the pharmacy recommendation for GDR. The Psychiatrist stated he discussed the GDR order with the nurse in charge of the psychotherapeutic medications. The Psychiatrist further stated his expectation was for the RN to follow the order to discontinue the clonazepam. The Psychiatrist stated he was not aware the clonazepam was not discontinued. On 4/9/26 at 1600 hours, an interview and concurrent record review was conducted with RN 1. RN 1 verified the clonazepam medication for Resident 4 was not discontinued as ordered by the Psychiatrist. RN 1 stated the clonazepam medication should have been discontinued, however, she did not know why the clonazepam medication was not discontinued. On 4/10/26 at 1324 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings as above.

Based on interview and medical record review, the facility failed to ensure the PASARR recommendations were followed up and incorporated into the resident's care for one of seven final sampled residents (Resident 8) reviewed for PASARR. * The facility failed to ensure the PASARR Level II recommendations were followed and incorporated into Resident 8's care. This failure had the potential for Resident 8 not to receive the adequate care that was recommended by the PASARR Level II evaluation report that completed by an appropriate state-designated authority.Findings: Medical record review for Resident 8 was initiated on 4/7/26. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 3/4/25, showed Resident 8 was competent and able to make decisions. Review of Resident 8's admission Records dated 4/9/26, showed Resident 8 had diagnoses which included schizophrenia. Review of Resident 8's Order Summary Report showed a physician's order dated 3/16/26, to administer haloperidol (antipsychotic) oral tablet 1 mg, give one tablet by mouth at bedtime for schizoaffective disorder. Review of the Department of Health Care Services (DHCS) letter sent to Resident 8 dated 12/16/19, showed the PASARR Level II evaluation was conducted on 10/01/19, by a licensed clinical psychologist from the DHCS. The letter further showed the personalized care recommendation were based on Resident 8's medical and social history, strength, and personal goals. Cultural and religious preferences should be considered when providing care. The recommendation showed the following:Psychotropic Medication and Education MonitoringMental Health Rehabilitation ActivitiesActivities of Daily Living (ADL) Training/ReinforcementSupportive ServicesPsychotherapy/CounselingSubstance Rehabilitative ServicesPsychiatry ConsultationNeuropsychology ConsultationInternal Medicine ConsultationOptometry ConsultationSocial Worker ConsultationPain Services ConsultationSleep Specialist ConsultationSmoking CessationSafety monitors for falling and harm to self or others However, further review of Resident 8's medical record did not show if the recommendations from the PASARR Level II evaluation was followed up and incorporated into the resident's care. Review of Resident 8's plan of care failed to show a care plan was developed to address the recommendations from the PASARR Level II evaluation. On 4/8/26 at 1514 hours, an interview and a concurrent medical record review for Resident 8 was conducted with the MDS Coordinator. The MDS Coordinator verified the above findings and stated she could not find documented evidence to show the recommendations from the PASARR Level II evaluation were followed up. The MDS Coordinator reviewed the resident's plan of care and stated she could not find the care plan problem addressing the recommendation for specialized services as per the PASARR Level II evaluation report. The MDS Coordinator stated Resident 8 was receiving services recommended from PASARR Level II evaluation and were already part of Resident 8's care plan. However, the MDS Coordinator stated the care plan did not address the PASSAR Level II evaluation and the result. The MDS Coordinator acknowledged there was a possibility the recommendation from the PASSAR level II evaluation could have been missed. On 4/10/26 at 1020 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the treatment and care in accordance with the professional standards of practice for one of four final sampled residents (Resident 10) reviewed for unnecessary medications and one nonsampled resident (Resident 87). * The facility failed to ensure the insulin injection site was rotated for Resident 10. * The facility failed to ensure the insulin injection site was rotated for Resident 87. The facility failed to ensure Resident 87's insulin was administered accurately as ordered by the physician. The insulin Regular Human injection (medication to lower blood sugar levels) solution was not administered to Resident 87 when the sliding scale (amount of insulin to be administered based on the blood sugar results) showed to administer 1 unit of insulin Regular Human injection solution. These failures had the potential for the residents not to receive appropriate care and treatment.Findings: Review of the facility's P&P titled Insulin Administration (undated) showed to provide guidelines for the safe administration of insulin to residents with diabetes. The Steps in the Procedure (Insulin Injections via Syringe) section showed select an injection site: a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately two inches around the navel. b. Injection sites should be rotated preferably within the same general area (abdomen, thigh, upper arm). 1. Medical record review for Resident 10 was initiated on 4/7/26. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Order Summary Report showed the following physician's orders: - dated 3/12/26, to administer glargine (a long-acting insulin used once daily used to treat diabetes by controlling blood sugar for 24 hours) insulin, inject 10 units subcutaneously (administered into the fatty tissue layer between the skin and muscle, often in the abdomen or upper arm) at bedtime. Hold if blood sugar is less than 100 mg/dL. - dated 2/1/26, to administer regular human insulin (medication to lower blood sugar levels) to inject as per sliding scale (amount of insulin to be administered based on the blood sugar results) before meals and at bedtime. Review of Resident 10's Location of Administration dated 4/1 through 4/30/26, showed the glargine insulin and the regular human insulin were administered consecutively on the same injection sites on the following dates and times: - on 4/3/26 at 0630 hours, regular insulin was administered to the LUQ of the abdomen; - on 4/3/26 at 2100 hours, regular insulin was administered to the LUQ of the abdomen; - on 4/3/26 at 2100 hours, glargine insulin was administered to the LUQ of the abdomen; - on 4/4/26 at 0630 hours, regular insulin was administered to the LLQ of the abdomen; - on 4/4/26 at 2100 hours, glargine was administered to the LLQ of the abdomen; - on 4/4/26 at 2106 hours, regular insulin was administered to the LLQ of the abdomen; - on 4/5/26 at 1630 hours, regular insulin was administered to the LLQ of the abdomen; - on 4/6/26 at 2100 hours, glargine insulin was administered to the LLQ of the abdomen; - on 4/7/26 at 0630 hours, regular insulin was administered to the LLQ of the abdomen; - on 4/7/26 at 1630 hours, regular insulin was administered to the LUQ of the abdomen; and -on 4/7/26 at 2100 hours, regular insulin was administered to the LUQ of the abdomen. On 4/10/26 at 1045 hours, an interview and concurrent medical record review for Resident 10 was conducted with LVN 7. LVN 7 verified the above findings and stated the insulin injection site should be rotated with each insulin administration. On 4/10/26 at 1406 hours, an interview was conducted with the DON. The DON stated the nursing staff were expected to rotate the insulin injection sites to prevent fat tissue buildup and ensure proper insulin absorption. The DON was informed and acknowledged the findings as above. 2. Medical record review for Resident 87 was initiated on 4/7/26. Resident 87 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 87's MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. a. Review of Resident 3's Order Summary Report dated 4/8/26, showed a physician's order dated 5/14/25, to administer insulin Regular Human injection solution, to inject as per sliding scale subcutaneously before meals and at bedtime. Review of Resident 3's Location of Administration Report dated 2/1 through 4/7/26, showed the insulin Regular Human injection was administered consecutively on the same site on the following dates, times, and locations of administration: - On 2/1/26 at 0549 and at 1150 hours, the location of administration was RLQ; - On 2/11/26 at 0549 and 1256 hours, the location of administration was LUQ; - On 2/21/26 at 0655 and 1300 hours, the location of administration was RLQ; - On 2/22/26 at 0615 and 1046 hours, the location of administration was LLQ; - On 2/24/26 at 2057 and 2/25/26 at 0541 hours, the location of administration was LLQ; - On 2/26/26 at 1038 and 1701 hours, the location of administration was LUQ; - On 3/3/26 at 1636 and 3/3/26 at 2102 hours, the location of administration was RLQ; - On 3/12/26 at 2038, 3/13/26 at 0540 and 1134 hours, the location of administration was LLQ; - On 3/16/26 at 0543, 1157, and 2124 hours, the location of administration was RLQ; - On 3/22/26 at 0624 and 1216 hours, the location of administration was LUQ; - On 3/26/26 at 1630 and 2130 hours, the location of administration was LUQ; - On 3/29/26 at 1234 and 1612 hours, the location of administration was LUQ; - On 4/1/26 at 2045 and 4/2/26 at 0554 hours, the location of administration was RLQ; - On 4/3/26 at 0537 and 1213 hours, the location of administration was LUQ; and - On 4/7/26 at 0544 and 1158 hours, the location of administration was RLQ. On 4/10/26 at 0926 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified the location of administration for Resident 87's insulin regular human injection solution was not rotated multiple times in February, March, and April 2026. LVN 2 stated the licensed nurse should have rotated the site of administration of Resident 87's insulin regular. LVN 2 further stated the location of administration should be rotated to prevent complication on the skin. LVN 2 stated failure to rotate the injection site could cause skin complications including hardening and scar tissue formation. b. Further review of Resident 87's medical record review showed the insulin Regular Human injection solution was not administered when the sliding scale showed to administer 1 unit of insulin Regular Human injection solution on the following dates and times: - On 2/9/26 at 0630 hours; - On 2/28/26 at 1130 hours; - On 3/7/26 at 1130 and 1630 hours; and - On 3/23/26 at 1630 hours. On 4/10/26 at 0926 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated the licensed nurse should have followed the insulin sliding scale dosing. On 4/10/26 at 1012 hours, an interview and concurrent medical record review was conducted with LVN 8. LVN 8 verified the above findings. LVN 8 stated the licensed nurse should have reviewed and double checked the insulin sliding scale before giving the medication. On 4/10/26 at 1317 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four final sampled residents reviewed for nutrition (Resident 8) received the appropriate services needed to maintain acceptable parameters of nutritional status. * The facility failed to follow up when Resident 8 refused CNA Helping Hands assistance, as recommended by the dietician and as ordered by the physician, after the resident experienced a weight loss of more than 5 (five) pounds in one month. This failure had the potential to result in inadequate monitoring and evaluation of the effectiveness of nutritional interventions and increase the risk for further weight loss and nutritional decline.Findings: Review of the facility P&P titled Nutrition (impaired)/ Unplanned Weight Loss Clinical Protocol (undated) showed the staff will report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. The staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. The physician will authorize appropriate interventions, as indicated. The physician will document if cause specific interventions could not be identified or are not feasible. The physician and staff will monitor nutritional status, an individual's response to intervention, and possible complication of such interventions (for example, additional weight gain or loss, nausea, or vomiting). Medical record review for Resident 8 was initiated on 4/7/26. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 3/4/25, showed Resident 8 was competent and able to make decisions. Review of Resident 8's Weights and Vitals Summary showed the following:On 3/2/26, 106 lbs.On 4/1/26, 101 lbs. and,On 4/6/26, 100 lbs. (6 lbs. weight loss since 3/2/26; 5.7% in one month) Review of Resident 8's Dietary Note dated 4/1/26 at 1345 hours, showed Resident 8 weighed 101 lbs., had a 5-lb weight loss since 3/2/26, and was consuming 0-50-100% of meals. Resident 8 received a controlled carbohydrate, soft and bite sized diet with thin liquids and fortified foods. The dietitian recommended CNA Helping Hands. Review of Resident 8's IDT Weight Management Update dated 4/2/26, showed the physician agreed to implement the dietitian's recommendations including CNA Helping Hands. Review of the Resident 8's Order Summary Report showed a physician's order dated 4/2/26, for CNA Helping Hands with meals. On 4/8/26 at 1255 hours, Resident 8 was observed sitting on a wheelchair beside her bed. CNA 2 was observed setting up the meal tray and then left the room. The resident's meal tray was observed to include pureed sweet potato, bite sized baked ham, pureed corn bread, bite sized cooked cabbage. Resident 8 was observed eating less than 50 % of her meal with no facility staff providing assistance or encouragement, despite the CNA Helping Hands order. On 4/9/26 at 0751 hours, Resident 8 was observed eating her breakfast independently with no facility staff assisting. Resident 8 was not observed eating the main entree of her meal and was observed eating less than 25% of her meal tray. CNA 2 was then observed removing the meal tray out without offering alternatives to Resident 8. Review of Resident 8's document titled Amount Eaten showed on 4/8/26, the resident consumed 26-50% of the lunch meal, and on 4/9/26, the resident consumed 0-25% of the breakfast meal.Review of Resident 8's document titled Meal Substitute Provided showed that on 4/8/26 for lunch meal substitute was not offered and on 4/9/26 for breakfast, Resident 8 refused the offered meal substitutes. On 4/9/26 at 0755 hours, an observation and concurrent interview was conducted with the CNA 2. CNA 2 verified the observations and stated Resident 8 only ate cereal and milk at breakfast. CNA 2 verified she did not offer meal alternatives to the resident and stated even if she offered the meal alternative to the resident, she knew the resident would refuse. CNA 2 stated she was supposed to assist the resident during the feeding; however, Resident 8 refuses to be assisted. CNA 2 stated she notified the assigned LVN of Resident 8's refusal to be assisted during the meal and that the resident ate less than 50% of her meal. When asked CNA 2 if she documented the notification to LVN, CNA 2 stated she notified LVN verbally and did not document it. On 4/10/26, at 0836 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated she was part of the facility weight management IDT team. LVN 2 explained CNA Helping Hands was equivalent to 1:1 meal assistance and required the staff to remain with the residents during meals. When asked LVN 2 if the CNA needed to stay in the room while resident ate, LVN 2 stated if a resident had an order for CNA Helping Hands then the CNA should stay with the resident during mealtime to assist and encourage the resident to eat. LVN 2 verified Resident 8 had a significant weight loss of more than 5% in a month. LVN 2 verified the dietician recommendation, and the physician's order for CNA Helping Hands for Resident 8. When asked if she was aware of Resident 8's refusal for the CNA assistance during the meal, LVN 2 stated she was not aware and was not able to find the documentation to show Resident 8's refusal of CNA Helping Hand, no notification to the physician, and no follow up by the dietitian or IDT. LVN 2 stated the resident's refusals should have been documented and communicated to the physician, and should have been addressed by the IDT weight management team. On 4/10/26 at 0915 hours, a telephone interview was conducted with LVN 4. LVN 4 stated Resident 8 had order for CNA Helping Hands during mealtime, and CNA should assist and encourage the resident during mealtime. LVN 4 stated the CNA should notify him if Resident 8 refused CNA Helping Hands. LVN 4 stated he had not been notified of any refusals or low intake. On 4/10/26 at 1020 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the PICC line assessments were performed and documented for one of one final sampled resident (Resident 58) reviewed for the IV management. * The facility failed to obtain and document the external catheter length measurement upon admission for Resident 58's PICC line. This failure posed the risk for the resident developing complications related to PICC line displacement, malfunction, or infection.Findings: Review of the facility's P&P titled PICC Dressing Change dated 3/2023 showed the length of external catheter is obtained upon admission. Medical record review for Resident 58 was initiated on 4/7/26. Resident 58 was admitted to the facility on [DATE]. Review of Resident 58's H&P examination dated 3/23/26, showed the resident had the capacity to make medical decisions. Review of Resident 58's PICC line insertion documentation (undated) showed the PICC was inserted on 3/22/26, at the acute care hospital. Review of Resident 58's Order Summary Report showed the following physician's orders: - dated 3/23/26, to change the PICC line dressing, Stat-lock (medical device used to securely anchor catheters to the resident's skin) every day shift every Saturday if gauze dressing is used change every 48 hours. - dated 3/31/26, for vancomycin (antibiotic medication) gram intravenously once a day in the evening until 3/31/26. - dated 4/4/26, for vancomycin 1.25 grams intravenously in the afternoon for MRSA (Methicillin-resistant Staphylococcus aureus; type of bacteria) in blood until 4/10/26 at 2359 hours. On 4/7/26 at 0815 hours, an observation and concurrent interview was conducted with Resident 58. Resident 58 was observed with a PICC line in the right arm. Resident 58 stated he was receiving IV antibiotics for an infection. On 4/8/26 at 1027 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 was asked to describe the facility's practice for the resident's PICC line management and assessment. LVN 2 stated upon admission to the facility and every 7 (seven) days thereafter, during the PICC line dressing changes, the RN would obtain measurements specific to the PICC line. LVN 2 stated the purpose of documenting the external length is to ensure the catheter remains in place. LVN 2 stated the measurements were recorded on the IV MAR or in progress notes. However, review of Resident 58's medical record failed to show documentation for the measurements of the PICC line external catheter length or Resident 58's arm circumference upon admission. LVN 2 verified the findings. On 4/10/26 at 1336 hours, an interview and concurrent medical record review was conducted with the Administrator and DON. The DON verified the above findings and stated the facility would ensure the licensed nurses measure and document the PICC line external catheter lengths and arm circumference upon admission. The Administrator and DON were informed and acknowledge the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure necessary respiratory care and services were provided for one of three sampled resident (Resident 44) reviewed for respiratory care. * The facility failed to ensure Resident 44 received the correct amount of oxygen via nasal canula per the physician's order. This failure had the potential to negatively affect Resident 44's medical conditions. Findings: Review of the facility's P&P titled Oxygen Administrator (undated) showed to verify that there is a physician's order; review the physician's order or facility protocol for oxygen administration. On 4/7/26 at 0744 hours, an observation of Resident 44 was conducted in the resident's room. Resident 44 was observed with a nasal canula tubing in her nose connected to the oxygen concentrator, which was on and set at 2.5 liters per minute. On 4/7/26 at 1009 hours, an observation of Resident 44 and concurrent interview was conducted with the DON inside the resident's room. The DON verified the oxygen concentrator was set at 2.5 liters per minute. The DON stated the physician's order was for 2 liters per minute, and licensed nurses are required to follow the ordered amount. Medical record review for Resident 44 was initiated on 4/7/26. Resident 44 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 44's H&P examination dated 3/30/26, showed Resident 44 had the capacity to understand and make decisions. Review of Resident 44's Order Summary Reported dated 4/8/26, show a physician's order dated 3/30/26, to administer oxygen at 2 liters per minutes via nasal cannula as needed for shortness of breath. On 4/9/26 at 1139 hours, a follow-up interview and concurrent medical record review was conducted with the DON. The DON verified Resident 44's physician's order for oxygen was at 2 liters per minute via nasal cannula. On 4/10/26 at 1335 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of the residents. * One of four LVNs (LVN 4) observed for medication administration discarded the liquid medication in the medication cart's trash bin. This failure had the potential for the medications to be administered in error and opportunities for drug misuse.Findings: Review of the facility's P&P titled Discarding and Destroying Medications (undated) showed non-controlled and Schedule V (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. Review of the facility's document titled Lesson Plan- Course Subject: Medication Admin/Blood Pressure Medication Parameters dated 1/8/26, showed the medications would be disposed in the red container located inside each nurse cart, not in the trash can or resident personal trash. Review of the facility's document titled Inservice Lesson Plan and Attendance Record dated 1/8/26, showed the in-service title: Proper Medication Disposal and Destruction with the objective to not throw medications in the trash can. The in-service attendance record showed LVN 4 was in attendance of the in-service. On 4/8/26 at 0835 hours, a medication administration observation and concurrent interview for Resident 106 was conducted with LVN 4. LVN 4 was observed pouring 15 ml of liquid iron sulfate (supplement) into the medication cup. LVN 4 stated he needed to discard the liquid iron sulfate and re-pour the medication because the resident's physician's order was for 7.5 ml. LVN 4 was observed discarding 15 ml of liquid iron sulfate into the medication cart trash bin and repouring 7.5 ml of the iron medication into another medication cup. When asked about his process when discarding medication, LVN 4 stated since the medication was liquid, it would be discarded in the trash bin. LVN 4 stated this was his normal process when he needed to discard liquid medications. On 4/8/26 at 1108 hours, a follow-up interview was conducted with LVN 4. LVN 4 verified he discarded the first liquid iron sulfate (15 ml) he prepared into the medication cart trash bin because he initially overpoured the medication and wanted to re-pour the right amount (7.5 ml) as ordered by the physician. LVN 4 stated there was a small red sharps container located in the medication cart where he would discard tablets, but he stated he did not use the sharps container to waste liquid medications. When asked about the facility's policy where to properly discard liquid medications, LVN 4 stated he would find out. On 4/8/26 at 1113 hours, a follow-up interview and concurrent observation was conducted with LVN 4. LVN 4 stated there was a container located inside the facility's biohazard room where the liquid medications were discarded. LVN 4 showed a white waste container with a blue lid inside the facility's biohazard room but stated he has never used the waste container to discard medications. On 4/8/26 at 1240 hours, an interview was conducted with the DON. The DON was informed of the above findings. The DON stated the licensed nurses were supposed to use the waste container inside the facility's biohazard room to discard non-controlled medication, including liquid medications. The DON stated the licensed nurses were provided with education on how to properly discard medications. On 4/9/26 at 1446 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, and facility P&P review, the facility failed to ensure the drugs, biologicals, or medical supplies were stored in a safely for one of 19 final sampled residents (Resident 6) and one nonsampled resident (Resident 91). * The facility failed to ensure Resident 6's Inhaler medication (ciclesonide) was not left at unattended at the resident's bedside. * The facility failed to ensure a packet of Vitamins A&D (skin protectant) ointment was properly stored for Resident 91. These failures had the potential to result in medications being contaminated, misused, or accidentally administered to the wrong resident.Findings: Review of the facility's P&P titled Medication Labeling, and Storage (undated) showed the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 1. Medical record review for Resident 6 was initiated on 4/7/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 2/1/26, showed Resident 6 had capacity to understand and make decisions. Review of Resident 6's Order Summary Report showed the following physician's orders: - dated 1/26/26, to administer ciclesonide (used to treat and prevent difficulty breathing, chest tightness, wheezing and coughing) inhalation 80mcg/act 1 puff inhale orally two times a day for Asthma, rinse mouth well after use. - dated 4/5/26, for Ciclesonide Inhalation Aerosol Solution 80mcg; one puff inhale orally two times a day for asthma. On 4/7/26 at 0852 hours, during the initial tour of the facility, an observation of Resident 6's room was conducted. An inhaler (handheld devices that deliver medication directly to the lungs to treat conditions like asthma) medication (ciclesonide) was observed unattended on top of the night stand on the left side of Resident 6's bed. On 4/7/26 at 0910 hours, an observation of Resident 6's room was conducted. The inhaler remained at the resident's bedside, unattended was still observed at the bedside left unattended. The facility staff, residents, and visitors were observed passing by the room, and a CNA entered to reposition the resident while the inhaler remained accessible. On 4/7/26 at 0930 hours, an observation and concurrent interview was conducted with LVN 1 inside Resident 6's room. LVN 1 verified the inhaler was left unattended and stated it should have been stored in the medication cart. LVN 1 stated leaving an inhaler at the bedside posed a risk for contamination or inappropriate use. On 4/10/26 at 1333 hours, an interview was conducted with the Administrator and DON. The DON stated inhalers and all the medications must be stored securely until needed. The Administrator and DON were informed and acknowledged the above findings. 2. On 4/7/26 at 0816 hours, during the initial tour of the facility, Resident 91 was observed sitting in bed with a packet of Vitamins A&D ointment on top of the bedside table. Medical record review for Resident 91 was initiated on 4/7/26. Resident 91 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 91's MDS assessment dated [DATE], showed the resident was cognitively intact. Review of Resident 91's Order Summary Report for April 2026 failed to show a physician's order for Vitamins A&D ointment. On 4/7/26 at 0843 hours, an observation and concurrent interview was conducted with Resident 91. Resident 91 stated the treatment nurse applied the ointment on her skin. On 4/7/26 at 0849 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 verified the ointment packet was on Resident 91's bedside table and stated the resident was not permitted to keep medications at the bedside. On 4/7/26 at 0853 hours, an observation and concurrent interview was conducted with RN 3. RN 3 verified the above findings. RN 3 stated the Vitamins A&D ointment should not have been left out at bedside because it was considered medication. On 4/7/26 at 0910 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated the Vitamin A&D ointment packet should have been returned to the treatment nurse and that a licensed nurse should obtain a physician's order before applying or storing the ointment for the resident. On 4/10/26 at 1317 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu and recipes were followed for one of 81 residents (Resident 14) who consumed food prepared in the kitchen. * The facility failed to ensure Resident 14 was served the braised cabbage as per the menu. This failure posed the risk of negatively impacting Resident 14's satisfaction and dietary compliance.Findings: Review of the facility's Diet Type Report dated 4/7/26, showed 81 of 87 residents consumed the food prepared in the kitchen. Review of the facility's P&P titled Menus (undated) showed menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Menus for regular and therapeutic diets are written at least two (2) weeks in advance and are dated and posted in the kitchen at least one (1) week in advance. The dietitian reviews and approves all menus. Review of the facility's document titled Week at a Glance (undated) showed the lunch menu for Wednesday, 4/8/26, was baked ham, whipped sweet potatoes, braised cabbage, cornbread, and banana gelatin. Medical record review for Resident 14 was initiated on 4/8/26. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Order Summary Report showed a physician's order dated 5/14/25, for Resident 14 to have a carbohydrate controlled, no added salt, regular texture, thin consistency, no caffeine, no decaf, fortified diet for liberalized diet. On 4/8/26 at 1240 hours, an observation of the tray line was conducted in the kitchen, Resident 14's noon meal ticket dated 4/8/26, showed baked ham, whipped sweet potatoes, braised cabbage, cornbread, and banana gelatin, water, melted margarine. Resident 14's lunch plate was observed with baked ham, whipped sweet potatoes, carrots, and cornbread. On 4/8/26 at 1240 hours, an interview and concurrent observation of Resident 14's meal tray was conducted with the DSS. The DSS verified Resident 14's tray had diced carrots instead of the braised cabbage. The DSS stated they ran out of the braised cabbage. On 4/8/26 at 1255 hours, an observation and concurrent interview was conducted with Resident 14. Resident was observed eating in her room. Resident 14 stated she was not informed by the staff she would receive carrots instead of the braised cabbage. Resident 14 further stated she liked cabbage. On 4/10/26 at 1302 hours, the DSS and Administrator were informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed. * The facility failed to conduct a facility-wide risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in facility water system. This failure posed a risk of exposure and potential illness to the residents, staff, and visitors by allowing unidentified and uncontrolled areas within the water system where Legionella and other opportunistic waterborne pathogens could grow. Findings: Review of the facility's P&P titled Legionella Water Management Program (undated) showed the facility was committed to the prevention, detection and control of water-borne contaminants, including legionella. The purpose of the water management program are to identify areas in the water system where legionella bacteria can grow and spread, and to reduce the risk of legionnaires disease. Further review of the P&P showed the identification of the situation that can lead to Legionella growth, such as :Construction;Water main breaks;Changes in municipal water quality;The presence of biofilm, scale or sediment;Water temperature fluctuations;Water pressure changes; and,Water stagnation; and inadequate disinfection. Review of CMS Quality, Safety and Oversight Group guidance titled Requirement to Reduce Legionella Risk in Healthcare Facility Water System to Prevent Cases and Outbreaks of Legionnaires' Disease revised 7/6/18, showed facilities must, at a minimum:- Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread.- Develop and implement a water management program that considers ASHRAE standards and the CDC toolkit.- Specify testing protocols, acceptable control measure ranges, and document testing results and corrective actions. Review of the facility's document titled Water System Flow Diagram showed the following:- The receiving water and the fire suppression sprinkler system in the kitchen were coded blue.- The cold water distribution system supplying the kitchen ice machine, and sinks and showers in resident care areas, was coded green.- The heating components, including the kitchen and laundry water heaters and the water heaters serving sinks and showers in resident care areas, were coded yellow.- The hot water distribution system supplying kitchen appliances, sinks, the dishwasher, resident care area sinks and showers, and laundry washing machines, was coded brown.- The sanitary sewer system was coded red. Review of the facility's document titled Areas Where Legionella Could Grow and Spread (undated) showed the same color coded descriptions as above but did not identify:- areas of potential water stagnation,- areas prone to temperature fluctuations,- areas where pressure changes could occur,- high risk locations for bacterial growth, or- the direction of water flow or sections of piping where hazardous conditions could develop. Review of the facility's documents related to Legionella and other opportunistic waterborne pathogens did not show evidence that the facility completed a comprehensive risk assessment identifying where pathogens could grow and spread within the water system. On 4/9/26 at 0941 hours, an interview and concurrent facility document review was conducted with the IP. The IP verified he document titled Areas Where Legionella Could Grow and Spread only identified water entry points, cold water distribution, and areas where water was heated and distributed. The IP confirmed the document did not include:- water flow direction,- identification of areas where stagnation, pressure changes, or temperature fluctuations could occur, or- identification of water system locations at highest risk for pathogen growth.When asked whether a facility wide risk assessment had been completed to identify where Legionella or other opportunistic waterborne pathogens could grow and spread, the IP was unable to provide documentation showing such an assessment had been done.The IP stated the facility had a water management program, monitored the water system, and conducted testing as needed; however, the IP could not provide documentation showing how the facility identified hazardous areas within the water system where opportunistic pathogens could grow. On 4/10/26 at 1020 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer and provide required education on the benefits and potential side effects for the seasonal influenza and pneumococcal immunizations for two of five residents (Residents 8 and 14) reviewed for the immunizations. * The facility failed to ensure Resident 8 was offered pneumococcal and seasonal influenza vaccinations and provided with education regarding their benefits and potential side effects. * The facility failed to ensure Resident 14 was offered seasonal influenza vaccination and provided with education regarding its benefits and potential side effects. These failures had the potential for the residents and/or their representatives not being informed of the benefits and risks of the seasonal influenza and pneumococcal vaccines to make an informed decisions and put the residents at increased risk of infection and transmission of influenza and pneumococcal vaccination.Findings: Review of the facility's P&P titled Influenza Vaccine dated 3/2022 showed all the residents and employees who have no medical contraindications to the vaccine will be offered influenza vaccine annually to encourage and promote benefits associated with vaccination against influenza. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. Prior to vaccination, the resident or their legal representative or employee will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. A resident refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the resident's medical record. Review of the facility's P&P titled Pneumococcal Vaccine dated October 2023 showed all the residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infection. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has completed the current recommended vaccine series. Before receiving a pneumococcal vaccine, the resident or their legal representative receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Resident/representatives have the right t refuse vaccination. If refused, appropriate information is documented in the resident medical records. 1. Medical record review for Resident 8 was initiated on 4/7/26. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 3/4/25, showed Resident 8 was competent and able to make decisions. Review of Resident 8's CAIR 2 report (undated) showed Resident 8 had not received pneumococcal and seasonal influenza vaccinations. Review of Resident 8's Immunization Report showed Resident 8 had refused both pneumococcal and influenza vaccines. Further review of Resident 8's medical record did not show if the Resident 8 was provided education regarding the benefits and potential side effects of the seasonal influenza and/or pneumococcal vaccines before refusing. 2. Medical record review for Resident 14 was initiated on 4/9/26. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's MDS assessment dated [DATE], showed Resident 8 was cognitively intact. Review of Resident 14's CAIR2 report (undated) showed Resident 14 had received influenza seasonal vaccine on 2/15/24, and was past due for the annual influenza vaccine as of 2/15/25. Review of Resident 14's Immunization Report showed Resident 14 refused the seasonal influenza vaccine. Further review of Resident 14's medical record did not show if Resident 14 was offered and provided education regarding the benefits and potential side effects of the season influenza vaccine. On 4/9/26 at 1015 hours, an interview and concurrent medical record review for Residents 8 and 14 was conducted with the IP. The IP stated the seasonal influenza vaccination should be offered every year. The IP verified the above findings. The IP stated he was not able to find the documented evidence to show if Resident 8 was offered or educated about the 2025 seasonal influenza and/or pneumococcal vaccine. The IP verified he could not find the documented evidence to show if Resident 14 was offered or educated regarding the benefits and potential side effects of the seasonal influenza vaccine. On 4/10/26 at 1020 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the residents were offered and provided education regarding the benefits and potential side effects of seasonal COVID-19 vaccine for two of five residents (Residents 8 and 14) reviewed for the COVID-19 immunization. * The facility failed to offer and provide education regarding the benefits and potential side effects of seasonal COVID-19 vaccine for Residents 8 and 14. This failure placed the residents at risk for increased risk of infection and transmission of COVID-19 and had the potential for the residents and/or their representatives not being informed of the seasonal COVID-19 vaccines.Findings: Review of facility P&P titled Coronavirus Disease (COVID-19) - Vaccination of Residents dated May 2023 showed each resident is offered COVID-19 vaccine unless the immunization is medically contraindicated or the resident is fully vaccinated. The resident (or resident representative) has the opportunity to accept or refuse a COVID-19 vaccine, and to change his/her decision. Before the COVID-19 vaccine is offered, the resident is provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. 1. Medical record review for Resident 8 was initiated on 4/7/26. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 3/4/25, showed Resident 8 was competent and able to make decisions. Review of Resident 8's CAIR2 report (undated) showed Resident 8 had not received seasonal COVID-19 vaccine and was past due as of 8/22/25. Review of Resident 8's Immunization Report showed Resident 8 refused the COVID-19 vaccine. Further review of Resident 8's medical record did not show documentation if Resident 8 was offered and provided education regarding the benefits and potential side effects of season COVID-19 vaccine prior to refusal. 2. Medical record review for Resident 14 was initiated on 4/9/26. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's MDS assessment dated [DATE], showed Resident 8 was cognitively intact. Review of Resident 14's CAIR2 report (undated) showed Resident 14 had received the seasonal COVID-19 vaccine on 5/7/24, and was past due for the next seasonal COVID 19 dose on 8/27/24. Review of Resident 14's Immunization Report showed Resident 14 refused the seasonal COVID-19 vaccine. Further review of Resident 14's medical record did not show documentation if Resident 14 was offered and provided education regarding the benefits and potential side effects of the seasonal COVID-19 vaccine prior to refusal. On 4/9/26 at 1015 hours, an interview and concurrent medical record review for Residents 8 and 14 was conducted with the IP. The IP stated the seasonal COVID-19 vaccone should be offered annually. The IP verified the above findings and stated he was not able to find the documented evidence to show if Residents 8 and 14 were offered and/or educated regarding the benefits and potential side effects of the seasonal COVID-19 vaccine for 2025. On 4/10/26 at 1020 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation and interview the facility failed to ensure the residents' care equipment was maintained in a safe operating condition. * One of four LVNs (LVN 1) observed for medication administration used a non-facility issued BP automatic machine to obtain Resident 6's BP prior to medication administration. The facility failed to ensure the calibration for the personal BP machine was conducted. This failure had the potential for the essential equipment not to function in the way it was intended and the risk of resulting in inaccurate resident BP measurements.Findings: Review of the Omron BP5100 (automated BP machine) Instruction Manual (undated) showed Home as the environment of use. On 4/8/26 at 0938 hours, a medication administration observation for Resident 6 was conducted with LVN 1. Prior to administering the medications for Resident 6, LVN 1 obtained the resident's BP reading using a non-facility issued automatic BP machine (Omron BP5100) and the resident's BP reading was 103/68 mmHg and heart rate was 68 beats per minute. On 4/8/26 at 1138 hours, an observation and concurrent interview was conducted with LVN 1 and LVN 3. The automated BP machine was observed labeled with [NAME]. LVN 3 stated the BP machine was his personal equipment and not facility issued. LVN 1 stated during the medication administration observation, his medication cart had no BP machine, or manual BP cuff but only a stethoscope, so he borrowed the Omron BP machine from LVN 3 and used it to obtain Resident 6's BP and heart rate measurements. On 4/8/26 at 1234 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed of the above findings. The DON was shown the Omron BP machine and was asked if the BP machine was facility issued. The DON was unsure, but the Administrator verified the BP machine was not facility issued. The Administrator stated the facility had facility issued vital signs machine towers for the staff to use. The DON stated the licensed nurses were not supposed to use their personal BP machines (brought from home). The DON was asked to provide the Omron BP machine's manufacturer's guidelines and documentation to show the calibration for the BP machine. On 4/8/26 at 1240 hours, a follow-up interview was conducted with the DON. The DON stated the facility did not have the manual/ manufacturer's guideline for the Omron BP machine and that the facility did not calibrate the Omron BP machine to ensure the BP machine was working properly and/or had accurate measurements. On 4/9/26 at 1426 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) maintained their highest practicable physical, mental, and psychosocial well-being as evidenced by: * The facility disregarded two separate physician's orders to have Resident 1 assessed by a dermatologist for the progression of a skin lesion/mass on the resident's left forearm, despite Resident 1's history of skin cancer. The lesion measured 0 cm in depth (height) on 3/3/23, increased to 0.5 cm on 4/5/23, and further grew to 3.7 cm in depth on 5/19/23. On 6/9/23, the mass was at least 5.0 cm in depth, until the resident was transferred to the acute care hospital for evaluation and treatment on 6/29/23. * Weekly Wound Evaluations were inconsistently conducted, with gaps of up to three weeks in between evaluations. During those periods, the mass exhibited growth of up to six times its previous size. These failures led to a delayed provision of care and services, which ultimately necessitated Resident 1's transfer to the emergency department and admission to the acute care hospital for the evaluation and treatment of the bleeding and rapidly growing arm mass. The biopsy of the mass revealed squamous cell carcinoma and given its size, made it a high-risk feature and increased the risk of locoregional and distant metastasis, according to the consulting dermatologist. Additionally, the dermatologist stated the delayed care will result in the resident undergoing a more extensive surgical procedure to remove the cancer and experiencing a longer healing time. Findings: Medical record review for Resident 1 was initiated on 7/5/23. Resident 1 was admitted to the facility on [DATE], transferred to emergency department on 6/29/23, and was admitted to the acute care hospital on 6/29/23. a. Review of the SOC 341 - Report of Suspected Dependent Adult/Elder Abuse dated 6/30/23, showed Resident 1 was transferred to the emergency department for a large mass on the left arm, presenting as early as April 2023. The SOC 341 reported Resident 1's responsible party had no knowledge of the large mass on Resident 1's arm. According to the report, the nursing facility staff had been aware of the progressively growing mass since April 2023 and were only providing daily dressing changes for it. The nursing facility did not arrange for Resident 1 to receive diagnosis and treatment until 6/29/23. The physician at the acute care hospital expressed concerns of possible medical neglect from the nursing facility due to the resident's wound and history of malignancy. Review of Resident 1's Emergency Department Note from the acute care hospital dated 6/29/23, showed Resident 1 had a history of basal cell skin cancer and squamous cell carcinoma in situ. On 7/5/23 at 1101 hours, a wound care observation for Resident 1 was conducted with LVN 1. Resident 1 had a dressing observed in place to the left forearm with a moderate amount of serosanguineous drainage noted. After removing the dressing, LVN 1 cleaned the skin mass with normal saline and patted the area dry. The mass appeared to be bright red, raw, was raised and had irregular borders, and was cauliflower-like in appearance. There was a moderate amount of active bleeding noted. LVN 1 verified the observation. Resident 1 denied having pain at the time, but stated the site was sometimes painful. LVN 1 measured the mass as 6.5 cm (length) X 5.5 cm (width) X 3 cm (depth). Review of Resident 1's Physician's Progress Notes dated 1/18/23, showed Resident 1 had a left upper extremity skin lesion and the physician recommended for the resident to consult the dermatologist for it. However, review of the physician's order dated 1/19/23, showed the order was transcribed as may have dermatology consult for the left forearm growth. A physician's order dated 1/27/23, showed Resident 1 could have a dermatology consultation as needed. Review of Resident 1's Progress Notes dated 1/27/23 at 1601 hours, showed Resident 1 was noted with a small, dry scab on the left anterior forearm measuring 1.0 cm (length) X 1.0 cm (width) X 0 cm (depth). After cleaning the area with normal saline, the scab fell off and left a lesion measuring the same size with noted light serosanguineous drainage (discharge that contains both blood and a clear yellow liquid known as blood serum). Review of Resident 1's Weekly Wound Evaluations completed by LVN 1 showed the following measurements of the resident's left forearm skin lesion/mass: - On 3/3/23, it was 2.0 cm (length) X 1.8 cm (width) X 0 cm (depth). - On 4/20/23, it was 2.5 cm (length) X 2.4 cm (width) X and 0.6 cm (depth), growing more than six times the size in depth since 3/3/23. Review of the physician's order dated 4/21/23, showed to obtain a dermatology consultation for Resident 1 for the growing skin lesion on her left forearm. Review of Resident 1's medical record did not show Resident 1 was evaluated by the dermatologist. On 7/5/23 at 1035 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 confirmed that he placed the dermatology consultation order dated 4/21/23, for Resident 1 after observing the growth of the skin lesion on her left forearm. LVN 1 also confirmed Resident 1 was not evaluated by the dermatologist as per the orders until she was transferred to the acute care hospital. LVN 1 stated it was the Case Manager's responsibility to arrange for the resident's consultation with the dermatologist. Upon reviewing Resident 1's Progress Notes, there was no documented evidence the facility had arranged a dermatology consultation for Resident 1 until 6/23 and 6/27/23. This was five months after the physician initially recommended it on 1/18/23, and two months after a second dermatology consultation was ordered on 4/21/23, when the lesion had already grown in size. On 6/9/23, the resident's forearm mass measured 4.5 cm (length) X 5.0 cm (width) and 5.0 cm+ (depth). On 7/5/23 at 1147 hours, an interview and concurrent medical record review was conducted with the Case Manager. The Case Manager stated she started the position in March 2023 and was not aware of Resident 1's orders for the dermatology consultation until June 2023 when she was working with Resident 1's insurance carrier to obtain the authorization for unrelated matters. The Case Manager stated getting authorization for the dermatology consultation could take time, so it was best to start working on it as soon as there was an order. After reviewing her emails and Resident 1's medical record, the Case Manger verified the facility did not begin arranging for the resident's dermatology consultation until 6/23/23. The Case Manager confirmed that Resident 1 was not evaluated by the dermatologist as per the physician's orders until she was transferred to the acute care hospital. On 7/5/23 at 1215 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated when he first saw Resident 1's skin lesion it looked like a skin tag. However, when he saw the lesion again sometime in June 2023, it had grown in size and resembled neoplasm (a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer) prompting the resident's transfer to the emergency department on 6/29/23, for further evaluation. The DON verified the Physician's Progress Notes dated 1/18/23, indicated Resident 1 had a skin lesion on the left upper extremity and the physician recommended a consultation with a dermatologist. The DON stated the physician's order for the dermatology consultation transcribed on 1/19/23, should not have been written as a PRN (as needed) order. The DON verified the Case Manager should work on arranging any consultations ordered as soon as there was an order for it as to not delay the resident's care. The DON confirmed Resident 1 was not evaluated by the dermatologist as per the physician's orders until she was transferred to the acute care hospital. Review of Resident 1's Weekly Wound Evaluations completed by LVN 1 showed the following measurements of the resident's left forearm skin lesion/mass: - On 4/20/23, it was 2.5 cm (length) X 2.4 cm (width) X 0.6 cm (depth), growing more than six times the size in depth since 3/3/23. - On 5/4/23, it was 2.7 cm (length) X 2.5 cm (width) X 0.6 cm (depth). - On 5/19/23, it was 3.3 cm (length) X 3.5 cm (width) X 3.7 cm (depth), growing significantly in length and width and more than six times the size in depth from the previous assessment. - On 5/26/23, it was 3.8 cm (length) X 4.2 cm (width) X and 4.2 cm+ (depth). - On 6/2/23, it was 4.3 cm (length) X 4.7 cm (width) X 4.8 cm+ (depth). - On 6/9/23, it was 4.5 cm (length) X 5.0 cm (width) X 5.0 cm+ (depth). Review of Resident 1's Transfer Form dated 6/29/23 at 1354 hours, showed Resident 1 had an unplanned transfer to the emergency department due to the progressively worsening of the left arm skin growth. Review of Resident 1's Emergency Department Note from the acute care hospital dated 6/29/23, showed Resident 1 presented with a left forearm large fungating mass measuring approximately 12 cm in diameter with slow oozing of blood. The dermatologist consulted recommended surgical consultation for possible removal of the mass. The CT scan was reviewed by the radiologist who noted a concern for the large soft tissue dermal mass concerning for malignancy. Review of Resident 1's Surgical Pathology report from the acute care hospital showed a shave biopsy on the left forearm mass was performed on 6/29/23. The result available on 7/5/23, revealed the presence of invasive moderately differentiated squamous cell carcinoma. On 7/7/23 at 0753 hours, an interview was conducted with Physician 1, the consulting dermatologist at the acute care hospital. Physician 1 emphasized that the rapidly growing and bleeding nature of the lesion was a clear indication to seek evaluation from a healthcare provider. Physician 1 stated the biopsy results confirmed the presence of squamous cell carcinoma; clinically, the skin mass measured at least 4 cm, indicating a high-risk feature that increased the resident's risk of both local and distant metastasis. Additionally, the delayed care will result in the resident undergoing a more extensive surgical procedure to remove the cancer and experiencing a longer healing time. b. Review of the facility's P&P titled Pressure Ulcers/Skin Breakdown - Clinical Protocol (undated) showed the licensed staff will evaluate the wound and document weekly the progress of wound healing, especially for those with complicated, extensive, or poorly-healing wounds. Wound status will be relayed to the physician for appropriate updated treatment. Review of Resident 1's Weekly Wound Evaluations completed by LVN 1 showed the resident's left forearm skin lesion/mass was not measured and evaluated weekly as per the facility's P&P as evidenced by: - On 3/3/23, it measured 2.0 cm (length) X 1.8 cm (width) X 0 cm (depth). However, there were no weekly wound evaluation performed for next three weeks until 3/27/23. - On 3/27/23, it measured 2.0 cm (length) X 1.8 cm (width) X 0.4 cm (depth). - On 4/5 and 4/12/23, it measured 2.2 cm (length) X 2.0 cm (width) X 0.5 cm (depth). - On 4/20/23, it measured 2.5 cm (length) X 2.4 cm (width) X 0.6 cm (depth), growing more than six times the size in depth since 3/3/23. There was no weekly wound evaluation performed for a week until 5/4/23. - On 5/4/23, it measured 2.7 cm (length) X 2.5 cm (width) X 0.6 cm (depth). However, there was no weekly wound evaluation performed for a week until 5/19/23. - On 5/19/23, it measured 3.3 cm (length) X 3.5 cm (width) X 3.7 cm (depth), growing significantly in length and width and more than six times the size in depth from the previous assessment. - On 5/26/23, it measured 3.8 cm (length) X 4.2 cm (width) X 4.2 cm+ (depth). - On 6/2/23, it measured 4.3 cm (length) X 4.7 cm (width) X 4.8 cm+ (depth). - On 6/9/23, it measured 4.5 cm (length) X 5.0 cm (width) X 5.0 cm+ (depth). However, there were no weekly wound evaluation performed for next three weeks until Resident 1 was transferred to the acute care hospital on 6/29/23. On 7/5/23 at 1035 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the above findings and confirmed he was supposed to conduct the weekly wound evaluations on Resident 1's left arm skin lesion/mass. On 7/6/23 at 0945 hours, an interview was conducted with the Administrator and DON. Both the Administrator and DON verified the weekly wound evaluations were required upon admission/readmission, weekly thereafter, for any change of condition, and annually. The DON explained the purpose of these evaluations was to monitor the wound's progress, assess whether it was improving or deteriorating, and adjust the treatment plan if necessary. On 7/12/23 at 1454 hours, a follow-up telephone interview was conducted with the DON. The DON stated that previously the Case Manager was solely responsible for obtaining authorizations for any consultations ordered and had no oversight to ensure it was being worked on. The DON stated moving forward, all ordered consultations will be discussed in the morning meetings to ensure they were carried out as ordered. Additionally, the DON stated only pressure-related wounds were audited to ensure the weekly wound evaluations were completed, but moving forward, the audits will include all wounds. Cross reference to F580.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for 15 of 15 residents (Residents 2, 10, 11, 24, 37, 39, 43, 53, 56, 63, 71, 76, 79, 92, and 394) who smoked in the facility. * The facility failed to ensure the safe smoking practices were followed for 15 residents who smoked in the facility as evidenced by: - The residents were not accurately and thoroughly assessed to determine if they required supervision or any adaptive safety equipment while smoking, nor if they could safely store their own cigarettes or lighters. - The residents who were assessed as requiring adaptive safety equipment, such as a smoking apron (a fireproof apron that protects the resident's body, clothing, and wheelchair from smoking-related injuries), were not provided with the adaptive safety equipment while smoking. - The residents who were assessed as requiring supervision while smoking or those with a history of non-compliance with the facility's smoking P&P were permitted to keep the cigarettes, lighters, and other smoking articles/materials in their possession. - The facility failed to address safe storage and use of the smoking articles. - The facility failed to ensure individualized care plan problems were developed to address the residents' safe smoking practices. - The residents were permitted to share smoking articles with the other residents. These failures posed the risk of fire and serious injuries to the residents who smoked and to the other residents who resided in the facility. On 8/18/22 at 1332 hours, the Administrator and DON were informed an IJ situation was identified due to the facility's failure to ensure safe smoking practices were followed for 15 of 15 residents (Residents 2, 10, 11, 24, 37, 39, 43, 53, 56, 63, 71, 76, 79, 92, and 394) who smoked in the facility as evidenced by: * The residents were not accurately and thoroughly assessed to determine if they required supervision or any adaptive safety equipment while smoking, nor if they could safely store their own cigarettes or lighters. * The residents who were assessed as requiring adaptive safety equipment, such as a smoking apron (a fireproof apron that protects the resident's body, clothing, and wheelchair from smoking-related injuries), were not provided with the adaptive safety equipment while smoking. * The residents who were assessed as requiring supervision while smoking or those with a history of non-compliance with the facility's smoking P&P were permitted to keep the cigarettes, lighters, and other smoking articles/materials in their possession. * The facility failed to address safe storage and use of the smoking articles. * The facility failed to ensure the individualized care plan problems were developed to address the residents' safe smoking practices. * The residents were permitted to share smoking articles with the other residents. On 8/19/22 at 1244 hours, the IJ was abated after the facility submitted a plan of corrective actions: * Conducted accurate and thorough assessments for all residents who smoked in the facility. * Developed and/or revised all 15 residents' care plan problems to address safe smoking practices. * In-serviced all staff on the facility's smoking P&P and safety measures related to smoking. * Implemented a supervised smoking schedule and ensured all residents who required adaptive safety equipment were provided with the equipment while smoking. * Ensured a list of the adaptive safety equipment (i.e. smoking apron and supervision) required for each resident while smoking was provided to the supervising staff. * Ensured the residents who required supervision were not permitted to keep the cigarettes, lighters, and other smoking articles in their possession. * Secured the smoking articles in a locked cart. * Educated the residents who smoked on the facility's smoking P&P and safe smoking practices. Findings: Review of the facility's P&P titled Smoking Policy - Residents revised February 2022 showed the facility shall establish and maintain safe resident smoking practices. The residents will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include their ability to smoke safely with or without supervision. The staff shall consult with the attending physician and DON to determine if safety restrictions need to be placed on a resident's smoking privileges. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. Any smoking-related privileges, restrictions, and concerns shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Only residents who have independent smoking privileges are permitted to keep cigarettes and other smoking articles in their possession. Residents are not permitted to give smoking articles to other residents. Residents without independent smoking privileges may not have or keep any smoking articles. 1.a. On 8/18/22 at 1100 hours, an observation of Resident 76 in the smoking patio was conducted with the Activity Assistant. The Activity Assistant stated she was assigned to supervise the residents who smoked. The Activity Assistant stated Resident 76 smoked regularly throughout the day. Resident 76 was observed lighting a cigarette using a lighter that he removed from his pant pocket. Resident 76 was observed with several burn holes on the sleeves of the jacket and shirt he was wearing. The Activity Assistant did not offer Resident 76 a smoking apron prior to or when the resident was observed lighting his cigarette. Resident 76 was observed inhaling several puffs from the cigarette, flicking the cigarette ashes onto the ground, and sharing the cigarette with another resident in the patio. The staff did not intervene nor remind the residents not to share their smoking articles or educate Resident 76 to use the nearby ash tray. The Activity Assistant verified Resident 76 kept his cigarettes and lighter in his possession. On 8/18/22 at 1118 hours, an interview was conducted with Resident 76. When asked if he had a lighter, Resident 76 removed a red lighter from his pant pocket. Resident 76 acknowledged he sometimes loaned his cigarettes and lighter to the other residents. When asked about the several burn holes on the jacket and shirt he was wearing, Resident 76 stated the burn holes were from smoking cigarettes. Medical record review for Resident 76 was initiated on 8/16/22. Resident 76 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 76's MDS dated [DATE], showed Resident 76 had severe cognitive impairment. Review of Resident 76's Quarterly Risk Data Collection Tool dated 7/25/22, showed Resident 76 could only sometimes recall the current season, that he was in a nursing home, the location of his room, and staff names and faces. The Quarterly Risk Data Collection Tool further showed Resident 76 had cognitive loss and required supervision and a smoking apron while smoking. Review of Resident 76's plan of care showed a care plan problem dated 6/8/21, showing Resident 76 was a supervised smoker and needed to be reminded not to give, sell, or lend smoking articles to the other residents. The interventions included to provide Resident 76 with the safety equipment as indicated. A care plan problem dated 7/19/21, addressing Resident 76 declining to use the smoking apron showed the interventions were to re-offer the smoking apron and explain the risks and benefits of using it. On 8/18/22 at 1236 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above information. The DON stated the residents who required supervision while smoking, had cognitive impairment, or those with a history of sharing their smoking articles were not allowed to keep cigarettes and lighters in their possession. The DON verified Resident 76 should not be permitted to keep the cigarettes and lighters in his possession because he required supervision while smoking, had cognitive impairment, and had a history of sharing his smoking articles with the other residents. The DON verified Resident 76 required a smoking apron while smoking to prevent injuries. The DON stated the smoking articles should not be shared between the residents in case it was given to a resident who could not smoke independently to prevent injuries. On 8/23/22 at 0950 hours, an interview was conducted with the DON. The DON verified a few articles of Resident 76's clothing, including his jacket and pants, were taken to be replaced because they had burn holes on them. b. Review of Resident 76's MDS dated [DATE], showed Resident 76 had severe cognitive impairment. Review of Resident 76's Quarterly Risk Data Collection Tool dated 7/25/22, showed Resident 76 could only sometimes recall the current season, that he was in a nursing home, the location of his room, and staff names and faces. The Quarterly Risk Data Collection Tool further showed Resident 76 had cognitive loss and required supervision and a smoking apron while smoking. However, review of Resident 76's Smoking assessment dated [DATE], inaccurately showed Resident 76 did not have cognitive loss. The assessment further showed Resident 76 required supervision while smoking, but was permitted to keep the cigarettes and lighters in his possession. On 8/18/22 at 1236 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 76 had severe cognitive impairment. The DON verified Resident 76 required supervision while smoking and should not be permitted to keep the cigarettes and lighters in his possession. The DON verified Resident 76's Smoking assessment dated [DATE] was not accurate. 2. On 8/16/22 at 0816 hours, Resident 2 was observed holding his own smoking materials and self-propelling his wheelchair coming from the patio area. Resident 2 stated he went to the smoking patio by himself and no staff present when he smoked. Medical record review for Resident 2 was initiated on 8/16/22. Resident 2 was readmitted to the facility on [DATE]. Review of the Quarterly MDS dated [DATE], showed Resident 2 had moderately impaired cognition. Review of the Quarterly Risk Data Collection Tool dated 7/28/22, under the Smoking section, showed Resident 2 was a smoker, did not have a cognitive loss, did not have any dexterity problem, and needed adaptive equipment such as an apron and cigarette holder. Resident 2 needed supervision when he smoked. Review of the Smoking assessment dated [DATE], showed Resident 2 had a dexterity problem and needed supervision. There was no check mark was placed in the yes or no column, next to question 8 which asked if the resident needed the facility to store cigarettes/lighter. Under the other information related to Smoking Assessment section showed Resident 2 liked to beg from others and asked for cigarette. Resident 2 had a problem lighting cigarette on his own and needed to be reminded to put out the trash after he smoked. Review of the plan of care showed a care plan problem was developed to address the risk for compromised health condition related to smoking. There was no care plan problem developed to address whether Resident 2 needed supervision for smoking, use of apron while smoking, and who was responsible for keeping his smoking materials. On 8/18/22 at 0756 hours, Resident 2 was observed self-propelling his wheelchair going to the smoking patio and using his own smoking materials. He was able to use his own lighter and not wearing an apron. The facility staff was present but did not offer the apron to Resident 2. On 8/18/22 at 0805 hours, an observation and concurrent interview was conducted with LVN 5. LVN 5 stated Resident 2 smoked in the patio area. On the bedside dresser of Resident 2, a disposable lighter was observed. LVN 5 was asked about the disposable lighter on top of the bedside dresser and stated Resident 2 did not let them have the smoking materials. LVN 5 verified the Resident 2 kept his own smoking materials. On 8/18/22 at 0840 hours, an observation and concurrent interview was conducted with CNA 4. CNA 4 stated Resident 2 smoked in the patio area more than five times per day. CNA 4 stated she did not see Resident 2 keeping his own smoking materials. However, when Resident 2 was self-propelling himself in his wheelchair, CNA 4 observed Resident 2 was holding his own disposable lighter and CNA 4 verified it. CNA 4 stated Resident 2 should not hold his own lighter for safety. On 8/18/22 at 0853 hours, an interview was conducted with the Activity Assistant. The Activity Assistant stated the smoking materials were kept in the safety cart in the activity room but not all residents smoking materials, and the other residents were allowed to keep their own smoking materials. The Activity Assistant stated Resident 2 kept his own smoking materials and did not need any apron when he smoked, and just needed a supervision. On 8/18/22 at 0932 hours, an interview and concurrent medical record review for Resident 2 was conducted with RN 1. RN 1 stated the smoking assessment was done upon admission and quarterly. RN 1 verified Resident 2 was a smoker and stated the cognition level of the resident was not stable and had episodes of angry outburst. RN 1 was asked if Resident 2 was able to keep his own smoking materials, RN 1 stated no because of his behavior. RN 1 verified the above findings. 3. Medical record review for Resident 37 was initiated on 8/16/22. Resident 37 was readmitted to the facility 10/23/20. On 8/16/22 at 0821 hours, an interview was conducted with Resident 37. Resident 37 stated he kept his own smoking materials and was able to show his blue color disposable lighter from his pocket. Resident 37 stated he went to the patio to smoke sometimes with the staff and sometimes no staff, and added no smoking schedule. Review of the Smoking assessment dated [DATE], showed Resident 37 smoked one to two times per day and did not need facility to store cigarette/lighter. Review of the Quarterly Risk Data Collection Tool dated 6/21/22, under smoking assessment, showed Resident 37 needed smoking apron, cigarette holder, and supervision. On 8/18/22 at 0932 hours, an interview and concurrent review of medical records for Resident 37 was conducted with RN 1. RN 1 reviewed the medical record and verified the above findings. 4. On 8/18/22 at 1101 hours, an observation and concurrent interview was conducted with Resident 11. Resident 11 was observed sitting in the wheelchair inside her room with an unzipped purse on her lap. An open pack of cigarettes and a lighter were observed sticking out from the purse. Resident 11 stated she was a smoker and she kept her own cigarettes and lighter. Several burn holes were observed on the right side of Resident 11's wheelchair seat cushion. When asked if they were cigarette [CONDITION(S)], Resident 11 answered yes. Medical record review for Resident 11 was initiated on 8/18/22. Resident 11 was readmitted to the facility on [DATE]. Review of Resident 11's MDS dated [DATE], showed Resident 11 had moderate cognitive impairment. Review of the Smoking assessment dated [DATE], showed Resident 11 had a cognitive loss and was not permitted to keep the cigarettes and lighter in her possession. The Smoking Assessment further showed Resident 11 had episodes of smoking outside the scheduled smoking times and being non-compliant with the facility's smoking policy. However, Review of Resident 11's Quarterly Risk Data Collection Tool dated 5/17/22, showed Resident 11 did not have cognitive loss and could only sometimes recall the current season, that she was in a nursing home, the location of her room, and staff names and faces. The Quarterly Risk Data Collection Tool further showed Resident 11 smoked five to 10 times a day and required supervision, a cigarette holder, and a smoking apron while smoking. Review of Resident 11's plan of care showed a care plan problem dated 3/28/18, addressing Resident 11 as a supervised smoker and needed to be reminded not to give, sell or borrow cigarettes to any other residents. Resident 11 required repetitive directions of the designated smoking area and had episodes of smoking outside of the smoking schedule times. The care plan further showed Resident 11 had episodes of being noncompliant with the facility's smoking policy. The interventions included to provide Resident 11 with the safety equipment as indicated and to check the resident for cigarette and lighting materials after a trip outside of the facility. The care plan failed to address safe storage and use of Resident 11's smoking materials. 5. On 8/18/22 at 1102 hours, an observation and concurrent interview was conducted with Resident 10. Resident 10 was observed lying in bed. Resident 10 stated she just got back from smoking. Resident 10 stated she kept her cigarettes and lighter and showed the smoking materials inside her purse. Medical record review for Resident 10 was initiated on 8/18/22. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's MDS dated [DATE], showed Resident 10 had severe cognitive impairment. Review of the Smoking assessment dated [DATE], showed Resident 10 had no cognitive loss and was not permitted to keep the cigarettes and lighter in her possession. The Smoking Assessment further showed Resident 10 was noncompliant with the smoking times and designated smoking area. Review of Resident 10's Quarterly Risk Data Collection Tool dated 5/19/22, showed Resident 10 did not have cognitive loss and could only sometimes recall the current season, that she was in a nursing home, the location of her room, and staff names and faces. The Quarterly Risk Data Collection Tool further showed Resident 10 smoked five to 10 times a day and required supervision, a cigarette holder, and a smoking apron while smoking. Review of Resident 10's plan of care showed a care plan problem dated 8/26/20, addressing Resident 10 as a supervised smoker and needed to be reminded not to give, sell or borrow cigarettes to any other residents. The care plan problem further showed Resident 10 needed repetitive directions of the designated smoking area. The interventions included to provide Resident 10 with the safety equipment as indicated. The care plan failed to address safe storage and use of Resident 10's smoking materials. 6. On 8/18/22 at 1100 hours, Resident 63 was observed lying in bed. Resident 63 stated she was a smoker and she kept her own cigarette and lighter inside her purse. Medical record review for Resident 63 was initiated on 8/18/22. Resident 63 was admitted to the facility on [DATE]. Review of Resident 63's MDS dated [DATE], showed Resident 63 had moderate cognitive impairment. Review of the Smoking assessment dated [DATE], showed Resident 63 had no cognitive loss and was permitted to keep the cigarettes and lighter in her possession. However, further review of the Smoking Assessment showed Resident 63 was noncompliant with the facility's smoking schedule and designated smoking area. Review of Resident 63's Quarterly Risk Data Collection Tool dated 7/12/22, showed Resident 63 did not have cognitive loss. The Quarterly Risk Data Collection Tool further showed Resident 63 smoked five to 10 times a day and required supervision, a cigarette holder, and a smoking apron while smoking. Review of Resident 63's plan of care showed a care plan problem dated 11/12/19, addressing Resident 63's smoking. The care plan problem showed Resident 63 was noncompliant with the facility's smoking policy and had a long history of sharing and asking for cigarettes and lighting materials from others, thus putting other residents at risk for unsupervised smoking. The care plan failed to address safe storage and use of Resident 63's smoking materials. 7. On 8/18/22 at 1107 hours, an interview was conducted with Resident 79. Resident 79 stated he was a smoker and he kept his own cigarettes and lighter. Medical record review for Resident 79 was initiated on 8/18/22. Resident 79 was admitted to the facility on [DATE]. Review of Resident 79's MDS dated [DATE], showed Resident 79 had moderate cognitive impairment. Review of Resident 79's Smoking assessment dated [DATE], showed Resident 79 had no cognitive loss and was not permitted to keep the cigarettes and lighter in his possession. Review of Resident 79's plan of care showed a care plan problem dated 8/9/22, addressing Resident 79's risk for injury related to smoking. The care plan problem showed Resident 79 had a history of falling while smoking. The interventions included storage of smoking material as per the facility's protocol (licensed nurse to monitor). 8. Medical record review for Resident 56 was initiated on 8/18/22. Resident 56 was readmitted to the facility on [DATE]. Review of Resident 56's MDS dated [DATE], showed Resident 56 had moderate cognitive impairment. Review of Resident 56's Smoking assessment dated [DATE], showed Resident 56 had no cognitive loss and was permitted to keep the cigarettes and lighter in his possession. However, review of Resident 56's Quarterly Risk Data Collection Tool dated 7/18/22, showed Resident 56 required supervision, a cigarette holder, and a smoking apron while smoking. Review of Resident 56's plan of care showed a care plan problem dated 7/19/21, addressing Resident 56's smoking. The care plan failed to address safe storage and use of Resident 56's smoking materials. 9. Medical record review for Resident 24 was initiated on 8/18/22. Resident 24 was readmitted to the facility on [DATE]. Review of Resident 24's MDS dated [DATE], showed Resident 24 had moderate cognitive impairment. Review of Resident 24's Smoking assessment dated [DATE], showed Resident 24 had no cognitive loss, but was not permitted to keep the cigarettes and lighter in her possession. The Smoking Assessment further showed Resident 24 had a history of smoking outside the designated smoking area of the facility. However, Review of Resident 24's Quarterly Risk Data Collection Tool dated 6/7/22, showed Resident 24 could only sometimes recall the current season, that she was in a nursing home, the location of her room, and staff names and faces. The Quarterly Risk Data Collection Tool further showed Resident 24 smoked five to 10 times a day and required supervision, a cigarette holder, and a smoking apron while smoking. Review of Resident 24's plan of care showed a care plan problem dated 8/1/20, addressing Resident 24's smoking. The care plan failed to address safe storage and use of Resident 24's smoking materials. 10. Medical record review for Resident 92 was initiated on 8/18/22. Resident 92 was admitted to the facility on [DATE]. Review of Resident 92's MDS dated [DATE], showed Resident 92 had moderate cognitive impairment. However, review of Resident 92's Smoking assessment dated [DATE], showed Resident 56 had no cognitive loss and was permitted to keep the cigarettes and lighter in his possession. Review of Resident 92's plan of care showed a care plan problem dated 7/26/22, addressing Resident 92's risk for injury related to smoking. The care plan problem showed Resident 92 was noted to share and ask for cigarettes/smoking materials from other residents. The care plan failed to address safe storage and use of Resident 92's smoking materials. 11. Medical record review for Resident 43 was initiated on 8/18/22. Resident 43 was readmitted to the facility on [DATE]. Review of Resident 43's MDS dated [DATE], showed Resident 43 had no cognitive impairment. Review of Resident 43's Smoking assessment dated [DATE], showed Resident 43 had visual deficit, required supervision while smoking, and was not permitted to keep the cigarettes and lighter in her possession. Review of Resident 43's Quarterly Risk Data Collection Tool dated 6/24/22, showed Resident 43 smoked five to 10 times a day and required 1:1 assistance, supervision, a cigarette holder, and a smoking apron while smoking. Review of Resident 43's plan of care showed a care plan problem dated 9/17/21, addressing Resident 43's smoking. The care plan failed to address safe storage and use of Resident 43's smoking materials. 12. Medical record review for Resident 39 was initiated on 8/18/22. Resident 39 was admitted to the facility on [DATE]. Review of Resident 39's MDS dated [DATE], showed Resident 39 had moderate cognitive impairment. However, review of Resident 39's Smoking assessment dated [DATE], showed Resident 39 had no cognitive loss and was permitted to keep the cigarettes and lighter in his possession. Review of Resident 39's plan of care showed a care plan problem dated 6/10/22, addressing Resident 39's smoking. The care plan failed to address safe storage and use of Resident 39's smoking materials. 13. Medical record review for Resident 53 was initiated on 8/18/22. Resident 53 was readmitted to the facility on [DATE]. Review of Resident 53's MDS dated [DATE], showed Resident 53 had no cognitive impairment. Review of Resident 53's Smoking assessment dated [DATE], showed Resident 53 required supervision while smoking, and was not permitted to keep the cigarettes and lighter in her possession. Review of Resident 53's Quarterly Risk Data Collection Tool dated 7/7/22, showed Resident 53 smoked five to 10 times a day and required supervision, a cigarette holder, and a smoking apron while smoking. Review of Resident 53's plan of care showed a care plan problem dated 7/19/21, addressing Resident 53's smoking. The care plan failed to address safe storage and use of Resident 53's smoking materials. 14. Medical record review for Resident 71 was initiated on 8/18/22. Resident 71 was admitted to the facility on [DATE]. Review of Resident 71's MDS dated [DATE], showed Resident 71 had moderate cognitive impairment. Review of Resident 71's Smoking assessment dated [DATE], showed Resident 71 required supervision while smoking and was not permitted to keep the cigarettes and lighter in his possession. Review of Resident 71's plan of care showed a care plan problem dated 8/9/22, addressing Resident 71's risk for injury related to smoking. The care plan problem showed Resident 71 had been observed asking and/or sharing smoking materials with other smokers. The care plan failed to address safe storage and use of Resident 71's smoking materials. 15. Medical record review for Resident 394 was initiated on 8/18/22. Resident 394 was readmitted to the facility on [DATE]. Review of Resident 394's MDS dated [DATE], showed Resident 394 had moderate cognitive impairment. Review of the medical record failed to show a smoking assessment was completed for Resident 394. Review of Resident 394's plan of care showed a care plan problem dated 8/15/22, addressing Resident 394's risk for injury related to smoking. The care plan problem showed Resident 394 required supervision and smoking apron while smoking. The care plan failed to address safe storage and use of Resident 394's smoking materials. On 8/18/22 at 1236 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated a Smoking Assessment was completed for the residents who wished to smoke upon admission, and the Quarterly Risk Data Collection Tool was completed quarterly and as needed. The DON verified the conflicting information on the residents' smoking assessments. The DON verified all residents were assessed to require smoking aprons while smoking; however, the residents were observed smoking without smoking aprons. When asked what the cigarette holder was, the DON stated he was not aware of the cigarette holder and the facility did not have one. The DON verified the residents' care plans failed to address safe storage and use of smoking materials. The DON stated he expected the facility staff to store/keep the cigarette and lighters for the residents who had cognitive impairment and required supervision while smoking, which meant all residents who smoked in the facility. However, the DON verified the residents were currently in possession of their cigarettes and lighters. The DON stated most residents who smoke had history of sharing their cigarettes to other residents posing the risk of not knowing if these residents were assessed as smokers or not. The DON verified the above findings.

Based on observation, interview and review of the clinical record and facility document, the facility failed to provide the necessary care and services to ensure the highest practicable level of psychosocial well-being related to dementia care and implement person-centered interventions for six of seven sampled residents (Residents 1, 2, 4, 5, 6 and 7). - For Resident 2, the facility failed to ensure the treating physicians evaluated the resident to determine a [DIAGNOSES REDACTED]. - For Resident 7, the facility failed to consistently communicate in her preferred language, resulting in functional decline, physical and psychological distress. - For Resident 5, the facility failed to have person-centered interventions. - The facility diagnosed Residents 1, 4 and 6 with dementia without clinical indications. These failures have affected psychosocial suffering to residents with dementia. Findings: 1. Clinical record review for Resident 2 was initiated on 7/31/14. Resident 2 was admitted to the facility on [DATE], with diagnoses, including senile dementia (decrease in cognitive abilities), unspecified [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder (mood swings that range from the lows of depression to the highs of mania). Review of Resident 2's admission face sheet identifies her as the responsible party for her care. Her occupation is listed as "unknown." Review of Resident 2's History and Physical dated 5/23/12, showed a [DIAGNOSES REDACTED]. Review of Resident 2's physician orders [REDACTED]. The www.lexi.com (a web-based internet site) showed: a. [MEDICATION NAME] is used for the treatment of [REDACTED]. A warning included: may cause CNS depression which may impair physical or mental abilities and may exacerbate or induce extrapyramidal symptoms; worsening of symptoms (e.g., tremors). b. [MEDICATION NAME] is used for the treatment of [REDACTED]. A Black Boxed Warning showed elderly patients with dementia-related [MEDICAL CONDITION] treated with antipsychotics are at an increased risk of death compared to placebo. It is not approved for the treatment of [REDACTED]. Review of Resident 2's MDS dated [DATE], showed she was cognitively intact and had no behavior episodes. Her active [DIAGNOSES REDACTED]. Review of Resident 2's Behavior Tracking record for June, 2014, showed she had 42 episodes of recurrent outbursts of anger and mood swings. Review of Resident 2's Psychologist Progress Note dated 7/17/14, showed the resident had "very irritated, multiple suspiciousness, symptoms of senile dementia was apparent in the beginning of the session." No documentation was available to show Resident 2 was evaluated or re-evaluated to confirm her [DIAGNOSES REDACTED]. On 7/31/14 at 1205 hours, Resident 2 was observed in the dining room. She was able to cut her own food and feed herself. During an interview on 7/31/14 at 1455 hours, LVN 4 stated Resident 2 was alert and oriented. She stated Resident 2 had no behavior episodes but had tremors of her hands. On 7/31/14 at 1545 hours, an interview was conducted with Resident 2. She was alert and oriented and stated her previous occupations were a CNA and a clerk. Resident 2 stated she had hand tremors and was receiving [MEDICATION NAME] (antianxiety) and [MEDICATION NAME] (aid in the treatment of [REDACTED]. She stated she is able to ambulate with a walker when assisted by staff. On 8/1/14 at 0600 hours, Resident 2 was observed in the dining room waiting for breakfast. She stated she is an early riser and goes to bed early. During an interview on 8/1/14 at 0605 hours, LVN 1 stated Resident 2 has a daily routine. She stated if the resident's routine is changed, it messes up the resident's whole day. During an interview on 8/1/14 at 0615 hours, CNA 2 stated Resident 2 is alert and orient and is able to make her needs known. She stated Resident 2 always gets up and out of bed by 0500 hours. CNA 2 stated she is unaware of Resident 2 having angry outbursts. She said Resident 2 is a very social person and likes to talk. During an interview on 8/1/14 at 0700 hours, LVN 2 stated Resident 2 is alert and oriented and able to make her needs known. She was unaware of Resident 2 having any behavior episodes, except that the resident gets upset about gaining weight. During a telephone interview on 8/1/14 at 0925 hours, Resident 2's psychologist stated Resident 2 has diagnoses, including senile dementia. When asked how she has determined the [DIAGNOSES REDACTED]. The psychologist stated she did not complete a mini-mental examination on Resident 2. When asked if she felt Resident 2 had dementia, the psychologist stated she would have to do a further examination to make that determination, she only took the information from physician's assessment of Resident 2. During a telephone interview on 8/1/14 at 0930 hours, Resident 2's psychiatrist stated Resident 2 has a [DIAGNOSES REDACTED]. He said Resident 2 has angry outbursts, yells if she does not get what she wants and is sometimes unreasonable. The psychiatrist stated Resident 2 has some memory loss but does not have "full-blow dementia." During an interview on 8/1/14 at 0945 hours, CNA 1 stated Resident 2 is alert and oriented and able to make her needs known. She stated Resident 2 sometimes will scream out if the staff does not attend to her needs fast enough. During a telephone interview on 8/1/14 at 1000 hours, Resident 2's physician stated Resident 2 has "senile dementia." He stated if a resident is "old and confused, that is dementia." Her physician stated he could not recall if Resident 2 had any radiology tests to determine dementia. He stated if the test does not show any (brain) atrophy, it still can be dementia. Resident 2's physician stated Resident 2's mentation fluctuates, some days she is forgetful. He reiterated dementia is based on a clinical examination; if old and confused then the resident has dementia. On 8/1/14 at 1025 hours, a follow-up interview was conducted with Resident 2. She stated she has had a [MEDICAL CONDITION] [DIAGNOSES REDACTED]. During an interview on 8/1/14 at 1340 hours, the DSS stated Resident 2 is receiving medications for a [MEDICAL CONDITION] disorder. He stated Resident 2 has episodes of getting angry and yelling if she does not get help as soon as she wants it. In addition, the DSS stated the resident attends the monthly Behavior Management meetings where the resident's medications are reviewed by the IDT and the psychiatrist. He was unaware of the reason the psychiatrist did not attend the quarterly QAA meetings. When asked about the plans of care with dementia residents, the DSS stated every day he sits down and talks to the dementia residents for approximately five minutes. 2a. Clinical record review showed Resident 7 was an [AGE] year-old admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. According to the Alzheimer's Foundation of America, dementia is a general term that describes a group of symptoms, such as loss of memory, judgment, language, complex motor skills and other intellectual functions due to permanent damage or death of the brain's nerve cells, or neurons. Review of Resident 7's multi-disciplinary MDS 3.0 (a federally mandated assessment for nursing home residents) dated 7/18/14, showed Resident 7 was Hispanic or Latino but did not identify a preferred language for communication. Resident 7's cognitive assessment (BIMS) indicated a score of seven, meaning Resident 7 was severely cognitively impaired. Resident 7 was assessed to usually be understood and understand conversations. Resident 7's MDS assessment further showed an absence of behavioral symptoms, such as hitting, kicking, or threatening others. Resident 7 was able to use a walker with one-person staff assistance and was assessed to have no pain. Review of Resident 7's comprehensive plans of care showed no language preference. The plan of care for activities did not show a potential language barrier. Review of the facility's P&P titled Care Plans-Comprehensive, revised in 4/10, showed "The comprehensive care plan is based on a thorough assessment that includes, but not limited to, the MDS. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change...Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas..." During an interview on 7/31/14 at 1140 hours, the Administrator and DON stated the facility's resident population included primarily English and Spanish speaking residents. On 7/31/14 at 1745 hours, Resident 7 was observed sitting in a wheelchair outside of her room across from the nursing station by herself wearing a sling on her right arm and shoulder. Resident 7 was occasionally verbalizing short phrases in Spanish and appeared somewhat anxious and fidgety. Further review of Resident 7's clinical record showed the x-ray report dated 7/22/14 (11 days after Resident 7's admission) indicating a probable rotator cuff (tendons and muscles that allow movement of the upper arm) tear of her right shoulder, an MRI (equipment that uses a large magnet and radio waves to view body tissues and diagnose conditions such as torn ligaments) was ordered. Resident 7's clinical record contained documentation the MRI was not performed on 7/29/14, due to "patient very uncooperative, unable to hold still." According to www.webmd.com/fitness-exercise/guide/rotator-cuff-tear, rotator cuff tears usually cause shoulder and arm pain. During a telephone interview on 8/1/14, beginning at 0935 hours, Resident 7's RP stated her mother was conversant in Spanish and English, and she had brought the staff's attention to Resident 7's right shoulder and arm pain when visiting on 7/21/14. The RP stated she was unable to accompany Resident 7 when the MRI was scheduled on 7/29/14, and was told by the staff that Resident 7 was not cooperative for the MRI procedure. Resident 7's RP stated, "she is different since she came here (to the facility) - kind of scared." b. Further clinical record review indicated Resident 7 had a physician's orders [REDACTED]. On 8/1/14 at 1305 hours, Resident 7 was observed for treatment in the PT department. PT 1 and another staff who spoke only English to Resident 7 assisted the resident to stand up from the wheelchair. During an interview on 8/1/14 at 1120 hours, the Director of Rehabilitation Services stated she had assessed Resident 7 on 7/14/14, (three days after admission) and no right arm or shoulder problem was identified. She further stated since the 7/22/14 rotator cuff injury, Resident 7 could no longer use a walker but was wheelchair bound. During an interview on 8/1/14 at 1140 hours, CNA 3 stated Resident 7 was cooperative with care when provided explanation as to what care was going to be provided. CNA 3 stated Resident 7 was now a two person (not one person) transfer from the bed due to her unsteadiness and wheelchair bound. CNA 3 further indicated she spoke Spanish in response to Resident 7's preference to speak Spanish or English based on Resident 7's preference. On 8/1/14 at 1200 hours, CNA 3 and another CNA were observed transferring Resident 7 from her bed to her wheelchair. Both CNAs were observed speaking English. Resident 7 appeared unsteady during the transfer. c. During an interview on 8/1/14, the Activities Director confirmed she spoke Spanish to Resident 7 as she was able to engage Resident 7 better than when she spoke English. During an interview on 8/1/14, beginning at 1325 hours, the DON confirmed the facility had not developed a comprehensive plan of care to guide staff with regard to Resident 7's language preferences and acknowledged residents with dementia who prefer speaking Spanish should be provided care by staff conversant in Spanish. The DON was unable to explain what behavior interventions could have been implemented on 7/29/14, to ensure Resident 7 did not refuse the diagnostic MRI procedure and delay appropriate and timely treatment. The DON acknowledged Resident 7's functional decline with regard to her mobility since the probable rotator cuff tear was identified on 7/22/14. 3. Clinical record review for Resident 5 was initiated on 8/1/14 at 1245 hours. Resident 5 was admitted in 2008, with [DIAGNOSES REDACTED]. Resident 5's most recent admitted d 1/8/13, included [DIAGNOSES REDACTED]. Resident 5 was discharged to the acute hospital on [DATE], after she became aggressive, agitated and was experiencing poor judgement. The facility cleared Resident 5 of any medical issues and sent her to the acute hospital's emergency department to be evaluated. The psychiatrist diagnosed Resident 5 with [MEDICAL CONDITION] not otherwise specified and moderate to severe medical and psychosocial decline. Psychology notes dated 5/1/14, showed Resident 5 talked to angels. Instructions to staff included to encourage expression of feelings and provide support. Recent psychiatry notes dated 5/14 to 7/14, showed Resident 5 had impaired judgement, was fixated on going home and still had auditory hallucinations. She was experiencing further memory loss and becoming accusatory. a. The [MEDICAL CONDITION] Tracking Record, dated 2014, showed Resident 5 still had visual hallucinations ranging from 1 to 51 per month. The care plan for risk for increasing confusion secondary to dementia was initiated on 5/16/14. The goal was "Resident will not have increased confusion demonstrated by knowledge of:_____". The space was left blank, indicating it had not been personalized for Resident 5. The approaches were all preprinted with no person-centered adjustments. There was a second care plan dated 7/29/14, addressing altered thought process related to dementia. The care plan did not have any person-centered information entered and all approaches were preprinted and indicated by a checkmark. Review of the CAA dated 1/25/14, showed Resident 5's cognitive loss and dementia put her at a risk for decline. The CAA reflected the facility would care plan the dementia in order to slow or minimize the decline, avoid complications and minimize risks. Review of the SSD notes dated 7/11/14 showed Resident 5 had confusion due to mental illness. There were no updates to her care plan and no indications for non-pharmalogical interventions. The note further showed she required 24 hour nursing care and Resident 5 had no unmet needs at this time. Review of the Quality of Life Quarterly assessment dated [DATE], showed Resident 5 was alert and oriented X 3 (person, place and time) with episodes of confusion. The facility was to provide Resident 5 with a monthly activity calendar and encourage and remind her to attend group activities. Her preferred activities were listed as group, independent and in room, and she enjoyed sitting in the front lobby socializing with others. There was no reference to music or dance, her favorite activities per her RP. The RP also mentioned during an interview on 8/1/14, that Resident 5 was a ballet dancer for a large internationally known ballet company. b. On 7/31/14 at 1935 hours, LVN 1 was observed trying to administer medications to Resident 5. LVN 1 informed the surveyor it was her third attempt to give Resident 5 her evening medication. Resident 5 was sitting on the couch in the front lobby with her eyes closed. Upon arousal, Resident 5 refused to get up and go to her room. Resident 5 told LVN 1 if she wanted her to take medications, she should have brought them with her. LVN 1 told Resident 5 she needed to be in her room to take her medications. There was no explanation or documentation as to why Resident 5 could not take her medications at her preferred location. On 8/1/14, clinical record review showed LVN 1 completed a communication form stating Resident 5 refused to take her medications. Documentation showed LVN 1 contacted the physician who ordered laboratory tests to rule out medical indications for her refusal of medications. Documentation showed each time LVN 1 offered Resident 5 medications, at 1800, 1900 and 1935 hours, she documented the resident refused to go to her room. The LVN documented she explained the risks and benefits each time and approached the resident in a calm manner. The LVN did not say why Resident 5 could not take her medications in the front lobby. Review of the facility's P&P titled Documentation of Medication Administration dated 2001 and revised 4/07, shows privacy should be provided if appropriate. The P&P titled Change in a Resident Condition or Status dated 2001 and revised 4/07, indicates the physician should be notified for refusal of treatments or medications if refused more than 2 consecutive times. c. On 8/1/14 at 1330 hours, an interview was conducted with Resident 5's RP. When asked if he had brought up any issues with the facility, he stated Resident 5 is always complaining her teeth hurt. Resident 5 has a smile full of natural teeth which are quite worn down with brown and black stains on them. Clinical record review on 8/1/14, showed Resident 5 sees the dental technician at least quarterly. Review of the Dentition note dated 5/28/14, showed Resident 5 had good motivation for treatment but refused any x-rays or fillings and desired treatment on emergency bases only. There was no documentation to show the nursing staff was aware of the dental notes. 4. Clinical record review for Resident 6 was initiated on 8/1/14. Resident 6 was admitted to the facility on [DATE], with diagnoses, including depression, dementia - unspecified without behavior disturbances and unspecified [MEDICAL CONDITION]. Resident 6 was admitted from the acute care hospital following a short stay related to recent falls at her assisted living facility. Her primary care physician is the facility's Medical Director. Resident 6 had a neurology consult in the acute care hospital at the request of her primary care physician. The neurological evaluation included a history of psychiatric illness which was "unclear" and medications which include [MEDICATION NAME] (an antipsychotic used to treat problem behaviors). The evaluation further notes Resident 6 was alert and oriented, and her gross mental status and speech appear normal. The assessment included no mention of dementia, [MEDICAL CONDITION], or any behaviors. On admission to the facility, Resident 6 had a psycho-social assessment form completed and dated 6/20/14. This form notes her [DIAGNOSES REDACTED]. Resident 6 was noted to be alert and oriented to person, place, time and event; had short-term and long-term memory intact and had good judgement. The form further listed she had no history of mental illness,and referral to psychology and psychiatry will be as needed. There were no psychology or psychiatry visits in the clinical record. The nursing admission and assessment dated [DATE], listed Resident 6 was alert and verbal, able to make decisions and cooperative. There were no behaviors or altered cognition noted. The nurse's notes dated 7/31/14, indicated Resident 6's [MEDICATION NAME] was discontinued per pharmacy recommendations because Resident 6 did not have any auditory hallucinations. Review of an IDT note dated 7/1/14, showed Resident 6 was alert and oriented to person, place, time and event. The note further states her outcome was listed as stable, and the team reviewed all medications and treatment with the MD__, family__, and the Resident__, although none were indicated with check marks. Her pyschotherapeutic drugs were listed [MEDICATION NAME](a sleeping pill), [MEDICATION NAME] (antidepressant) and [MEDICATION NAME], with no indication for use, but it was documented Resident 6 was "recently admitted ". The box indicating the medications continue to be appropriate and necessary was marked "yes". Review of Resident 6's CAA sheet dated 7/3/14, showed a BIMS of 15/15, showing Resident 6 was cognitively intact. The narrative notes documented [MEDICAL CONDITION] medications use for psychotic mood disorder but listed no symptoms or behaviors. Review of a care plan for dementia showed the plan was initiated on 6/22/14. The only goal was Resident 6's daily ADL needs would be anticipated for 3 months. There was no indication as to which approaches would be used, but they were all pre-printed. Review of the care plan for anti-psychotic medication dated 6/22/14, showed [MEDICATION NAME] was used for psychotic mood disorder, manifested by auditory hallucinations, or hearing voices. The only goal was to have no side effects from the medication for 3 months. The only approach indicated was to always approach resident calmly and unhurriedly and speak in a calm voice. This care plan was noted to be discontinued on 7/31/14. A care plan for [MEDICAL CONDITION] medication dated 7/3/14, had only one goal to show minimal/no side effects of medication by 90 days. The appropriate interventions for Resident 6 were all pre-printed and not person centered. Review of the PRN psychoactive/[MEDICAL CONDITION] assessment flowsheet for the month of July 2014, showed the only PRN medication used in July [MEDICATION NAME] was used every night, with one exception since it was ordered. During an interview with Resident 6 on 7/31/14 at 1900, she stated she is unaware of any [DIAGNOSES REDACTED]. During two days of observations, Resident 6 was able to recognize and remember the surveyor, answer questions appropriately, showed no behaviors and could appropriately state the schedule of her favorite baseball team. Resident 6, being her own RP, was not aware of any diagnoses, including dementia or [MEDICAL CONDITION]. 5. On 7/31/14, the Administrator was requested for a list of all their residents with dementia. Review of the list showed Resident 1's name was included. On 7/31/14 at 1430 hours, Resident 1 was observed laying in bed. The surveyor introduced herself to Resident 1. The resident stated the surveyor's name sounded like her name since the first two letters on the resident's name is the surveyor's name. The surveyor told Resident 1 her full name and the resident said it is a Spanish name. The resident then informed the surveyor she has been staying in bed because she has been sick the past days with "pneumonia" (infection of the lungs) and her doctor had ordered a chest x-ray and an antibiotic. Resident 1 also said she preferred to stay in her room because of her poor eyesight and she loves listening to her talking books. She also stated she loves detective stories like Perry Mason and Agatha Christie. When asked how she gets her books, she said the Activity Director gets it for her. She stated when she is done with the book that she is listening to, she would wheel herself to the Activity Director's office to have it exchanged. On 7/31/14 at 1445 hours, LVN 1 was interviewed. When asked about Resident 1's cognition, LVN 1 stated the resident is alert and oriented. On 7/31/14 at 1446 hours, clinical record review for Resident 1 was initiated. Documentation showed the resident's primary care physician is the Medical Director. Review of the physician's orders [REDACTED]. On 7/31/14 at 1550 hours, the surveyor went back to Resident 1's room. When the surveyor asked the resident if she could enter the room, the resident said, "Oh it is you .......(surveyor's name)!" The resident was able to remember the surveyor's name. On 8/1/14, review of the clinical record was continued. Review of the Order Summary Report dated 6/26/14, and signed by the Medical Director on 7/7/14, showed the listed [DIAGNOSES REDACTED]." Review of the MDS, with an assessment completion date of 5/2/14, showed under Section I, one of the resident's active [DIAGNOSES REDACTED]. Section C of the same MDS showed a BIMS score of 15,which is indicative of a cognitively intact resident. Further review of the clinical record failed to find a care plan addressing the resident's dementia nor was there documented evidence Resident 1 was evaluated to confirm her [DIAGNOSES REDACTED]. During two days of observations, Resident 1 was able to recognize and remember the surveyor, answer questions appropriately, showed no behaviors, and could appropriately name the staff, the years the staff had worked at the facility and their positions. On 8/1/14 at 1030 hours, the DON was requested to find documentation when Resident 1 was first diagnosed with [REDACTED]. There was no documentation in the current clinical record and the archived clinical record showing Resident 1 was evaluated to confirm the [DIAGNOSES REDACTED]. 6. Resident 4's clinical record was reviewed on 8/1/14. Review of the Order Summary Report dated 7/29/14, showed the listed [DIAGNOSES REDACTED]." The medications listed in the Order Summary Report included [MEDICATION NAME] sprinkles 500 mg two times per day related to [MEDICAL CONDITION] disorder manifested by laughing loudly to self; [MEDICATION NAME] 300 mg one tablet three times per day related to unspecified [MEDICAL CONDITION] manifested by persistent expansive mood; and [MEDICATION NAME] 10 mg two times per day for unspecified [MEDICAL CONDITION] manifested by hallucinations. Review of the comprehensive care plan showed a care plan problem, addressing the risk for increasing confusion secondary to dementia. Review of the MDS, signed as complete by the RN Assessment Coordinator on 6/17/14, showed a BIMS total of 9 (moderately impaired). Further review of the clinical record showed no documented evidence the resident was evaluated to confirm the dementia diagnosis.

Based on interview and clinical record review, the facility failed to administer [MEDICATION NAME] (a medication used to prevent [MEDICAL CONDITION]) to Resident 1 as ordered by the physician for 12 days. As a result, Resident 1 had several [MEDICAL CONDITION] and was transferred to the acute care hospital and admitted . The facility failed to administer Atrovent and [MEDICATION NAME] (inhaled medications used to prevent wheezing for residents with [MEDICAL CONDITION] and other respiratory conditions) to Resident 1 as ordered for 10 days. Resident 1 experienced wheezing and shortness of breath while at the facility. Upon transfer to the hospital, Resident 1 was diagnosed with [REDACTED]. The facility failed to ensure Resident 1 had a consultation with a neurologist (a physician who specializes in conditions of the brain and nervous system) as ordered. Resident 1 had a recent hospitalization and was treated for [REDACTED]. The failure to follow up on a neurological consultation had the potential for a delay in treatment and services. Findings: a. On 6/11/12, clinical record review for Resident 1 was initiated. The resident was admitted on [DATE], from the acute care hospital. Resident 1 was dependent on staff for all activities of daily living. The H&P dated 4/12/12, showed the resident had a [MEDICAL CONDITION] disorder and [MEDICAL CONDITION]. Review of the acute care hospital's Discharge Medication Reconciliation form dated 4/10/12, (sent with the resident upon admission to the facility), showed an order to continue [MEDICATION NAME] 60 mg twice daily. The form also showed orders to continue Atrovent 0.5 mg inhalant every six hours and [MEDICATION NAME] 0.63 mg inhalant every six hours. However, review of the Physician Admitting Orders forms dated 4/10/12, showed no orders to continue the [MEDICATION NAME], Atrovent and [MEDICATION NAME]. The facility's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the nurse's notes dated 4/20/12 at 0900 hours, showed Resident 1 had a [MEDICAL CONDITION] approximately two minutes. The note showed, at 1015 hours, the resident had another [MEDICAL CONDITION] approximately two minutes. The Daily Skilled Documentation forms dated 4/20/12 through 4/22/12, showed Resident 1 had wheezing, coughing and shortness of breath. The nurse's note dated 4/22/12 at 0615 hours, showed Resident 1 was being monitored for two [MEDICAL CONDITION] which occurred at the beginning of the shift (no specific times of [MEDICAL CONDITION] entered). The physician's orders [REDACTED]. The Resident Transfer Record dated 4/22/12, showed Resident 1 was transferred to the hospital for shortness of breath and fever. The nurse's note dated 4/22/12, showed Resident 1 was admitted to the acute care hospital due to multiple [MEDICAL CONDITION]. On 6/11/12 at 1515 hours, during an interview and clinical record review with RN 2, the RN stated Resident 1 was admitted to the facility on [DATE], with admission orders [REDACTED]. RN 2 stated she called the resident's physician to confirm the orders sent from the hospital but she "missed" the page of orders showing the [MEDICATION NAME], Atrovent and [MEDICATION NAME]. The RN stated this page of medications was not discussed with the physician and were not continued at the facility. Review of the acute care hospital's Emergency Department Physician Encounter Sheet form dated 4/22/12, showed Resident 1 was transferred to the hospital due to multiple [MEDICAL CONDITION] and an elevated temperature. The form showed Resident 1 had a sub-therapeutic level of [MEDICATION NAME] in his blood stream, rhonchi (a coarse rattling sound in the lungs caused by secretions), and pneumonitis (inflammation of the lungs). The acute care hospital's laboratory results dated [DATE], showed Resident 1 had a [MEDICATION NAME] level of 7.2 ug/ml (normal range is 15 to 40 ug/ml). The acute care hospital's neurology consultation report dated 4/23/12, showed Resident 1 had a recent prolonged stay at the hospital, and his [MEDICAL CONDITION] were stabilized prior to admission into the facility. The report showed Resident 1 had been improving at the facility and was preparing to discharge home, but was noted with several [MEDICAL CONDITION] at the facility. The report showed Resident 1 had been placed on [MEDICATION NAME] at the hospital, prior to admission into the facility. The physician noted the [MEDICATION NAME] was effective; however, it was not continued at the facility, and the [MEDICAL CONDITION] re-occurred. The pulmonology consultation dated 4/22/12, showed Resident 1 had acute [MEDICAL CONDITION] and was treated with antibiotics and placed on a ventilator. b. Review for Resident 1's clinical record showed Resident 1 had a recent history of [MEDICAL CONDITION] and was being treated by a neurologist. The Physician Admitting Orders dated 4/10/12, showed an order for [REDACTED]. On 6/11/12 at 1140 hours, during an interview and clinical record review with the SSD, the SSD stated his department would not follow up on obtaining a neurology consultation. The SSD stated the nursing department would follow up with that type of consultation. On 6/11/12 at 1145 hours, during an interview and clinical record review with RN 1, RN 1 stated the nursing department would arrange a neurology consultation by finding which physician the consultation should be with, then calling their office and arranging an appointment. RN 1 stated this consultation was not arranged for Resident 1. RN 1 stated she would check with medical records to see if they had any paperwork. On 6/11/12 at 1200 hours, during an interview with the medical records employee, he stated he did not have any paperwork related to Resident 1's neurology consultation; maybe the business office did. On 6/11/12 at 1530 hours, during an interview with the DON, the DON stated the business office employee has been on a leave of absence since 4/8/12. The DON stated they facility has no paperwork to show a neurology consultation was done for Resident 1 or that a request of authorization was ever made to the resident's insurance.

Based on observation, interview and clinical record review, the facility failed to protect all residents in the facility by not securing and locking the building during the night or early morning hours. According to staff, the facility is located in a crime "hot spot" and gang graffiti is reportedly removed daily from the building exterior walls. On 5/24/11 at 0630 hours, three windows and three doors of the facility's perimeter were found open and/or unlocked. On 5/26/11 at 0630 hours, two windows and two doors to the perimeter were found unlocked. The facility did not use any type of lock or other device to prevent a potential intruder from entering open windows or doors at night; or from allowing resident(s) to elope unnoticed. In addition, the facility has a sliding glass door and a window with inoperable locks; the window was not able to lock and the sliding glass door would not consistently lock. Interviews confirmed staff were opening windows and doors in residents' rooms and conference room to allow air to circulate at night. The conference room was not occupied at night and not in view from the nurses' station; potentially allowing an intruder to enter the building unseen. In addition, Resident B stated she has not had the sliding glass door in her room locked in over four or five months and she worries about her safety. On 5/26/11 at 0900 hours, the facility's Administrator, DON and Maintenance Supervisor were notified that Immediate Jeopardy was identified due to the lack of safety and security of residents at night. On 5/27/11 at 1500 hours, the Administrator, DON, and Maintenance Supervisor were notified Immediate Jeopardy was abated. The actions taken by the facility to abate the Immediate Jeopardy are as follows: Developing a new P&P to address building security entitled "Facility Security - Doors and Windows" and new locks installed on all exterior windows and doors. A contractor certified the locks on the perimeter doors and windows were now in working order. In addition, 100% of the facility's staff were inserviced/instructed on resident safety by securing and locking the building at night. Findings: According to the Relocation Essentials Crime Report website (www.relocationessentials.com/aff/www/tools/crime/crime), the city the facility is located in is identified to have five to ten times more burglaries than the national average; and is listed as having two to three times more robbery and rape than the national average. The local city's Police Department website showed from 1/1/10 through 12/31/10, the city was divided into 209 districts. Based on the total number of crimes in each district, the area surrounding the facility was located within the area that had the top 7% of crimes committed in the city. In 2011, from 1/1/11 through 4/30/11, the area surrounding the facility was listed as having the top 12% of crimes committed in the city. The facility layout is in the shape of a square. The front of the building faces a busy four lane public road. Between the road and the facility is an easement approximately five feet wide where a cinder-block wall is located. The block wall has three unlocked gates which are adjacent to the public sidewalk. The gates are made of metal and have the capacity to be locked; however there was no device or locks found to secure the gates to discourage anyone from entering the facility's property at night. Directly behind the gates is a concrete path which runs alongside residents' rooms. Several of the resident rooms were found to have unlocked/unsecured windows and sliding glass doors. In addition, residents' room and staff office windows located adjacent to the facility's parking lot (south side of the building) were found to have unlocked and/or unsecured windows. The north side of the building has permanently locked resident room windows. According to staff these window were permanently locked for safety. Finally, the west side of the building has operable sliding glass doors but no windows. Immediately next to the facility is a motel which was observed to have security bars on all first floor windows. Immediately behind the facility are apartments. The apartments were also observed to have security bars on the windows. 1. On 5/23/11 at 1330 hours, during tour with RN 3, Room T was observed to have a large window which faces the front of the facility. The window was divided into three panes, the center window pane did not open. However, the two end panes could slide open. The left pane did not have a latch to secure it but the right one did. On 5/24/11 at 0635 hours, RN 3 stated the facility doors are locked at approximately 2000 hours each night. The RN stated the windows are always kept closed and locked. RN 3 was asked to try to open the sliding doors in Rooms U through Z to see if they were locked. The sliding glass doors in Rooms U and Y were found unlocked. The sliding glass door in Room V was open approximately one inch. There was no device from preventing the door from being opened further. RN 3 was asked to attempt to open the windows in rooms A though F to see if they were unlocked. The windows in Rooms A and F were found open approximately 6 inches and without a device to secure them from being opened further. In Room T, RN 3 stated the sliding (right side) window was unlocked and the left window was not able to be locked. The RN stated there is no way to lock the left sliding window due to a missing latch. While in Resident B's room checking the security of the sliding glass door, Resident B stated, "They locked it, finally" referring to her sliding glass door. The resident added her sliding glass door has been unlocked for 4 or 5 months. On 5/24/11 at 0650 hours, during an interview with CNA 1, she stated her room assignment that night included Rooms U, V, and Y. She stated she kept all resident rooms' sliding glass doors locked last night and had not opened them that morning. On 5/24/11 at 0655 hours, CNA 2 stated the outside windows are always kept locked at night for security. She stated Resident D, in Room A, keeps his window open all the time, including during the night to get fresh air. On 5/24/11 at 0705 hours, during an interview with the Maintenance Supervisor, he stated all of the charge nurses are trained to secure and lock the doors, gates, and windows each evening. He stated it is up to the resident to decide if they want to leave their window open. Review of the facility floor plan showed Rooms A through Z are located on the perimeter of the facility. Rooms T, U, V and Z were located adjacent to a busy street. Rooms A and F have direct access to the parking lot. Both of these area have no barrier to prevent an intruder entering unlock unsecured windows or doors or from a confused resident eloping unnoticed. On 5/25/11 at 0800 hours, during the environmental tour with the Maintenance Supervisor, two laundry room windows were found to have metal security bars on them. The Supervisor stated they were the for safety as it is a "hot area" for gangs in the apartments behind the facility. He stated the metal gate located between the laundry room and the maintenance garage used to be 2 feet higher for security reasons, but the city made the facility lower the gate. The Maintenance Supervisor stated everyday he has to paint over the graffiti on the back of the facility. In addition, he stated the gate located at the west side of the facility is kept locked due to the "troublemakers living back there." He was referring to the apartment building located behind the facility. He added most of the facility's back walls have been tagged by gang members and he has to routinely repaint it. On 5/25/11 at 1020 hours, a follow-up interview the Maintenance Supervisor was conducted. He was asked if the facility has any type of security system. He stated no, they did not. He was asked to provide the facility's P&P for securing and locking the facility's doors and windows. He stated the 3 to 11 shift staff is responsible for locking doors and windows and securing the building when visiting hours are over. Review of the facility's P&P for visiting hours (undated) showed "depending on daylight savings, the facility will secure doors at approximately sundown. Visitors may still enter and exit." No other P&P for building security was provided when asked. An observation conducted on 5/26/11 at 0628 hours, identified a metal gate leading to the easement on the east side to the building. The gate was open approximately 24 inches. There was no mechanism to secure the gate. There was no one observed entering or exiting from the door at this time. On 5/26/11 at 0630 hours, rounds were made with the DSD to check for locked doors and windows throughout the facility. In Room Y, when the DSD attempted to slide the door open, he stated, "It's not locked." The sliding glass door in Room V was also found unlocked. The DSD stated the family visits often and want the door open. He stated the family has been told to keep the door closed and locked. On 5/26/11 at 0635 hours, with LVN 3 was observed to identify the conference room window was unlocked and open approximately 12 inches. An interview with LVN 3 was initiated on 5/26/11 at 0635 hours. LVN 3 stated Station B gets too warm at night and the window in the conference room is left open to ventilate the area. The conference room window, which opens to the outside perimeter of the facility, is not visible to staff working at the nurses' station. On 5/26/11 at 0650 hours, an interview and observation with the DON and RN 1 was initiated. The DON stated she just arrived 5 minutes ago. RN 1 was asked to check if the DON's window was open and/or locked. RN 1 pulled the curtain and stated it was open. The DON was asked if she had left the window open all night. She didn't answer. On 5/26/11 at 0640 hours, CNA 1 was asked if she had opened any sliding glass doors in Rooms U through Z last night. She stated she did not unlock any doors last night or this morning. On 5/26/11 at 0642 hours, CNA 3, who just had began her shift, stated she had not yet unlocked or opened any doors or windows this morning. On 5/26/11 at 0645 hours, when asked what the facility's P&P is for locking doors and windows, the DSD stated the charge nurses are to check all the doors and windows at sunset to make sure they are locked. He stated there is no written policy, they just do it. The DSD stated, if a resident is alert, they can ask for the door or windows to be opened. On 5/26/11 at 0700 hours, an interview with LVN 2 was conducted. The LVN was asked about securing residents' windows and sliding glass doors. The LVN stated the windows and sliding doors are supposed to be locked every night. She stated she did not open any doors last night. She stated sometimes the CNAs will open the doors and windows at night to air out the facility due to odors when they are changing residents. On 5/26/11 at 0800 hours, Resident C, who resides in Room V, stated his roommate has friends who stay "all day long and go in and out of the sliding glass door a lot." He stated the visitors come and go "24 hours a day." Clinical record review was initiated for Resident C on 5/31/11. His MDS dated [DATE], showed he is understood and understands others with clear comprehension. 2. On 5/24/11 at 0635 hours, while in Room T, the window was observed to be a three pane window. The center pane did not open however, the left and right sides slid open. RN 3 verified the right side of the three pane window was unlocked. The RN stated the left side of the window was unable to be locked since the latch was missing. On 5/24/11 at 0705 hours, the Maintenance Supervisor was taken to Room T and shown the left side of the window. He stated, "I didn't notice it. For some reason, the window doesn't have a latch to lock it." 3. On 5/26/11 at 0840 hours, the sliding glass door in Room U was checked to see if it would lock. Observation of the door's latch showed it was slightly bent and after six attempts it was determined the door did not lock. At 0900 hours, a staff member asked the surveyor to retry the lock. The door locked on the first try but did not unlock immediately and had to be tried three times until it unlocked. 4. On 5/24/11 at 0655 hours, CNA 2 stated Resident D, who resides in Room A, keeps his window open all night and all day to get fresh air. An observation of Resident D's room window on 5/25/11 at 1100 hours, showed the sliding window was open approximately six inches. There were no locks or other devices noted to keep the window from sliding open any further. Clinical record review for Resident D was initiated on 5/25/11. He was admitted to the facility on [DATE]. His MDS dated [DATE], shows he understands and is understood with clear comprehension. On 5/26/11 at 0800 hours, during an interview with Resident D, Resident D stated he insists his window stay open all the time. He said the window has been open 24 hours a day since he was admitted to the facility. 5. On 5/24/11 at 0635 hours, accompanied with RN 3, while inspecting the sliding glass door in Room W, Resident B, who resides in the room, stated, "They locked it, finally." Resident B stated her sliding glass door has been unlocked for 4 or 5 months. On 5/26/11 at 0750 hours, Resident B stated they fixed the lock on her sliding door two days ago, on 5/24/11. She stated the sliding glass door had been unlocked for several months and it made her "a little uncomfortable knowing it could not be locked because somebody might come in the door." Resident B stated she had never seen staff during the evening or night hours checking sliding glass doors to ensure they were locked or secured. Resident B added, "It's a relief knowing it's locked" (referring to her sliding glass door). On 5/26/11 clinical record review for Resident B was initiated. The MDS for Resident B dated 4/19/11, shows she is alert and oriented.

Based on observation and interview, the facility failed to provide a secure facility when they failed to ensure two of the entrance/exit doors were locked. On 7/19/11 at 0530 hours, Emergency Exit Door 1 was found ajar and unlocked. The survey team entered the facility at this time through Emergency Exit Door 1. At 0550 hours, Emergency Exit Door 2 was found unalarmed and unlocked from the outside. A potential intruder could enter the facility through either of the two unlocked doors during the night. A resident could potentially leave the facility unnoticed through unalarmed Emergency Exit Door 2. Findings: Review of the CMS-672 (Centers for Medicare and Medicaid Services) Resident Census and Conditions of Residents form completed by the facility on 7/19/11, showed the resident census was 81. Of the 81 residents, 24 residents were identified with dementia, multi-infarct, senile, Alzheimer's type, or other than Alzheimer's type. 1. On 7/19/11 at 0520 hours, CNA 7 was observed exiting through Emergency Exit Door 1, taking out two laundry carts, and then entering the facility through the same door. On 7/19/11 at 0530 hours, the survey team approached Emergency Exit Door 1 from the parking lot. The door was seen ajar and not securely latched into the door frame. The surveyors easily opened the door and entered the facility through Emergency Exit Door 1. The facility staff was not aware the surveyors were in the building until the survey team approached LVN 6 in station B. During an interview with LVN 6 on 7/19/11 at 0535 hours, LVN 6 verified Emergency Exit Door 1 was open. The LVN stated she saw CNA 7 walk out of the door a few minutes ago, and must have not closed the door all the way when he re-entered the facility. When LVN 6 was asked if Emergency Exit Door 1 was unlocked from the outside, she stated "Yes, it was." During an interview with CNA 7 on 7/19/11 at 0540 hours, he stated he locked Emergency Exit Door 1. However, the survey team was able to enter the facility through Emergency Exit Door 1. On 7/19/11 at 0630 hours, during an interview with the Maintenance Supervisor, he stated he was lubricating Emergency Exit Door 1's latch, and he was unable to find anything wrong with Emergency Exit Door 1's door lock. He stated the door probably was not secured from the outside. The Maintenance Supervisor stated the staff was instructed to close the doors at 2000 hours and open them only at 0600 hours. 2. During initial tour with LVN 7 on 7/19/11 at 0535 hours, she stated all the doors and windows are locked by 2000 hours each evening. LVN 7 stated the facility's doors can be unlocked at 0600 hours. During an observation and interview with LVN 7 on 7/19/11 at 0550 hours, LVN 7 was observed to push several times on Emergency Exit Door 2's alarm button (the alarm is located on the inside of the door), and the alarm sounded. The surveyor went to the outside of Emergency Exit Door 2, pulled on the door handle, and was able to easily open the door. The alarm did not sound as the door was opened. LVN 7 stated she thought the door was locked and the alarm turned on. The door was then opened and closed numerous times. It was observed Emergency Exit Door 2 locked sometimes. Sometimes the door remained unlocked and could be opened from the outside. During an observation and interview with the Maintenance Supervisor on 7/19/11 at 0605 hours, the Maintenance Supervisor arrived at Emergency Exit Door 2. He tried closing and opening the door. The door locked. Sometimes the door latched into the door frame and remained locked. Sometimes the door was able to be opened from the outside. The Maintenance Supervisor confirmed Emergency Exit Door 2 does not always shut and lock. He then pulled the door shut and turned the alarm on. On 7/19/11 at 0620 hours, the Maintenance Supervisor stated Emergency Exit Door 2 is "working good now." During an interview with the Operations Manager on 7/20/11 at 0815 hours, he stated when the facility's emergency exit door alarm button is pressed, if the alarm sounds it means the alarm is turned off. If the alarm is silent when the button is pressed, it means the alarm is turned on. During an interview with the Administrator on 7/20/11 at 0815 hours, she stated the facility's practice is to secure and lock all the doors. She stated the door alarms should be turned on 24 hours a day unless the door is in use.