Every finding on record at Healthcare Center of Orange County

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 risk and development of pressure injuries for two of three final sampled residents (Residents 4 and 7) reviewed for pressure injuries. * The facility failed to ensure the low air loss mattress (LAL) setting was on alternating mode for Residents 4 and 7. This failure had potential for Residents 4 and 7 not receiving full treatment to prevent the worsening of pressure injuries.Findings: 1. According to KMS Alternating Pressure Pump and Mattress User Manual for ProtekTM Aire 6000, undated, on the operation section showed a firm surface will make it easier for the patient to transfer or reposition. Make use of the static mode function. It can support the patient by keeping the mattress from bottoming out when the patient is in a sitting position Medical record review for Resident 4 was initiated on 8/10/26. Resident 4 was admitted to the facility on [DATE], with a diagnosis of pressure ulcer Stage 4 on the sacral region. Review of Resident 4's H&P examination dated 1/28/26, showed Resident 4 had no capacity to understand and make decisions. Review of Resident 4's MDS assessment dated [DATE] showed Resident 4 had unhealed pressure ulcers. On 8/10/26 at 0918 hours, an observation was conducted with Resident 4. Resident 4 was observed lying on her back on a LAL mattress inside her room. The LAL mattress setting was on static mode. On 8/12/26 at 0800 hours, another observation was conducted with Resident 4. Resident 4 was observed lying on her back with the head of the bed slightly elevated on a LAL mattress inside her room. The LAL mattress setting was on static mode. On 8/12/26 at 0838 hours, an interview and concurrent observation for Resident 4 inside her room was conducted with LVN 1. LVN 1 stated Resident 4 had Stage 4 sacral pressure ulcer and Resident 4 was on LAL mattress. LVN 1 verified Resident 4's LAL mattress setting was on static mode. LVN 1 stated she did not know what static mode meant, and the LAL mattress was on static mode since yesterday. On 8/12/26 at 1518 hours, a follow up interview was conducted with LVN 1. LVN 1 stated Resident 4's LAL mattress should be on alternating mode to relieve pressure from Resident 4. 2. According to Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss user manual item # 14027 (undated) on the operation section showed the control unit is preset in alternating mode and its cycle time is set at 10 min/60Hz. Press the Static button to set it in static mode, and the Static indicator will come on. The static mode will begin within 5 minutes. Press the Static button again to switch back to alternating mode. NOTE! In static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition. The static mode prevents the patient from bottoming out when in a sitting position. Medical record review for Resident 7 was initiated on 8/10/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's MDS assessment dated [DATE], showed Resident 7 had unhealed pressure ulcers. Review of Resident 7's H&P examination dated 7/11/26, showed Resident 7 had no capacity to understand and make decisions. On 8/11/26 at 1030 hours, an observation was conducted for Resident 7 inside her room. Resident 7 was observed lying on her back with the head of the bed elevated on a LAL mattress. The LAL mattress setting was on static mode. On 8/12/26 at 0910 hours, another observation was conducted for Resident 7 inside her room. Resident 7 was observed lying on her back with the head of the bed elevated on a LAL mattress. The LAL mattress setting was on static mode. On 8/12/26 at 1103 hours, an interview and concurrent observation for Resident 7 was conducted with LVN 2. LVN 2 stated Resident 7 had Stage 4 sacral pressure injury and Resident 7 was on a LAL mattress. LVN 2 verified Resident 7's LAL mattress setting was on static mode. LVN 2 stated he did not know what static mode meant, and the setting should be according to Resident 7's weight. LVN 2 stated the treatment nurses were monitoring the LAL mattress. On 8/12/26 at 1518 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 7's LAL mattress should be on alternating mode to relieve pressure from Resident 7. 8/13/26 at 1442 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure five of six final sampled residents (Residents 1, 3, 5, 8, and 38) and one nonsampled resident (Resident 69) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 1's BIPAP (Bilevel Positive Airway Pressure, a machine used to provide pressurized air into the airways while asleep) mask was properly stored when not in use. * The facility failed to ensure the manufacturer's recommendation for cleaning and disinfecting of the ventilator machines was followed for Residents 3, 8, and 38. * The facility failed to ensure Resident 5's VOCSN ventilator machine was cleaned and maintained per the manufacturer's recommendations. * The facility failed to ensure Resident 69's respiratory set up bag was free from white residue and changed in a timely manner. These failures had the potential to affect the respiratory health and well-being of the residents in the facility. Findings: 1. Review of the facility's P&P titled VOCSN Device Management (undated) showed care and monitoring for the residents utilizing the VOCSN device will be provided in accordance with the physician orders, manufacturer recommendations, resident care plans, and applicable infection prevention standards. To perform routine cleaning disinfection, and maintenance per manufacturer recommendations. Review of the VOCSN- Clinical and Technical Manual (undated) under the section Cleaning and Maintenance showed the organization responsible for the use and maintenance of VOCSN should perform all adjustments, cleaning, and disinfection of VOCSN. Follow all instructions provided in this Clinical and Technical manual to prevent damage to VOCSN during cleaning and maintenance procedures. Clean the air and fan filters every two weeks to ensure VOCSN internal components are protected from dirt and dust. Replace the filters every six months, or as needed, due to damage. Remove the air and fan filters and wash the air and fan filters using warm water and soap or a mild detergent. Rinse the filters thoroughly under running water to remove all soap or detergent residue. Place the filters on a clean surface and allow them to dry completely. a. Medical record review for Resident 3 was initiated on 8/11/26. Resident 3 was admitted to the facility on [DATE]. On 8/10/26 at 0914 hours, an observation was conducted for Resident 3. Resident 3 was observed asleep in bed. Resident 3 was observed with a tracheostomy connected to the ventilator machine and with oxygen supply from concentrator machine. Review of Resident 3's Order Summary Report dated 8/11/26, showed a physician's order dated 7/31/26, for the ventilator setting as follows: AC (Assist Control), VT - 450, rate - 14, 4 liters oxygen, PEEP + 5 two times a day. b. Medical record review for Resident 8 was initiated on 8/11/26. Resident 8 was admitted to the facility on [DATE]. On 8/10/26 at 0937 hours, an observation was conducted for Resident 8. Resident 8 was observed asleep in bed. Resident 8 was observed with a tracheostomy, connected to the ventilator machine and with oxygen supply from concentrator machine. Review of Resident 8's Order Summary Report dated 8/11/26, showed a physician's order dated 6/27/26, for the ventilator setting as follows: AC (Assist Control), VT - 430, rate - 14, 2 liters oxygen, PEEP + 5 four times a day. c. Medical record review for Resident 38 was initiated on 8/11/26. Resident 38 was admitted to the facility on [DATE]. On 8/10/26 at 0944 hours, an observation was conducted for Resident 38. Resident 38 was observed asleep in bed. Resident 38 was observed with a tracheostomy connected to the ventilator machine and with oxygen supply from the concentrator machine. Review of Resident 38's Order Summary Report dated 8/11/26, showed a physician's order dated 10/14/25, for the ventilator setting as follows: AC (Assist Control), VT - 500, rate - 14, 2 liters oxygen, PEEP + 5 four times a day. Further review of the Order Summary Report for Residents 3, 8, and 38 failed to show a physician's order to clean and disinfect the ventilator machine per manufacturer's recommendation were obtained. In addition, further review of the medical record for Residents 3, 8, and 38 failed to show documented evidence of the cleaning and disinfecting of the ventilator machine. On 8/11/2026 at 1530 hours, an interview and concurrent medical record review for Residents 3, 8, and 38 was conducted with RT 3. RT 3 was asked for the cleaning and disinfecting of the ventilator machines. RT 3 stated they cleaned the ventilator machine when the resident left or when they went to the acute care hospital. RT 3 stated they cleaned the ventilator machine every day only as needed using the Sani-cloth. RT 3 verified there was no routine cleaning and no documentation of the cleaning of the ventilator machines. On 8/12/2026 at 0917 hours, an interview and concurrent medical record review for Residents 3, 8, and 38 was conducted with RT 1. RT 1 was asked how many residents in the Sub-acute unit were using the ventilator machines and stated there were 31 residents. RT 1 verified they were using only one brand of ventilator machine, the VOCSN, and they started using the machine since 6/2025. RT 1 stated the ventilator machine was serviced by a contracted company last 4/2026 for general maintenance. RT 1 was asked about the care and maintenance of the ventilator machine. RT 1 stated they were cleaning the machine exterior part once a week every Sunday. RT 1 was asked to review the ventilator machine cleaning and maintenance manual. RT 1 was able to show the ventilator machine manual and asked if the manual for cleaning and maintenance was followed. RT 1 was asked if there was a documentation or record of cleaning performance of each ventilator machine documented and who did the cleaning of the machines. RT 1 verified and acknowledged there were no recorded log for the cleaning of the ventilator machines per the manufacturer's recommendation of cleaning and maintenance. On 8/13/26 at 1446 hours, an interview for Residents 3, 8, and 38 was conducted with the DON. The DON was informed and verified the above findings. 2. On 8/10/26 at 0924 hours, during the initial tour of the facility, Resident 5 was observed lying in bed with the tracheostomy tubing connected to the VOCSN ventilator machine. Medical record review for Resident 5 was initiated on 8/10/26. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's H&P examination dated 10/17/25, showed Resident 5 had no capacity to understand and make decisions. Review of Resident 5's Order Summary Report dated 8/11/26, showed a physician's order dated 6/27/26, for Resident 5's ventilator settings- Assist-Control (AC): 14 breaths per minute, tidal volume (VT, the amount of air delivered to the lungs with each single breath): 450 cc, positive end-expiratory pressure (PEEP, pressure left in the breathing tubes at the end of each breath): 5 cmH2O, FiO2 (the percentage or concentration of oxygen delivered to a patient): 5 LPM, four times a day. On 8/12/26 at 1518 hours, an interview was conducted with RT 2. RT 2 stated Resident 5 was dependent on the ventilator. When asked about the care of the ventilator machine, RT 2 stated the ventilator machine was cleaned weekly on Sundays using the Sani wipes to clean the external parts of the ventilator machine. On 8/12/26 at 1631 hours, an interview was conducted with RT 1. RT 1 stated the cleaning of ventilator machines should be done per the manufacturer's guidelines. RT 1 stated the cleaning of the air and fan filters should be done every two weeks. RT 1 verified the facility did not document the cleaning of the air and fan filters. When asked how he knew the air and fan filters were being cleaned every two weeks, RT 1 stated just by looking at it. 3. On 8/10/26 at 1005 hours, during the initial tour of the facility, Resident 1 was observed in bed. Resident 1's BIPAP facemask was observed on top of Resident 1's bedside drawer. The BIPAP mask was observed uncovered and not stored inside of a storage bag. Resident 1 stated she used the BIPAP nightly. Medical record review for Resident 1 was initiated on 8/10/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/4/26, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Order Summary Report dated 8/11/26, showed the following physician's orders: - dated 5/7/26, for the BIPAP settings at bedtime: IPAP (Inspiratory Positive Airway Pressure): 18 cmH2O (centimeters of water pressure) , EPAP (Expiratory Positive Airway Pressure): 13 cmH2O, FIO2: 3 LPM. - dated 7/17/26, for the BIPAP machine cleaning, to regularly clean all components: mask, tubing, and water chamber. To clean the mask and tubing daily with mild soap and water. On 8/10/26 at 1026 hours, an interview and concurrent observation and medical record review for Resident 1 was conducted with LVN 4. LVN 4 stated the BIPAP was applied at night and removed in the morning by the RN Supervisor. LVN 4 stated upon removal of the BIPAP mask and when not in use, the BIPAP mask should be placed inside a set-up bag to prevent contamination. Concurrent observation at Resident 1's bedside was conducted with LVN 4. LVN 4 verified the above findings. On 8/13/26 at 1520 hours, an interview was conducted with the Administrator, DON, and ADON. The Administrator, DON, and ADON were informed and acknowledged the above findings. 4. Review of the facility's P&P titled Respiratory Equipment Change and Cleaning Schedule (undated), showed disposable equipment is for single patient use and will be changed as regularly scheduled and on a PRN (as needed) basis. Furthermore, the Yankauer (rigid medical suction tip used to clear secretions from a patient's mouth and throat) and set up bag will be changed every Wednesday night shift to minimize the risk of infection. On 8/10/26 at 1014 hours and 8/11/26 at 0913 hours, Resident 69 was observed lying in bed. An unopened Yankauer suction dated 7/9/26, was observed in a respiratory set up bag dated 7/9/26. The respiratory set up bag contained white debris. Medical record review for Resident 69 was initiated on 8/10/26. Resident 69 was admitted to the facility on [DATE]. Review of Resident 69's Order Summary Report showed a physician's order dated 4/9/26, to assess the resident for oral or NT (nasotracheal) suctioning as needed, may do oral or NT suction. On 8/11/26 at 1637 hours, an interview and concurrent observation for Resident 69 was conducted with the DON. The DON stated the respiratory set up bags should be replaced weekly or as needed when soiled, for infection prevention. The DON verified the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for two of 19 final sampled residents (Residents 1 and 26) reviewed for pain management and two of five final sampled residents (Residents 9 and 21) reviewed for unnecessary medications. * The facility failed to ensure Resident 1 was administered the pain medication as per the physician's orders and failed to implement the nonpharmacologic pain interventions prior to the administration of PRN pain medication. * The facility failed to ensure there was documented evidence of the nonpharmacological interventions implemented prior to the PRN pain medication administration for Resident 9. *The facility failed to ensure the nonpharmacological pain interventions were provided prior to the administration of the PRN hydrocodone-acetaminophen (opioid pain medication) for Resident 21. * The facility failed to ensure Resident 26 was administered his scheduled hydrocodone-acetaminophen per the physician's order. In addition, the facility failed to ensure the oxycodone (opioid pain medication) was administered to Resident 26 as per the physician's orders. These failures had the potential to put Residents 1, 9, 21, and 26 at risk for ineffective pain management and/or adverse effects related to the use of unnecessary pain medications. Findings: Review of the facility's P&P titled Pain- Clinical Protocol revised 3/2018 showed the physician would order appropriate nonpharmacologic and medication interventions to address the individual's pain. Pain medications should be selected based on pertinent treatment guidelines. Generally, and to the extent possible, an analgesic regimen should utilize he simplest regimen and lowest risk medications before using more problematic or higher risk approaches. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions. 1. On 8/10/26 at 1005 hours, during the initial tour of the facility, Resident 1 stated she had pain in her shoulders and was administered pain medications. Medical record review for Resident 1 was initiated on 8/10/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/4/26, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Order Summary Report showed the following physician's orders: - dated 5/4/26, to administer acetaminophen (analgesic, OTC pain medication) 325 mg, give two tablets by mouth every four hours as needed for mild pain (pain level of 1 to 3 out of 10, with 0=no pain, and 10=worst pain); - dated 5/4/26, to administer hydrocodone- acetaminophen 5-325 mg, give one tablet every six hours as needed for severe pain (pain level of eight to 10 out of 10); - dated 5/4/26, to administer oxycodone (opioid pain medication) 5 mg, give 1/2 (half) tablet by mouth every four hours as needed for severe pain (pain level of 8 to 10 out of 10); and - dated 5/5/26, to administer tramadol (opioid pain medication) 50 mg, give one tablet by mouth every four hours as needed for moderate pain (pain level of 4 to 7 out of 10). Review of Resident 1's Care Plan Report showed the following care plan problems: - dated 6/10/26, addressing Resident 1 has pain; and - dated 8/11/26, addressing Resident 1's risk for pain. However, further review of the care plan problem failed to show nonpharmacological interventions were implemented for Resident 1. Review of Resident 1's MAR for July and August 2026 showed Resident 1 was administered the hydrocodone-acetaminophen 5-325 mg pain medication when the pain level was outside of the ordered pain parameters of severe pain (pain level of 8 to 10) on the following dates and times: - on 7/6/26 at 2049 hours, for a pain level of 0 (zero); - on 7/11/26 at 1310 hours, for a pain level of 7; - on 7/12/26 at 1638 hours, for a pain level of 6; - on 7/13/26 at 2049 hours, for a pain level of 0; - on 7/20/26 at 1702 hours, for a pain level of 0; - on 7/29/26 at 0911 hours, for a pain level of 7; - on 8/2/26 at 2023 hours, for a pain level of 6; and - on 8/3/26 at 2057 hours, for a pain level of 0. Further review of the MAR for July and August 2026 failed to show documented evidence of the nonpharmacologic pain interventions implemented on the above dates and times when the PRN hydrocodone-acetaminophen medications were administered to Resident 1 for pain. Review of Resident 1's medical record failed to show a physician's order was obtained to implement the use of nonpharmacological pain interventions, and failed to show documented evidence the nonpharmacological interventions were implemented for the above dates and time. On 8/11/26 at 1557 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 5. LVN 5 stated when the resident complained of pain, nonpharmacologic pain interventions should be implemented before the administration of the PRN pain medication. LVN 5 stated if the nonpharmacologic interventions were ineffective, then the PRN pain medication should be administered as per the physician's orders. LVN 5 reviewed Resident 1's medical records and verified the above findings. On 8/13/26 at 1405 hours, an interview was conducted with the DON. The DON stated when a resident complained of pain, the licensed nurse should assess the pain level to administer the proper pain medication. The DON stated prior to the administration of the PRN pain medication the licensed nurse should attempt the nonpharmacologic pain interventions and document its effectiveness in the medical record. The DON further stated if the nonpharmacological interventions were not effective, the PRN pain medications should be administered as per the physician's orders and within the ordered pain parameters. On 8/13/26 at 1520 hours, an interview was conducted with the Administrator, DON and ADON. The Administrator, DON, and ADON were informed and acknowledged the above findings. 2. Medical record review for Resident 21 was initiated on 8/10/26. Resident 21 was admitted to the facility on [DATE]. Review of Resident 21's Order Summary Report showed physician's order dated 1/2/26, to administer hydrocodone-acetaminophen 5-325 mg, one tablet by mouth every six hours as needed for severe pain (7-10). Review of Resident 21's H&P examination dated 1/26/26, showed Resident 21 had capacity to understand and make decisions. Review of Resident 21's MAR for August 2026 showed Resident 21 was administered hydrocodone-acetaminophen medication on the following dates and times: - dated 8/2/26 at 0857 hours; - dated 8/3/26 at 2217 hours; - dated 8/4/26 at 1015 hours; - dated 8/6/26 at 1409 hours; - dated 8/8/26 at 1410 hours; - dated 8/9/26 at 1613 hours; and - dated 8/11/26 at 1126 hours. Review of Resident 21's medical record did not show documented evidence nonpharmacological pain interventions were attempted prior to the administration of hydrocodone-acetaminophen 5-325 mg pain medication for the above dates and times. On 8/13/26 at 0916 hours, an interview and concurrent medical record review for Resident 21 was conducted with RN 1. RN 1 stated before administering the pain medications, nonpharmacological pain interventions should be implemented and if not effective, PRN pain medication would be administered to the residents. RN 1 stated nonpharmacological pain interventions are documented on the resident's MAR. RN 1 reviewed Resident 21's medical records, and verified there was no documentation to show nonpharmacological pain interventions were implemented for the above dates and times. On 8/13/26 at 1442 hours, the DON was informed and acknowledged the findings above. 3. Medical record review for Resident 26 was initiated on 8/10/26. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's Order Summary Report showed the following physician's orders:- dated 3/10/26, to administer oxycodone-acetaminophen 5-325mg , give two tablets by mouth every six hours as needed for severe pain (pain level of 7 out of 10); and- dated 8/7/26, to administer hydrocodone-acetaminophen 5-325mg, give one tablet every six hours for pain management. Review of Resident 26's H&P examination dated 3/11/26, showed Resident 26 had the capacity to understand and make decisions. Review of Resident 26's Care Plan Report showed a care plan problem revised 7/15/26, addressing Resident 26's chronic pain. The interventions included to administer the oxycodone and hydrocodone medications as per the physician's orders. a. On 8/10/26 at 0852 hours, during the initial tour of the facility, Resident 26 stated he had pain in his groin area and feet. Resident 26 further stated he did not receive his scheduled pain medication on 8/9/26 and was told the medication needed to be delivered from pharmacy. Review of Resident 26's MAR for August 2026 showed on 8/9/26 at 1200 and 1800 hours, Resident 26 did not receive his scheduled hydrocodone medication for pain management. The MAR was coded 9 which indicated Other / See Progress Notes. Review of Resident 26's Progress Note dated 8/9/26 showed the following:- at 1413 hours, the hydrocodone medication was unavailable and pending delivery from the pharmacy; and- at 1745 hours, the hydrocodone medication was not available. b. Review of Resident 26's MAR for August 2026 showed Resident 26 was administered the oxycodone pain medication when the pain level was outside of the ordered pain parameters on the following dates and times:- dated 8/6/26 at 1639 hours, for a pain level of 0; and- dated 8/12/26 at 0712 hours, for a pain level of 0. On 8/13/26 at 1059 hours, an interview and concurrent medical record review for Resident 26 was conducted with LVN 10. LVN 10 stated when a resident reported they had pain, the licensed nurses were expected to assess the resident, provide nonpharmacological interventions, and administer pain medications per the physician's orders. LVN 10 stated scheduled medications should be reordered when six to eight tablets remained in the bubble pack. If a scheduled pain medication was unavailable, licensed nurses were expected to contact the pharmacy and reorder the medication. LVN 10 stated pharmacy deliveries occurred daily, and emergency kit medications could be used for pain management if needed. LVN 10 also stated medications must be administered according to the ordered parameters. LVN 10 verified the above findings. On 8/13/26 at 1211 hours, an interview and concurrent medical record review for Resident 26 was conducted with the DON. The DON stated she expected licensed staff members to reorder scheduled pain medications when three to five days of medications were left in the resident's bubble pack to ensure an adequate supply. The DON further stated emergency kit pain medications could be used if a pain medication was unavailable. The DON also stated the pain medications must be administered within ordered parameters to ensure residents received the appropriate pain management. The DON verified the above findings. 4. Review of the facility's P&P titled Pain – Clinical Protocol, dated 3/2018 showed the physician will order appropriate nonpharmacological and medication interventions to address a resident's pain, staff will provide a comforting environment and appropriate physical and complementary interventions, including repositioning, and the effectiveness of current interventions for pain will be evaluated. Medical record review for Resident 9 was initiated on 8/12/26. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's care plan for alteration in comfort related to multiple pressure injuries, surgical wounds, and impaired mobility dated 6/2/26, showed the interventions included to monitor for nonverbal signs and symptoms of pain, position the resident for comfort, and provide a calm and relaxing environment. Review of Resident 9's MAR for May, July, and August 2026 showed the physician's orders with the following PRN pain medication: - dated 4/27/26, Hydrocodone-acetaminophen 5-325 mg, give one tablet via GT every six hours as needed for moderate pain, with a pain scale 4-6. The medication was discontinued on 5/22/26; - dated 6/16/26, acetaminophen 500 mg, give two tablets via GT every six hours as needed for moderate pain, with a pain scale of 4–7; and - dated 7/19/26, Tramadol 25 mg, give one tablet via GT every six hours as needed for severe pain, with a pain scale of 8–10. Further review of Resident 9's MARs showed tramadol 25 mg was administered 20 times in July 2026 and four times in August 2026; hydrocodone-acetaminophen 5-325 mg was administered eight times in May 2026; and acetaminophen 500 mg was administered five times in July 2026 and three times in August 2026. The MARs showed a total of 40 PRN pain medication administrations during the reviewed periods. Review of Resident 9's MARs and medical record failed to show documented evidence nonpharmacological pain interventions were attempted or implemented to alleviate the resident's pain prior to the PRN pain medication administrations. Review of Resident 9's medical record showed no documented evidence the identified nonpharmacological interventions including positioning for comfort and providing a calm and relaxing environment, were attempted or implemented prior to the resident's PRN pain medication administrations. On 8/12/26 at 1613 hours, an interview and concurrent medical record review for Resident 9 was conducted with the ADON. The ADON stated the residents receiving pain medications should be provided with nonpharmacological pain interventions to assist with pain management. On 8/13/26 at 1036 hours, an interview was conducted with the ADON. The ADON acknowledged the facility had not implemented nonpharmacological pain interventions for Resident 9's pain management. The ADON stated the nursing staff should attempt nonpharmacological pain interventions, such as repositioning, to determine whether the interventions could alleviate the resident's pain before administering pain medication. On 8/13/26 at 1047 hours, an interview was conducted with RN 1. RN 1 stated Resident 9 was nonverbal and unable to independently reposition. RN 1 stated the nursing staff assessed the resident for signs of pain, including facial grimacing, guarding, body movement, and changes in heart rate. RN 1 stated nonpharmacological pain interventions for pain included repositioning the resident, adjusting the lighting, and providing a quiet environment. RN 1 stated there were no progress notes showing nursing staff attempted or implemented nonpharmacological pain interventions to alleviate Resident 9's pain prior to administering the pain medication.

Based on interview, facility document review, and facility P&P review, the facility failed to ensure the employees reviewed for competency had specific competencies and standard of practice skill sets necessary to provide safe and efficient nursing care. * The facility failed to ensure Registry CNA 1's skill set competencies were validated prior to providing nursing care. * The facility failed to ensure Registry CNA 2's skill set competencies were validated by a licensed nurse. Additionally, the competency checklist for Registry CNA 2 inappropriately included ventilation troubleshooting and oxygen equipment management, which are outside of the CNA scope of practice. * The facility failed to ensure LVNs 1 and 2 demonstrated competency in operating a low air-loss mattress used for pressure injury management. These failures had the potential to result in adequate residents care and placed the residents at risk for adverse outcomes.Findings: Review of the facility's P&P titled Registry and Agency Nursing Staff, Utilization (undated) showed it is the policy of this facility to utilize registry and agency nursing staff only when such staff meet the same licensure/ certificate, competency, and orientation requirements as facility-employed staff, and are supervised to ensure safe, consistent resident care. 1. Review of Registry CNA 1's CNA Core Clinical Competencies, Subacute CNA Initial/Annual Skill Competency Evaluation, and Competency Sub-Acute CNA/RNA signed by Registry CNA 1 on 7/10/26, did not show any validated skill set competencies. 2. Review of Registry CNA 2's CNA Core Clinical Competencies signed by Registry CNA 2 on 7/9/26, showed CNA 3 validated the competency checklist on 7/9/26. Review of Registry CNA 2's Competency Sub-Acute CNA/RNA signed by Registry CNA 2 on 7/9/26, and by the Respiratory Therapy Director (RTD) on 7/9/26, showed competency validation included ventilator troubleshooting, securing/handling H-tanks and E-tanks, and connecting/removing oxygen tubing. On 8/12/26 at 1355 hours, an interview and concurrent facility document review for Registry CNAs 1 and 2 was conducted with the DSD. The DSD stated the facility used registry staff when internal staff were not available to cover a shift. The DSD stated the registry CNAs received orientation and competency validation by CNA 3 prior to providing nursing care. After reviewing Registry CNA 1's competency checklist, the DSD verified it had not been completed. In addition, the DSD verified CNA 3 had validated the skills set competency for Registry CNA 2. The DSD stated CNA 3 should not validate CNA competencies, as it is out the CNA scope of practice, and validation must be completed by a licensed nurse. On 8/12/26 at 1501 hours, an interview and concurrent facility document review was conducted with the RTD. The RTD stated he validated respiratory-related competencies to the staff who worked in the Sub-Acute Unit prior to them providing resident care. The RTD reviewed Registry CNA 2's skills set competency documentation, the RTD verified the ventilator and oxygen management were included. The RTD stated these competencies were meant for equipment awareness only and CNAs were not permitted to handle ventilators or oxygen equipment. The RTD further stated he had requested an update of the competency checklist to better emphasize emergency management. On 8/12/26 at 1515 hours, an interview was conducted with CNA 3. When asked to explain the process of orientating the Registry CNAs, CNA 3 stated he provided facility tours to the registry CNAs and had them self-attest to competency by checking the competent box on the form because registry CNAs went to school and are certified. CNA 3 verified he signed the competency checklist for Registry CNA 2. 3. Review of the facility's document titled Job Description Treatment Nurse-RN/LVN dated 10/2003 showed the primary purpose of your position is to provide direct nursing care (treatments) to the residents with treatment orders and to manage the overall wound program. Review of the facility's document titled Job Description Charge Nurse (Sub-Acute Unit) (undated) showed job responsibilities to initiate plans of care to promote positive patient care outcomes. Review of the facility's document titled Wound Management in-service education dated 8/7/26 to 8/9/26, failed to show attendance of LVNs 1 and 2. 3. a. On 8/10/26 at 0918 hours and 8/12/26 at 0800 hours, Resident 4 was observed lying on her back on a low air loss mattress set to static mode. On 8/12/26 at 0838 hours, an observation and concurrent interview for Resident 4 was conducted with LVN 1. LVN 1 stated she was the treatment nurse and was responsible for providing treatment to residents with pressure injuries. LVN 1 verified Resident 4 was lying in bed on a low air loss mattress set to static mode. When asked what the static mode setting meant, LVN 1 was unable to explain what static mode meant. LVN 1 stated the low air loss mattress was adjusted by the resident's weight. On 8/12/26 at 1518 hours, a follow up interview was conducted with LVN 1. LVN 1 stated Resident 4's low air loss mattress should be in alternating mode to relieve pressure. LVN 1 stated she had received in-service training on managing low air loss mattress but could not recall when it was provided. b. On 8/11/26 at 1030 hours and 8/12/26 at 0910 hours, Resident 7 was observed lying on her back on a low air loss mattress set to static mode. On 8/12/26 at 1102 hours, an observation and concurrent interview Resident 7 was conducted with LVN 2. LVN 2 verified Resident 4 was lying in bed an a low air loss mattress set to static mode. When asked what the static mode setting meant, LVN 1 was unable to explain what static mode meant. LVN 2 stated the low air loss mattress was adjusted only by the resident's weight and it was monitored by LVN 1. When asked about attending wound management in-service education, LVN 2 remained silent and did not answer. On 8/13/26 at 1315 hours, an interview and concurrent facility document review was conducted with the DSD. The DSD verified LVNs 1 and 2 did not attend the wound management in-service education and could not provide competency validation documentation for operating a low air-loss mattress for LVNs 1 and 2. On 8/13/26 at 1442 hours, an interview was conducted with the DON. The DON stated the low air loss mattress should be in alternating pressure mode. The DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure accurate accountability of the controlled substances for four of eight nonsampled residents (Residents 17, 48, 82, and 85) from two of four Medication Carts (Medication Carts A and B) reviewed for controlled substances accountability. * The record of the controlled substances accountability for Residents 17, 48, 82, and 85 documented the removal of the controlled substances; however, the MARs did not contain the corresponding documentation of the medication administration to the identified residents. This failure resulted in inaccurate accountability of the controlled substances and had the potential to increase the risk for diversion or misuse of the controlled substances. Findings: Review of the facility's P&P titled Documentation of Medication Administration, dated 4/2007 showed all medications administered were to be documented on the resident's MAR immediately after administration, including the date and time of administration, signature and title of the person administering the medication, and resident response to the medication if applicable for PRN, pain medication. Review of the facility's P&P titled Controlled Substance, dated 12/2012 showed the controlled substance record must contain the time of administration and the signature of the nurse administering the medication. Review of the facility's P&P titled Medication Administration - General Guidelines, dated 4/2019 showed the individual administering a medication was to record the administration on the resident's MAR directly after the medication was given and was not to report off duty without recording the administration. 1. Medical record review for Resident 82 was initiated on 8/10/26. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's 8/2026 MAR showed a physician's order dated 7/30/24, for hydrocodone-acetaminophen 5-325 mg (a controlled medication used to relieve pain), with directions to give one tablet via GT every six hours as needed for severe pain scale 8-10 (pain rating scale for 0 with no pain and 10 with worst possible pain). On 8/10/26 at 1606 hours, an inspection of Medication Cart A was conducted with LVN 8. Resident 82's medication blister card for hydrocodone-acetaminophen 5-325 mg and corresponding records were reviewed. Review of Resident 82's record of controlled substances dated 8/1 through 8/10/26, showed the licensed nursing staff removed one hydrocodone-acetaminophen 5-325 mg tablet from the medication blister card on 8/9/26 at 1000 hours, and documented the removal of the medication in the record of controlled substances. However; review of Resident 82's 8/2026 MAR showed no corresponding record documenting the administration of the hydrocodone-acetaminophen 5-325 mg dose removed from the blister card on 8/9/26 at 1000 hours, to Resident 82. The MAR also did not contain a corresponding pain assessment associated with the dose. 2. Medical record review for Resident 48 was initiated on 8/10/26. Resident 48 was admitted to the facility on [DATE]. Review of Resident 48's 8/2026 MAR showed a physician's order dated 7/28/2026, for Percocet 5-325 mg (controlled medication to relieve pain), with directions to give one tablet by mouth every six hours as needed for severe pain (8-10) for 30 days.On 8/10/26 at 1606 hours, an inspection of Medication Cart A was conducted with LVN 8. Resident 48's medication blister card for Percocet 5-325 mg and corresponding records were reviewed. Review of Resident 48's record of controlled substances dated 7/29 through 8/10/26, showed the licensed nursing staff removed one Percocet 5-325 mg tablet from the medication blister card on 8/9/26 at 1200 hours, and documented the removal in the record of controlled substances. However; review of Resident 48's 8/2026 MAR showed no corresponding record documenting the administration of the Percocet medication dose removed from the blister card on 8/9/26 at 1200 hours, to Resident 48. The MAR also did not contain a corresponding pain assessment associated with the dose. 3. Medical record review for Resident 85 was initiated on 8/10/26. Resident 85 was admitted to the facility on [DATE]. Review of Resident 85's 8/2026 MAR showed a physician's order dated 8/6/26, for Ativan (antianxiety medication) 0.5 mg, with directions to give one tablet by mouth every six hours as needed for anxiety manifested by verbalization of feeling anxious for 14 days. On 8/10/26 at 1606 hours, an inspection of Medication Cart A was conducted with LVN 8. Resident 85's medication blister card for Ativan 0.5 mg and corresponding records were reviewed. Review of Resident 85's record of controlled substances dated 7/19 through 8/10/26, showed the licensed nursing staff removed one Ativan 0.5 mg tablet from the medication blister card on 8/9/26 at 1000 hours, and documented the removal in the record of controlled substances. However; review of Resident 85's 8/2026 MAR showed no corresponding record documenting the administration of the Ativan medication dose removed from the blister card on 8/9/26 at 1000 hours, to Resident 85. On 8/10/26 at 1619 hours, an interview and concurrent medical record review for Residents 48, 82, and 85 was conducted with LVN 8. LVN 8 verified the discrepancies for Residents 48, 82, and 85. LVN 8 stated the licensed nursing staff should have documented the removal of the controlled substances in the record of controlled substances when the medications were removed from the medication blister cards and documented the administration in the MAR after the medications were administered to the residents. 4. Medical record review for Resident 17 was initiated on 8/11/26. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's 7/2026 MAR showed a physician's order dated 7/14/26, for Ativan 1 mg, with directions to give one tablet via GT every 12 hours as needed for anxiety manifested by verbalization of feeling anxiety for 14 days. On 8/11/26 at 1447 hours, an inspection of Medication Cart B was conducted with LVN 9. Resident 17's medication blister card for Ativan 1 mg tablet and corresponding records were reviewed. Review of Resident 17's record of controlled substances dated 7/16 through 7/31/26, showed the licensed nursing staff removed one Ativan 1 mg tablet from the medication blister card on 7/19/26 at 0030 hours and documented the removal in the record of controlled substances. Review of Resident 17's 7/2026 MAR showed no corresponding record documenting the administration of the Ativan dose removed from the blister card on 7/19/26 0030 hours, to Resident 17. On 8/13/26 at 0903 hours, an interview and concurrent medical record review for Resident 17, 48, 82, and 85 were conducted with the ADON. The ADON verified the discrepancies between the record of controlled substances and the MARs for Residents 17, 48, 82, and 85. The ADON stated she expected the licensed nursing staff to document the medication administration in the MAR after administering the medication to the resident.

Based on observation, interview, medical record review, manufacturer's labeling review, and facility P&P review, the facility failed to ensure medications were properly stored and labeled in two of three medication storage rooms (Medication room [ROOM NUMBER] and Central Supply Room) and three of seven medication carts (Medication Carts A, B, and C) reviewed for medication storage and labeling. * Medication room [ROOM NUMBER] was maintained above the manufacturer-required storage temperatures for the medications stored in the room * The ipratropium-albuterol (a combination medication used to improve breathing) inhalation solution was not protected from light as required by the manufacturer, and the discontinued famotidine (a medication used to reduce stomach acid) remained stored in Medication Cart A * The expired Arginaid (a nutritional supplement used to support wound healing) remained stored in Medication Cart C * An unused, unopened Lantus SoloStar (insulin glargine, a long-acting insulin used to control blood sugar) pen was stored at a room temperature in Medication Cart B without documentation showing when the pen was removed from the refrigerated storage to determine whether it was within the manufacturer's 28-day room temperature storage period * The Central Supply Room, where medications were stored, did not have a documented room-temperature monitoring. These failures had the potential to compromise the medication integrity and increase the risk of the residents receiving medications stored outside the manufacturer's requirements, expired medications, or discontinued medications.Findings: Review of the facility's P&P titled Storage of Medications, dated 4/2019, showed medications were to be stored safely and properly, following the manufacturer's recommendations. The P&P further showed medication storage conditions were to be monitored and corrective action taken if problems were identified. 1. a. On 8/10/26 at 1432 hours, an observation of Medication room [ROOM NUMBER] and interview were conducted with RN 3. The wall-mounted thermometer showed a room temperature of 79 F. A posted label above the thermometer showed staff were to notify the RN Supervisor when the medication room temperature was outside the range of 59 F to 77 F. RN 3 verified the findings. Concurrent review of the Medication room [ROOM NUMBER] temperature log showed RN 3 had documented 67 F for the 8/10/26 0700-1500 hours shift. RN 3 stated she had mistakenly read the humidity instead of the room temperature when she made the entry. RN 3 was observed correcting the 8/10/26 0700-1500 hours shift temperature log entry from 67 F to 79 F. Further review of the temperature log showed a temperature of 78 F was recorded on 7/15/26 during the 2300-0700 hours shift. RN 3 stated she did not know how long the room temperature had been at 79 F or what actions were required when the temperature was outside the established range. On 8/10/26 at 1534 hours, an interview was conducted with the DON. The DON confirmed Medication room [ROOM NUMBER] temperature was 79 F and stated the staff should investigate the cause of an out-of-range temperature, identify the medications that may have been affected, and consult with the pharmacy regarding whether the medications required replacement. 1. b. On 8/10/26 at 1445 hours, an observation of medications in Medication room [ROOM NUMBER] and interview were conducted with RN 3. There were six bottles of lactulose (a medication used to treat constipation) 10 g/15 ml oral solution, 473 ml, labeled for Resident 39, and one bottle of valproic acid (a medication used to treat seizures) 250 mg/5 ml oral solution labeled for Resident 61. The manufacturer labeling showed both medications were to be stored at 68 F to 77 F. RN 3 verified the findings and acknowledged the medications were stored above the manufacturer-required temperature range. 1. c. On 8/10/26 at 1519 hours, an observation of the IM E-kit in Medication room [ROOM NUMBER] and interview were conducted with RN 3. RN 3 verified the following medications were stored in the IM E-kit. The manufacturer labeling showed the medication had storage requirements of 68 F to 77 F:one vial of lidocaine (a medication used to numb an area) 1%, 100 mg/10 ml;two vials of ceftriaxone (an antibiotic used to treat infections) 1 g;three vials of sterile water (sterile solution used to dilute medications for injection) 10 ml per vial;two vials of ampicillin (an antibiotic used to treat infections) 1 g;two vials of ceftazidime (an antibiotic used to treat infections) 1 g;two vials of cefazolin (an antibiotic used to treat infections) 1 g; andone vial of epinephrine (a medication used to treat severe allergic reactions and other emergencies) 1 mg/ml. 1. d. On 8/10/26 at 1520 hours, an observation of the IV E-kit in Medication room [ROOM NUMBER] and interview were conducted with RN 3. RN 3 verified the following IV solutions and injectable medications were stored in the IV E-kit. The manufacturer labeling showed the medication had storage requirements not exceeding 77 F:one 500 ml bag, three 250 ml bags, and two 1,000 ml bags of 0.9% sodium chloride (a solution used for fluid and electrolyte replacement);one 1,000 ml bag of 0.45% sodium chloride (a solution used for fluid and electrolyte replacement);one 1,000 ml bag of potassium chloride (an electrolyte used to prevent or treat low potassium levels) 20 mEq/L in 5% dextrose (a form of glucose used to provide fluid and calories) and 0.9% sodium chloride;one 1,000 ml bag of 5% dextrose and 0.45% sodium chloride (a solution used for fluid, electrolyte replacement, and calories);two 1,000 ml bags of 5% dextrose and 0.9% sodium chloride (a solution used for fluid, electrolyte replacement, and calories);one 1,000 ml bag of 5% dextrose;two 100 ml bags of metronidazole (an antibiotic used to treat infections) 500 mg;two vials of cefazolin 1 g;two vials of cefepime (an antibiotic used to treat infections) 2 g;two vials of ceftriaxone 1 g;two vials of ceftazidime 1 g;one vial of ertapenem (an antibiotic used to treat infections) 1 g;two vials of meropenem (an antibiotic used to treat infections) 1 g;three vials of vancomycin (an antibiotic used to treat infections) 1 g; andthree vials of piperacillin-tazobactam (an antibiotic used to treat infections) 3.375 g. On 8/10/26 at 1549 hours, RN 3 and the DON confirmed Medication room [ROOM NUMBER] temperature had increased to 80 F. On 8/13/26 at 0815 hours, an interview was conducted with the DON. The DON acknowledged multiple IV solutions and injectable medications had manufacturer storage requirements not exceeding 77 F. The DON stated manufacturer storage requirements should be followed to ensure medications were properly stored. 2.a. Review of the facility's P&P titled Storage of Medications dated 4/2019 showed contaminated or deteriorated medications were to be removed from stock and disposed of according to procedures for medication disposal. Review of the manufacturer's PI for ipratropium bromide and albuterol sulfate inhalation solution showed the medication was to be protected from light before use, and unused vials were to be kept in the protective foil pouch or carton. The PI showed once removed from the foil pouch, the individual vials were to be used within one week. On 8/10/26 at 1552 hours, an observation of Medication Cart A and interview were conducted with LVN 8. Five vials of ipratropium-albuterol 0.5 mg/3 mg per 3 ml inhalation solution labeled for Resident 2 were dispensed by the pharmacy in a clear plastic bag and stored without protection from light. The prescription label affixed to the clear plastic bag showed a pharmacy fill date of 6/12/26. 2.b. Review of the facility's P&P titled Discontinued Medications - Disposal dated 4/2019 showed the medications were to be removed from the medication cart immediately upon receipt of an order to discontinue to avoid inadvertent administration. On 8/10/26 at 1555 hours, an observation of Medication Cart A and interview were conducted with LVN 8. A blister card of famotidine 20 mg labeled for Resident 2 remained stored in the medication cart. Concurrent medical record review showed the medication had been discontinued on 6/24/26. LVN 8 stated she had identified the famotidine medication as discontinued the previous night and left it in the medication cart. On 8/13/26 at 0820 hours, an interview was conducted with the DON. The DON acknowledged the manufacturer's labeling for ipratropium-albuterol inhalation solution required protection from light. The DON stated the pharmacy should have dispensed the medication in a brown bag to protect it from light. The DON verified the famotidine medication order had been discontinued and stated the discontinued medications should not remain stored in the medication carts and should be removed for proper disposal. 3. Review of the facility's P&P titled Storage of Medications dated 4/2019 showed the outdated medications were to be removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. On 8/11/26 at 1435 hours, an observation of Medication Cart C and interview were conducted with LVN 2. One packet of Arginaid with an expiration date of 5/14/26, was stored in a drawer of Medication Cart C. LVN 2 stated the expired medications should not be stored in the medication carts and should be disposed of in the medication destruction bin. On 8/13/26 at 0820 hours, an interview was conducted with the DON. The DON stated the nursing staff should check the medication expiration dates when dispensing and administering the medications and during weekly medication cart inspections. 4. Review of the facility's P&P titled Storage Table 1 (undated) showed Lantus (insulin glargine, a long-acting insulin used to control blood sugar) was good for 28 days after opening or removal from the refrigerator. Review of the manufacturer's PI for Lantus SoloStar showed an unused, unopened pen stored at room temperature could be stored for 28 days. On 8/11/26 at 1447 hours, an observation of Medication Cart B and interview were conducted with LVN 9. An unused Lantus SoloStar insulin pen labeled for Resident 34 was stored in the Medication Cart B at room temperature. The pharmacy label showed a fill date of 7/9/26. However, the pen did not contain documentation showing when it was removed from the refrigerated storage. LVN 9 verified there was no date on the pen and stated he was unable to determine how long the pen had been stored at room temperature. On 8/13/26 at 0913 hours, an interview was conducted with the DON. The DON stated the unused Lantus SoloStar insulin pens should be stored under refrigeration and once removed from refrigeration and stored at room temperature, staff should date the pen. 5. On 8/11/26 at 1600 hours, an observation of the Central Supply Room and interview were conducted with RN 4. The OTC and prescription medications were stored in the room. However, no room-temperature monitoring log was available. RN 4 stated she was unsure whether the room temperature was being monitored. On 8/12/26 at 0813 hours, an observation and interview were conducted with the CSS. No room-temperature monitoring log was available. The CSS stated he monitored the room temperature but did not document the readings because he was unaware documentation was required. On 8/12/26 at 0915 hours, an interview was conducted with the DON. The DON stated she was unaware the Central Supply Room did not have a temperature monitoring log and stated the room temperature should be documented because medications were stored in the room. On 8/13/26 at 0915 hours, an interview was conducted with ADON. The ADON stated the Central Supply Room temperature should be monitored and documented to ensure medications were stored according to manufacturer requirements.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed. * The ice machine was not cleaned and sanitized per the manufacturer's guidelines. * The food preparation utensil was not in a clean and sanitized condition when [NAME] 1 was preparing food. These failures pose the risk for food borne illnesses in a highly susceptible resident population of 34 of 85 residents who received food prepared in the kitchen.Findings: Review of the facility's Therapeutic Diet Count dated 8/10/26 showed 34 of 85 residents who resided in the facility consumed food prepared in the kitchen. Further review showed 3 out of 34 residents received a puree diet. 1. On 8/10/26 at 0831 hours, during the initial tour of the kitchen, the ice machine's bin was observed clean and free from residue. On 8/10/26 at 1052 hours, an interview and concurrent observation of the ice machine was conducted with the Maintenance Director. The Maintenance Director stated he cleaned the ice machine monthly, which included the external part of the ice machine and the inside of the bin; while an external company would clean the internal components quarterly. When the Maintenance Director was asked how he cleaned the ice machine's bin, the Maintenance Director stated he would empty out the ice from the bin, wipe down the machine with a soft fiber rag, then clean the bin with chlorine. Review of Atosa's YR Series Icemaker End-User Manual under the Maintenance section, showed to maintain the ice machine in accordance with the instruction to the manual. Ice machine cleaners are used to remove lime scale and mineral deposits, while ice machine sanitizer disinfects removed algae and slime. The recommended cleaner and sanitizer for the ice machine were Ecolab's products: [NAME] Delimer as the cleaner and Kay5 as the sanitizer. The steps to clean the ice machine included to remove all ice from the bin and dispenser, clean all food zone services of the ice machine and bin with the cleaner solution and cloth thoroughly, then rinse throughout with clean water. After the cleaning process, use the sanitizer solution to sanitize all food zone surfaces of the ice machine and bin, wait twenty minutes and rinse the surface with drinking water. On 8/10/26 at 1602 hours, a follow up interview was conducted with the Maintenance Director. The Maintenance Director stated he used chlorine as the cleaner and sanitizer for the ice machine's bin, then he rinsed the chemicals out with water. The Maintenance Director stated he used Clorox Germicidal Bleach with water to clean the ice machine. The Maintenance Director reviewed the ice machine manufacturer's guidelines and verified the above findings.2. According to the USDA Food Code 2022, Chapter 4. Equipment, Utensils, and Linens showed equipment food-contact surfaces and utensils shall be cleaned at any time during the operation when contamination may have occurred. On 8/11/26 at 1029 hours, an observation of [NAME] 1 and concurrent interview was conducted with the Dietary Manager. [NAME] 1 was observed preparing puree food in the kitchen. [NAME] 1 was observed holding a red-handled portion scoop, placing the scoop on top of a recipe binder, and then placing another binder on top of the scoop. [NAME] 1 then proceeded to use the same scoop to prepare chicken puree. The Dietary Manager was informed and stated she expected the staff members to use clean utensils when preparing food.

Based on interview and facility document review, the facility failed to ensure the Facility Assessment was complete. * The facility failed to ensure the Facility Assessment included the active involvement of the required individuals in developing the facility assessment, the resources necessary to care for the residents including weekends, staffing recruitment and retention plan, and contingency plan for staffing needs. This failure placed the residents at risk for unmet care needs if the assessed population's needs and resources were not comprehensively identified and addressed.Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included the staffing resources necessary to care for the residents, including the weekends; a plan to maximize recruitment and retention of direct care staff member, and a contingency plan for staffing needs for the events not to activate the facility's emergency plan. Review of the Facility assessment dated [DATE], failed to show the following was included in the assessment:- input from the residents, resident representative, and family members;- facility resources related to staffing plan did not show staffing plan for the Sub-Acute unit and it did not show staffing plan for the weekends to include evening and night shift;- staffing plan for recruitment and retention plan; and- contingency plan for staffing needs. On 8/12/26 at 1541 hours, an interview and concurrent facility document review was conducted with the DON. The DON stated she was not familiar with QSO-14-13-NH. The DON stated she was not sure if the residents, resident representatives, and family members had input on the Facility Assessment. The DON reviewed the Facility Assessment and verified the facility resources for the staffing plan did not include the Sub-Acute Unit and it did not include the staffing plan for the weekends to include evening and night shifts. The DON further verified the Facility Assessment did not have plan documented to maximize recruitment and retention plan and contingency plan for staffing needs. On 8/12/26 at 1636 hours, an interview was conducted with the Administrator. The Administrator stated she was not familiar with QSO-14-13-NH. The Administrator stated she was not aware of the requirements about the input from the resident, resident representative, and family members; specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population; develop and maintain a plan to maximize recruitment and retention of direct care staff; and contingency planning for events that do not require activation of the facility's emergency plan. On 8/13/26 at 1442 hours, the DON was informed and acknowledged the above findings.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control program in accordance with the facility's P&P. * The facility failed to maintain an accurate infection control surveillance program for February to July 2026. The facility conducted surveillance only on the residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications. The facility failed to ensure the residents exhibited signs and symptoms of an infection but were not prescribed antimicrobial medications were included in the facility's infection control surveillance log, and in the monthly infection surveillance report. * The facility failed to ensure Resident 10 was provided adequate and timely isolation precautions, assessment, and care for possible shingles (a painful rash caused by the varicella-zoster virus). * The facility failed to ensure Resident 11's indwelling urinary catheter tubing was not touching the floor. * The facility failed to change Resident 82's water pitcher in a timely manner. These failures posed the risk of not identifying the residents' infections and not controlling the potential transmission of communicable diseases to other residents, staff, and visitors throughout the facility. Findings: 1. Review of the facility's P&P titled Infection Prevention and Control Program revised 12/2023 showed an infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection prevention and control program is coordinated and overseen by the IP. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. The information obtained from infection control surveillance activities is compared with acknowledged standards and used to assess effectiveness of established infection prevention and control practices. Standard criteria are used to distinguish community-acquired from facility-acquired infections. On 8/12/26 at 1503 hours, an interview and concurrent facility document review was conducted with the IP. The IP was asked to explain the facility's surveillance program and stated the surveillance was initiated only when a resident was prescribed antimicrobial medications or was diagnosed with an infection. The IP stated the McGeer's criteria was used to determined a true infection. Review of the facility's monthly Infection Prevention and Control Surveillance Logs from February 2026 through July 2026 showed the following infection surveillance data for HAIs, CAIs, and the residents who did not meet McGeer's Criteria (DNMC): - for 2/2026: HAI – 8, CAI – 3, and DNMC – 9; - for 3/2026: HAI – 10 , CAI – 3, and DNMC – 6; - for 4/2026: HAI – 15, CAI – 1, and DNMC – 7; - for 5/2026: HAI – 7 , CAI – 2, and DNMC – 14; - for 6/2026: HAI – 0, CAI – 0, and DNMC – 3; and - for 7/2026: HAI – 5 , CAI – 1, and DNMC – 11. Further review of the facility's monthly Infection Prevention and Control Surveillance Logs from February 2026 through July 2026 showed all the residents included in the facility's infection surveillance program were determined to have either a HAI or CAI (with prescribed antimicrobial medications or having been diagnosed with an infection). The Infection Prevention and Control Surveillance logs failed to show any residents that did not meet McGeer's criteria without the prescription of antibiotic. The IP verified no residents in the facility were classified as having not met the McGeer's Criteria between the months of February 2026 through July 2026. The IP stated surveillance was conducted only on residents prescribed antimicrobial medications and did not include residents with signs and symptoms of infection without antimicrobial prescriptions, such as residents with influenza. On 8/13/26 at 1501 hours, an interview and concurrent medical record review was conducted with the ADON, DON, and Administrator. The ADON, DON, and Administrator were informed and verified the above findings. 2. Review of facility's P&P titled Catheter Care, Urinary dated 9/2014 showed the facility should prevent catheter-associated urinary tract infections by observing infection control practices. Including on the practices were to maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag and to make sure the catheter tubing and drainage bag are kept off the floor. On 8/10/26 at 0909 hours and 8/11/26 at 0845 hours, Resident 11 was observed in bed asleep with an indwelling urinary catheter bag placed on the side of the bed and the catheter tubing was touching the floor. Medical record review for Resident 11 was initiated on 8/11/26. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 10/24/25, showed Resident 11 had no capacity to understand and make decision. Review of Resident 11's Order Summary Report dated 8/11/26, showed physician's order dated 5/3/26, for a urinary Foley catheter for neurogenic bladder. On 8/11/26 at 9049 hours, an observation and concurrent interview was conducted with CNA 1 at Resident 11's bedside. CNA 1 verified Resident 11 used a urinary catheter and stated the responsibility for emptying the catheter bag at the end of each. CNA 1 stated the urinary catheter tubing should be placed inside a basin with the drainage bag and verified the tubing was touching the floor. On 8/11/26 at 1445 hours, an interview and concurrent medical record review for Resident 11 was conducted with LVN 12. LVN 12 verified the resident's physician's order for the urinary Foley catheter for neurogenic bladder and stated the urinary catheter tubing should not be touching the floor. On 8/13/26 at 1446 hours, an interview and concurrent medical record review for Resident 11 was conducted with the DON. The DON was informed and verified the above findings. 3. Review of the facility's P&P titled Shingles (Herpes Zoster) (undated) showed the policy of the facility was to promptly identify and manage suspected or confirmed shingles and to use appropriate infection-control precautions based on whether the infection is localized or disseminated and whether the resident was immunocompromised. For immunocompromised residents with localized shingles, the facility will use airborne, contact, and standard precautions until disseminated shingled had been ruled out. The nursing responsibilities included to assess the location and extent of lesions and monitor for new or spreading lesions, fever, pain, secondary infection, or change in condition; to notify the attending practitioner and Infection Preventionist; document the assessment, notifications, precautions initiated, treatment and resident response; and to administer the antiviral and pain medications as ordered. Medical record review for Resident 10 was conducted on 8/10/26. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including End Stage Renal Disease and dependence on renal dialysis. Review of Resident 10's clinician medication order obtained from the dialysis center showed an order dated 8/11/26, to administer acyclovir (antiviral) 500 mg five times a day for seven days for shingles on the right lateral thorax. Review of Resident 10's eINTERACT Change in Condition Evaluation – V 5.1 dated 8/11/26, showed Resident 10 returned to the facility from the dialysis appointment with an order for acyclovir 500mg for shingles on the right lateral thorax in the afternoon of 8/11/26. Resident 10's skin status evaluation showed small, itchy, red patches on the right lateral thorax. Resident 10's facility's clinicians were notified of the shingles diagnosis. Review of Resident 10's Progress Note showed the following: - dated 8/11/26 at 0447 hours, a late entry for Resident 10's Pre/Post Dialysis Evaluation. Resident 10 returned to the facility on 8/11/26 at 1758 hours, from dialysis with an order for acyclovir 500 mg to administer five times a day for seven days. Resident 10's physician was notified and the order for the acyclovir medication was changed to 800 mg once a day after the dialysis. Review of Resident 10's Order Summary Report showed a physician's order dated 8/12/26, to administer acyclovir 800 mg one tablet via GT in the afternoon for three days for shingles. On 8/12/26 at 1116 hours, an EBP signage was observed outside of Resident 10's room. Residents 10 and 85 were both present in the room. On 8/12/26 at 1118 hours, an interview, observation and concurrent medical record review for Resident 10 was conducted with the IP. The IP stated if a resident had an active shingles diagnosis, the resident should be isolated because shingles was contagious. The IP stated she was not informed of Resident 10's shingles diagnosis. The IP further stated she expected the facility to isolate the resident and notify the IP regarding the infection. The IP was informed and verified the above findings. On 8/12/26 at 1357 hours, a follow-up interview was conducted with the IP. The IP stated she contacted Resident 10's physician regarding the shingles diagnosis. The IP further stated upon skin assessment, Resident 10's rash was red, flat and did not have vesicles. The IP stated according to the physician, Resident 10 did not need isolation precautions until the facility's physician conducted their own assessment. Review of Resident 10's Progress Note dated 8/12/26 at 1420 hours, showed according to NP 1, Resident 10 did not require isolation for the shingles. Review of Resident 10's Physician Note dated 8/12/26 at 1800 hours, showed Resident 10's rash was evaluated by Physician 1. The dialysis staff members evaluated the rash and raised concern for a possible shingles infection. Further review, showed Physician 1 assessed Resident 10's skin and had a concern for a possible shingles infection. The plan included to initiate appropriate transmission-based precautions immediately and to obtain an VZV PCR (a test to detect Varicella Zoster Virus from active skin blisters or lesions) from a fresh vesicle, lesion base or crust. On 8/13/26 at 1045 hours, a follow-up interview was conducted with IP. The IP stated a VZV PCR was ordered for Resident 10. The IP clarified Resident 10 should have been isolated as a precaution until shingles was ruled out to prevent the spread of the infection. On 8/13/26 at 1211 hours, an interview for Resident 10 was conducted with the DON. The DON stated the facility was made aware of Resident 10's shingles diagnosis on 8/11/26, after the resident's dialysis appointment. The DON further stated Resident 10 should have been isolated immediately to prevent the spread of infection. The DON was informed and acknowledged the above findings. 4. Review of the facility's P&P titled Sanitizing Water Pitchers dated 2018 showed the residents will be provided with clean drinking water on a regular basis unless contraindicated by the physician's orders. Appropriate ice and water handling practices prevent contamination and the potential for waterborne illness. On 8/10/26 at 0942 hours, during the initial tour of the facility, Resident 82 was observed asleep in bed. A water pitcher dated 8/5/26, was observed on top of his bedside table. On 8/10/26 at 1006 hours, an interview and concurrent observation for Resident 82 was conducted with LVN 11. LVN 11 stated the water pitchers should be changed daily for infection control. LVN 11 verified the above findings.

Based on interview, facility document review, and facility P&P review, the facility failed to accurately determine whether one final sampled resident (Resident 26) who was prescribed with antimicrobial therapy and three nonsampled residents (Residents 27, 48, and 97) met the criteria for true infection. * Residents 26, 27, 48, and 97 who did not meet the McGeer's (a standardized surveillance definitions used to detect infections in long-term care facilities, ensuring consistent reporting and monitoring) criteria were prescribed antimicrobial therapy. These failures resulted in continued use of unnecessary antibiotic therapy, potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic-resistant bacteria. Findings: According to the Centers for Disease Control and Prevention (CDC), antibiotics are among the most frequently prescribed medications in the nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile (a type of bacteria that can cause diarrhea and inflammation of the colon), increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms. Review of the facility's P&P titled Antibiotic Stewardship dated 12/2016 showed the antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Under the Policy Interpretation and Implementation, When antibiotics are prescribed over the phone, the primary care practitioner will assess the resident within 72 hours of the telephone order. Review of the facility's P&P titled Infection Prevention and Control Program dated 12/2023 showed the elements of infection Prevention control program was the Antibiotic Stewardship. The culture reports, sensitivity data, and antibiotic usage reviews are included in surveillance activities. Medical criteria and standardized definitions of infections are used to help recognize and manage infections. Antibiotic usage is evaluated and practitioners are provided feedback on reviews. Review of the facility's Infection Prevention and Control Surveillance Logs for February, March, April, and July 2026 showed the following:- Resident 26 was prescribed Cefuroxime axetil (antibiotic medication) 250 mg. However, the McGeer's Criteria for true infection was not met;- Resident 27 was prescribed Vancomycin (antibiotic medication) 250 mg. However, the McGeer's Criteria for true infection was not met;- Resident 48 was prescribed Amoxicillin (antibiotic medication) 500 mg. However, the McGeer's Criteria for true infection was not met: and- Resident 97 was prescribed Cephalexin (antibiotic medication) 500 mg. However, the McGeer's Criteria for true infection was not met. Review of the Infection Surveillance Outcome for Residents 26, 27, 48, and 97 showed each resident exhibited signs and symptoms of infection; however, the residents did not meet the criteria for true infection based on the checklist. On 8/12/26 at 1522 hours, an interview, facility document review, and concurrent facility P&P review was conducted with the IP. The IP stated the facility used the McGeer's criteria as part of the antibiotic stewardship program. The IP stated for the residents who DNMC and were prescribed antibiotic medications, the facility completed the Infection Surveillance Outcome for each resident, which was documented in the resident's medical record. The IP stated she reviewed the resident's signs and symptoms with the RN supervisor to determine if the continuation of the antibiotic therapy was appropriate. The IP was able to show the documentation of the Infection Surveillance Outcome for Residents 26, 27, 48, and 97, showing the physician was made aware of the residents' signs and symptoms and opted to continue the course of the antibiotic therapy. However, the IP was asked if the prescribing physician documented the clinical rationale for continuing the antibiotic medication despite not meeting the criteria, the IP verified there was no physician's progress note documented to show the rationale for the continued use of the antibiotic medication for the residents. On 8/13/26 at 15016hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and verified the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the accurate and complete consent was obtained for one of five final sampled residents (Resident 12) reviewed for unnecessary medications. * Resident 12's informed consent for the paroxetine (anti-depressant medication) contained an incorrect trade name and did not include the duration and accurate frequency of administration. These failures had the potential for violating the resident's rights of not being fully informed of the medication as ordered by the physician.Findings: Review of the CDPH 9168 document titled Psychotherapeutic Drug Informed Consent Form dated 12/2025 showed to include the following psychotherapeutic drug information: drug category, drug name, dosage prescribed, frequency, duration, administration method, caution and warning summary, reason for use of the psychotherapeutic drug and benefits, the probable side effects and significant risks associated with the use of the psychotherapeutic drug. Review of the facility's P&P titled Psychoactive Medication Informed Consent revised 2026 showed the purpose of the policy was to ensure that the informed consent had been obtained and verified prior to initiation of psychotropic medication use. Informed consent will be obtained from the resident, who has decisional capacity, whenever psychoactive medications are prescribed, ordered or when orders are increased by the physician. Medical record review for Resident 12 was initiated on 8/10/26. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's Order Summary Report showed a physician's order dated 3/27/26, to administer one paroxetine 30 mg tablet by mouth two times a day for depression manifested by self-isolation. Review of Resident 12's H&P examination dated 3/28/26, showed Resident 12 could make their own medical decisions. Review of Resident 12's Psychotherapeutic Drug Informed Consent form dated 3/28/26, showed the consent for the paroxetine medication; however, the form incorrectly listed Prozac (anti-depressant) in parenthesis as the trade name. The paroxetine medication's correct trade name was Paxil. The consent form also failed to include the duration of the medication, and the frequency was documented only as q12 without specifying the medication was to be administered two times a day. Review of Resident 12's MAR for 8/2026 showed Resident 12 was administered the paroxetine medication from 8/1 to 8/11/26. On 8/11/26 at 1624 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DON. The DON stated an informed consent for the psychotherapeutic medications must include information such as adverse reactions, indications, dosage and frequency. The DON further stated the correct trade name for the paroxetine medication was Paxil. The DON stated Resident 12 was administered the paroxetine medication twice a day and confirmed that the informed consent frequency section listed q12 only. The DON verified Resident 12's informed consent was inaccurate due to listing the incorrect trade name and incomplete due to missing the medication duration and accurate frequency.

Based on observation, interview, and medical record review, the facility failed to ensure the resident's preference and choices about aspects of their life was implemented in the care for one of 19 final sampled residents (Resident 65) reviewed for self-determination. * On 7/13/26, during Resident 65's quarterly care conference meeting, Resident 65 requested to be weighed weekly, however the request was not carried out timely. This failure posed the risk of Resident 65 not being able to make choices about his care.Findings: On 8/10/26 at 1210 hours, an interview was conducted with Resident 65. Resident 65 stated he wanted to be weighed weekly but the facility was only weighing him once a month. Resident 65 stated he would like to know his weight weekly. Resident 65 stated he had discussed his wishes with the facility during his care plan meeting a month ago, however the facility did not give him an answer. Medical record review for Resident 65 was conducted on 8/10/26. Resident 65 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 65's H&P examination dated 1/5/26, showed Resident 65 had the capacity to understand and make decisions. Review of Resident 65's Multidisciplinary Care Conference dated 7/13/26, showed Resident 65 currently weighed 305 pounds and verbalized wanting to lose weight to about 250 pounds. The document further showed the resident requested to be weighed weekly. Review of Resident 65's Order Summary Report dated 8/11/26, showed the following physician's orders:- dated 9/15/25, to weight Resident 65 weekly, and- dated 8/10/26, to weight weekly as requested. Review of Resident 65's Monthly Weight Report showed the following for Resident 65's weight:- dated June 2026, a weight of 304 lbs.;- dated July 2026 , a weight of 305 lbs.; and- dated August 2026, a weight of 307 lbs. On 8/12/26 at 1025 hours, an interview and concurrent medical record review for Resident 65 was conducted with the DON. The DON stated if the resident requested to be weighed weekly, it was the resident's right. The DON stated when the resident verbalized the request to be weighed weekly, the physician would be informed and a physician's order would be obtained for weekly weights within 72 hours. The DON reviewed Resident 65's medical records and verified the above findings. The DON stated she made rounds on 8/10/26, and Resident 65 had verbalized his wishes to be weighed weekly. The DON verified a physician's order was placed for weekly weights on 8/10/26. On 8/13/26 at 1520 hours, an interview was conducted with the Administrator, DON and ADON. The Administrator, DON, and ADON were informed and acknowledged the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to provide assistance on formulating an advance directive for one of five final sampled residents (Resident 1) reviewed for advance directives. * Resident 1 was not provided assistance to formulate an advance directive. This failure had the potential for Resident 1's decisions regarding the healthcare and treatment to not be honored.Findings: Review of the facility's P&P titled Advance Directives revised 12/2016 showed upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If the resident indicated that he or she had not established an advanced directive the facility staff would offer assistance in establishing the advance directive. Nursing staff would document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Medical record review for Resident 1 was initiated on 8/10/26. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/4/26, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Advance Directive Acknowledgement dated 5/5/26, showed Resident 1 selected the statement: I have not executed an Advance Directive and I wish to execute an Advance Directive. Review of Resident 1's Social Service History, Initial Assessment and Quarterly Note dated 8/3/26, showed Resident 1 would remain full code and Resident 1 had not formulated an advanced directive under the Advance Directives section. Review of Resident 1's medical record failed to show documented evidence Resident 1 was offered literature on how to formulate an advance directive or Resident 1 was assisted to formulate an advance directive. On 8/11/26 at 1430 hours, an interview and concurrent medical record review for Resident 1 was conducted with LVN 6. LVN 6 stated she was assisting the Social Services Director with the advance directives. LVN 6 stated upon the resident's admission to the facility, the licensed nurse completed the POLST and the social services staff would follow-up with the resident or family if the resident had an advance directive. LVN 6 stated the resident would sign the Advance Directive Acknowledgment form and if the resident selected they wished to execute an advance directive, the Ombudsman would be informed as soon as possible, to come to the facility and assist and witness the formulation of the resident's advanced directives. LVN 6 reviewed Resident 1's medical records and verified Resident 1's Advance Directive Acknowledgement form showed Resident 1 wished to execute an Advance Directive. LVN 6 further reviewed Resident 1's medical records and verified there was no documentation Resident 1's advance directive was formulated or any documentation Resident 1 was provided literature on and assisted to formulate the advance directive. On 8/13/26 at 1405 hours, an interview was conducted with the DON. The DON stated the purpose of the advance directive was for the resident to express their healthcare wishes for medical treatment or appoint a healthcare agent in the event the resident no longer have the capacity to make decisions. The DON stated upon admission to facility, the admitting nurse would inquire if the resident had an advanced directive. The DON stated if the resident did not have an advance directive, the facility would provide the resident with education on how to formulate an advance directive. The DON further stated if the resident wished to formulate an advance directive, the Social Services staff would be informed to assist the resident and notify the Ombudsman to be present. On 8/13/26 at 1520 hours, an interview was conducted with the Administrator, DON and ADON. The Administrator, DON, and ADON were 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 19 final sampled resident (Resident 6) and one nonsampled resident (Resident 36) was free from the physical restraints. * The facility failed to ensure Resident 6's right hand mitten had a physician's order and informed consent. * The facility failed to follow and document the release of Resident 36's left hand mitten as per the physician's order. These failures posed the risk of compromising the residents' independence and psychosocial well-being.Findings: Review of the facility's P&P titled Use of Restraints revised 4/2027 showed the following: - Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully; - Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls; and - When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. The Policy Interpretation and Implementation section showed the following: - Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. - Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove. - Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). -The following safety guidelines shall be implemented and documented while a resident is in restraints: d. The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed. e. Restrained residents must be repositioned at least every two (2) hours on all shifts. 1. On 8/10/26 at 1001 hours, during the initial tour of the facility, Resident 6 was observed in bed, receiving morning care with a hand mitten on her right hand. Medical record review for Resident 6 was initiated on 8/10/26. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 10/5/25, showed the resident had no capacity to understand and make decisions. Review of Resident 6's MDS assessment dated [DATE], showed Resident 6 had bilateral upper and lower extremities impairment. Review of Resident 6's Order Summary Report failed to show documented evidence a physician's order was obtained for the use of the right-hand mitten. Further review of Resident 6's medical record failed to show an informed consent was obtained for the use of right-hand mitten. On 8/10/26 at 1440 hours, a follow up observation of Resident 6 was conducted inside her room. Resident 6 was lying in bed and observed a hand mitten was placed on her right hand. On 8/12/26 at 1106 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated before the application of the physical restraints, the resident would be monitored for three days for behaviors of pulling out medical devices. If the resident was consistent with the behavior, a physician's order for a physical restraints would be obtained. The physical restraints would be removed every two hours for 10 to 15 minutes. LVN 2 stated Resident 6 was wearing the same right-hand mitten before due to pulling out medical devices. LVN 2 verified Resident 6 had no active physician's order for the right hand mitten and there was no informed consent obtained. 8/13/26 at 1442 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. On 8/10/26 at 0901 hours and 8/11/26 at 0951 hours, Resident 36 was observed lying in bed with a left hand mitten in placed. Resident 36 was able to move her left arm and was observed touching her body. Medical record review for Resident 36 was initiated on 8/11/26. Resident 36 was admitted to the facility on [DATE]. Review of Resident 36's plan of care date 8/10/24, showed a care problem addressing Resident 36's use of hand mitten to prevent injury. The interventions included to release of hand mitten and check skin at least every two hours for circulation. Review of Resident 36's MDS assessment dated [DATE], showed Resident 36's cognitive skills for daily decision making was severely impaired. Review of Resident 36's Physician Order Summary dated 8/11/26, showed the following physician's orders dated 10/23/25: - to apply left hand mitten to prevent from pulling out on medical devices every shift; - to monitor left hand for swelling every day and night shift secondary to hand mitten application, and - to remove left hand mitten every two hours for at least 10 minutes and change the resident position, exercise resident as tolerated and check for circulation, mobility and sensation. Review of Resident 36's MAR for July and August 2026 showed the day and night shift checking of the left soft hand mitten, monitoring for the signs and symptoms of circulatory impairment related to the left hand mitten use every two hours, and release of the left soft hand mitten every two hours for at least 10 minutes for circulation and skin integrity every two hours. Further review of the MAR showed the licensed nurses initials when the left hand mitten was released every two hours. However, there was no indication when the left hand mitten was released and what intervention the staff provided to the resident when the left hand mitted was removed. In addition, there were no documented evidence when the left hand mitten was reapplied after the release for at least 10 minutes. On 8/11/2026 at 1042 hours, an observation and concurrent interview was conducted with CNA 4 at Resident 36's bedside. CNA 4 stated the resident had the left hand mitten due to the resident's behavior of pulling out her tubes like the tracheostomy tubes and GT. CNA 4 was asked if the left hand mitten was released and by whom. CNA 4 stated she would sometimes take the hand mitten off when she provided care to the resident such as cleaning and changing the resident's diaper. CNA 4 stated sometimes the charge nurse would remove it. CNA 4 stated she would inform the nurse when she removed the hand mitten and when she provided care and ADLs to the resident. CNA 4 stated for approximately five minutes the hand mittens were taken off and then she would put it back after she was done providing care to the resident. CNA 4 stated she would check for any skin problem on the left hand when she removed the hand mittens and she would report to the nurse right away if there were any problems. CNA 4 was asked if she would document the removal of Resident 36's hand mittens. CNA 4 stated no, the nurse documented for her. On 8/11/26 at 1445 hours, an interview and concurrent medical record review for Resident 36 was conducted with LVN 12. LVN 12 was asked about the removal of Resident 36's hand mittens and application as ordered. LVN 12 was able to show the documentation on the medical recorded on the nursing assessment flowsheet. However, when asked if there was documentation for the hand mitten when it was removed and what interventions were provided to the resident while the hand mitten was off and what time the mitten was reapplied. LVN 12 verified and acknowledged there was no documentation. On 8/13/26 at 0833 hours, an interview and concurrent medical record review for Resident 36 was conducted with RN 2. RN 2 verified the resident use of the left hand mittens to prevent the resident pulling out her medical devices. RN 2 stated they have to follow the physician's order and to monitor the skin at least every two hours and provide exercises to the hand to prevent any complications on using the hand mittens. RN 2 verified there was no documentation for the interventions provided when the hand mitten was released and there was no specific time recorded when the hand mitten was reapplied. On 8/13/26 at 1446 hours, an interview and concurrent medical record review for Resident 36 was conducted with the DON. The DON was informed and verified the above findings.

Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident was free from unnecessary psychotropic medication for one of five residents (Resident 9) reviewed for unnecessary psychotropic medication use. * The facility failed to ensure the nonpharmacological interventions were attempted, implemented, or monitored for Resident 9's anxiety and associated behaviors. This failure had the potential to result in the resident's unnecessary psychotropic medication use and expose the resident to adverse side effects, including sedation and falls.Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 7/2022 showed nonpharmacological approaches are used, unless contraindicated, to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible. Medical record review for Resident 9 was initiated on 8/12/26. Review of Resident 9's admission Record showed the resident was admitted to the facility on [DATE]. Review of Resident 9's Psychiatric Evaluation Note dated 4/30/26, showed the resident was diagnosed with seizure disorder and GAD. Review of Resident 9's MAR for July 2026 showed a physician's order dated 7/10/26, for Ativan (medication used to treat anxiety) 0.5 mg, with directions to give one tablet via GT every six hours as needed for anxiety as manifested by pulling out the medical devices. Review of Resident 9's care plan initiated on 6/10/26, showed a goal for the resident to have decreased number episodes of anxiety and the interventions included to administer antianxiety medications as ordered, monitor for medication side effects and effectiveness every shift, and monitor for physical restlessness. The care plan contained no documented nonpharmacological interventions to address the resident's anxiety as manifested by pulling out the medical devices. Review of Resident 9's IDT Conference Record - Behavior Management 1 dated 7/30/26, and the MAR for July and August 2026 showed the resident continued to exhibit anxiety and associated behaviors. Resident 9's IDT's Behavior management record showed 25 behaviors in June 2026. The MAR for July 2026 records showed 140 behaviors and there were 39 behaviors from 8/1/26 through 8/12/26. In addition, Resident 9's MAR showed the Ativan medication for anxiety was administered 31 times in July 2026 and 12 times in August 2026. However, the records contained no documented evidence of the nonpharmacological interventions were attempted, implemented, or monitored to address the resident's anxiety and associated behaviors, or if the nonpharmacological interventions were clinically contraindicated. On 8/12/26 at 1048 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON acknowledged the nonpharmacological interventions associated with Resident 9's Ativan medication use were not provided or documented. On 8/12/26 at 1630 hours, a follow-up interview was conducted with the ADON. The ADON stated there was no physician's order for nursing staff to implement nonpharmacological interventions for Resident 9's Ativan medication use. The ADON stated the nursing staff should have obtained a physician's order for appropriate nonpharmacological interventions and implemented the interventions, such as distracting the resident, to alleviate the resident's anxiety and reduce the behavior of pulling out medical devices. The ADON verified there were no documented evidence to show the nonpharmacological interventions were ordered, implemented, or monitored for Resident 9.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one of one final sampled resident (Resident 84) reviewed for abuse. * The facility failed to ensure the abuse allegation was reported timely to the CDPH L&C Program and Ombudsman when Resident 84 alleged CNA 3 leaned his elbows to Resident 84's stomach. This failure had the potential for the abuse to go unreported and uninvestigated timely.Findings: Review of the facility's P&P titled Abuse Reporting and Investigation dated 7/2024 showed the facility will report all allegations of abuse, unless indicated below, as required by law and regulations to the appropriate agencies within 2 hours. The facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, exploitation, misappropriation of resident property, or injuries of an unknown source when appropriate. Medical record review for Resident 84 was initiated on 8/10/26. Resident 84 was admitted to the facility on [DATE]. Review of Resident 84's H&P examination dated 10/16/25, showed Resident 84 had capacity to understand and make decisions. Review of Resident 84's eINTERACT Change in Condition Evaluation - V5.1 dated 8/1/26, showed Resident 84's family member visited on 7/31/26, and claimed CNA 3 put his elbows on Resident 84's stomach and resulted to Resident 84 having pain. However, review of the facility's transmission verification receipt showed the facility's SOC 341 for Resident 84's abuse allegation was faxed to the CDPH L&C program on 8/1/26 at 2159 hours, and Ombudsman on 8/1/26 at 2202 hours. On 8/11/26 at 0955 hours, an interview was conducted with the Administrator. The Administrator stated Resident 84's family member came to visit on 7/31/26, and reported the allegation of abuse to RN 1. The Administrator stated RN 1 reported the allegation of abuse to her on 7/31/26, and accepted it as Resident 84's grievance. The Administrator verified the SOC 341 was faxed a day after the allegation of abuse. The Administrator stated the expectation to report allegation abuse to appropriate agencies was within two hours. 8/13/26 at 1442 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 comprehensive care plan was developed to reflect the individual care needs for one of nineteen final sampled residents (Resident 26). * The facility failed to develop a care plan problem to address Resident 26's use of the zolpidem tartrate (sedative-hypnotic medication used for short-term treatment of insomnia). This failure had the potential for Resident 26 to not be provided with appropriate, consistent, and individualized care.Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed the comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical psychosocial and functional needs was developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.The comprehensive, person centered care plan included the following: - measurable objectives and timeframes;- describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; - includes the resident's stated goals upon admission and desired outcomes;- reflect treatment goals, timetables and objectives in measurable outcomes; - builds on the resident's strengths; and- reflects currently recognized standards of practice for problem cares and conditions. Medical record review for Resident 26 was initiated on 8/10/26. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's Order Summary Report showed a physician's order dated 7/28/26, to administer zolpidem tartrate 5 mg by mouth every 24 hours as needed for insomnia manifested by inability to sleep. Review of Resident 26's plan of care dated 8/13/26, failed to show a care plan problem was developed to address Resident 26's use of the zolpidem tartrate medication. On 8/13/26 at 1059 hours, an interview and concurrent medical record review for Resident 26 was conducted with LVN 10. LVN 10 stated the purpose of the residents' care plans were to ensure the care provided was appropriate for each resident. LVN 10 reviewed Resident 26's care plan and verified the above findings. On 8/13/26 at 1229 hours, an interview for Resident 26 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 comprehensive plan of care was revised to reflect the current care needs and interventions for one of 19 final sampled residents (Resident 21). * Resident 21's care plan for altered renal function was not revised to include fluid restriction intervention as ordered by the physician. This failure posed the risk of not providing individualized and person-centered care.Findings: Review of the facility's P&P titled Care Plan Revision (undated) showed it is the policy of this facility that each resident's care plan is reviewed and revised as necessary to reflect the resident's current status, needs, and goals, and in accordance with regulatory requirements. Medical record review for Resident 21 was initiated on 8/10/26. Resident 21 was admitted to the facility on [DATE], with diagnoses of End Stage Renal Failure and dependence on renal dialysis. Review of Resident 21's H&P examination dated 1/26/26, showed Resident 21 had capacity to understand and make decisions. Review of Resident 21's Order Summary Report showed physician's order dated 1/12/26, for a 1500 ml fluid restriction, including a breakdown for dietary (720 ml total: 240 ml each for breakfast, lunch and dinner) and nursing (780 ml total: 520 ml from 0700 - 1900 hours and 260 ml from 1900 - 0700 hours). Review of Resident 21's Care Plan Report showed the care plan problem addressing the resident's altered renal function revised on 7/21/26; however, it did not show documented evidence of the fluid restriction intervention or breakdown fluid restriction as ordered by the physician. On 8/13/26 at 0916 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated Resident 21 was on a 1500 ml fluid restriction per 24 hours. RN 1 verified the care plan did not include the fluid restriction intervention and did not show the breakdown of fluids for nursing and dietary. RN 1 stated care plan should reflect the resident's current condition. On 8/13/26 at 1442 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings above.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the care and services were provided for one of 19 final sampled residents (Residents 3). * The facility failed to ensure the injection sites for the heparin (anticoagulant medication) administration were rotated for Resident 3. This failure had the risk for lipodystrophy (buildup of fatty lumps) and decreased medication absorption. Findings: Review of the facility's P&P titled Subcutaneous Medication Administration Procedures dated 4/2019 showed the medication administered subcutaneously will help to promote slow medication absorption and prolong medication action. The licensed nurses should select an appropriate site for injection and document the injection sites on the MAR along with the site used. Medical record review for Resident 3 was initiated on 8/11/26. Resident 3 was admitted to the facility on [DATE].Review of Resident 3's H&P examination dated 3/20/26, showed Resident 3 had no capacity to understand and make decisions. Review of Resident 3's MAR for the months of May, June, and July 2026 showed the injection site to administer the heparin medications injection were not rotated. For example, Resident 3 received the heparin medication at the right lower quadrant of the abdomen on the following dates and times:- on 5/15/26 at 0950 hours, and 5/15/26 at 2201 hours;- on 6/19/26 at 1026 hours, and 6/19/26 at 2205 hours; and - on 7/31/26 at 0916 hours, and 7/31/26 at 2155 hours. Review of Resident 3' Order Summary Report dated 8/11/26, showed a physician's order dated 3/20/26, to administer heparin injection solution 5,000 unit subcutaneously two times a day for DVT prophylaxis and rotate the site. On 8/12/26 at 1357 hours, an interview and concurrent medical record review for Resident 3 was conducted with LVN 7. LVN 7 stated they needed to rotate the injection sites to prevent any complication and the absorption of the medication. LVN 7 was asked to review the MAR for the location of the injection sites for heparin in the months of May, June, and July 2026. LVN 7 verified the location of injection sites for heparin medication were not rotated. On 8/13/26 at 0907 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 2. RN 2 was asked about the facility's process when administering a subcutaneous injection. RN 2 stated the licensed nurses should always follow the rights on giving medication to the residents. RN 2 stated for the administration of the injection subcutaneously, she expected for the licensed nurses to rotate the sites to prevent any complication to the skin of the resident, and may affect the absorption of the medication. RN 2 was asked to review the MAR for the location of the injection sites for heparin medication for May, June, and July 2026. RN 2 verified the location of injection sites for heparin medication were not rotated. On 8/13/2026 at 1446 hours, an interview and concurrent medical record review for Resident 3 was conducted with the DON. The DON was informed and verified the above findings.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate treatment and services were provided to one of 19 final sampled resident (Resident 7) reviewed for positioning/mobility. * The facility failed to assess and check the skin of Resident 7 when the splint device was applied. In addition, the facility failed to provide documented evidence that the splint for Resident 7 was applied for up to four hours per day as ordered by the physician. These failures had the potential to result in the decline in Resident 7's ROM which could lead to further deterioration in the resident's physical well-being.Findings: Review of the facility's P&P titled Resident-Specific Rehab Medical Supplies, Orthosis and Positioning Devices undated showed all the residents will be assessed upon admission and quarterly for positioning needs and adaptive equipment needs. Positioning devices may include splints, braces and other orthosis, wedge cushions, positioning devices or wheelchair conversions/custom seats and backs. The goal is to improve the residents' quality of life, increase function and safety and prevent further deterioration of mobility and skin integrity. Review of the facility's P&P titled Restorative Nursing Services revised 7/2017 showed the resident will receive restorative nursing care as needed to help promote optimal safety and independence. Medical record review for Resident 7 was initiated on 8/10/26. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's MDS assessment dated [DATE], showed Resident 7 had impairment on both upper extremities. Review of Resident 7's H&P examination dated 7/11/26, showed Resident 7 had no capacity to understand and make decisions. Review of Resident 7's Order Summary Report showed the following physician's orders:- dated 7/12/26 to apply L (Left) PRAFO five times a week for fours as tolerated;- dated 7/12/26 to apply R (Right) PRAFO five times a week for fours as tolerated;- dated 7/12/26 to apply L (Left) WHFO five times a week for fours as tolerated; and- dated 7/12/26 to apply R (Right) WHFO five times a week for fours as tolerated. Review of Resident 7's Documentation Survey Report v2 for August 2026 showed documented application of the left PRAFO, right PRAFO, left WHFO, and right WHFO from 8/3 to 8/11/26, except on 8/8 and 8/9/26. However, further review of the document did not show when the orthosis devices were removed, or how long the resident tolerated the application of the orthosis devices. Also, the document failed to show documented evidence the orthosis devices were removed every two hours. On 8/12/26 at 1048 hours, an interview and concurrent medical record review for Resident 7 was conducted with RNA 1. RNA 1 stated she applied the splinting devices on both arms and feet of Resident 7 five times a week for four to six hours as tolerated. RNA 1 stated there was no specific time when to apply the splinting devices and she would remove the splinting devices only when Resident 7 had pain and after four to six hours. RNA 1 reviewed the documentation on the splinting devices. RNA 1 verified there was no documented evidence when the splinting devices were removed and how long Resident 7 tolerated wearing the splinting devices. RNA 1 stated the EHR system only asked for how many minutes of ROM was provided to Resident 7. On 8/12/26 at 1103 hours, an interview was conducted with LVN 2. LVN 2 stated he was the assigned licensed nurse for Resident 7. LVN 2 stated Resident 7 had splinting devices for both hands and feet for four to six hours. LVN 2 stated the splinting devices were not removed for the whole duration of four to six hours and LVN 2 did not perform assessments. LVN 2 stated the RNAs were responsible for Resident 7's splinting devices. On 8/13/26 at 0916 hours, an interview and concurrent medical record review for Resident 7 was conducted with RN 1. RN 1 stated Resident 7 had physician's orders to apply WHFO to both hands and PRAFO boots on both feet. RN1 stated the splinting devices should be removed every two hours to check Resident 7's skin integrity and assess for pain. RN 1 reviewed Resident 7's medical record. RN 1 verified there was no documented evidence to show the splinting devices were removed every two hours with skin integrity and pain assessment, and how long Resident 7 tolerated wearing the splinting devices. On 8/13/26 at 1442 hours, an interview was conducted with the DON. The DON stated Resident 7's splinting devices should be removed every fifteen minutes to assess skin integrity. The DON stated the EHR system had no option to document the duration of treatment. The DON acknowledged the above findings.

Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) was free from accident hazards. * Resident 1 had an unwitnessed fall incident on 9/18/25. The facility failed to investigate Resident 1's family member's grievance regarding Resident 1's position near the edge of the bed on 9/16/25. Resident 1's fall risk assessment was inaccurate resulting in an incorrect fall risk score status. In addition, the facility failed to update Resident 1's care plan addressing the resident's risk for fall and his behavior of dangling his legs off the bed prior to his fall incident. These failures resulted in Resident 1 sustaining a subdural hematoma (a collection of blood that accumulates between the brain and the inner layer of the skull) and hospitalization.Findings: Review of the facility's P&P titled Grievance/Complaint Log revised 4/2008 showed the Social Services will be responsible for the grievance log. The following information as a minimum must be recorded:a) The date the grievance/complaint was received;b) The name and room number of the resident following the grievance complaint;c) The name and relationship of the person filing the grievance/complaint in behalf of the resident;d) The date the alleged incident took place;e) The name of the person (s) investigating the incident;f) The disposition of the grievance (i.e., resolved, dispute, etc.,).Review of the facility's Fall Program: Falling (Yellow) Star Program (undated) showed the IDT (Interdisciplinary Team) will review appropriate interventions for the residents identified as a fall risk; interventions will be based on the resident's fall risk factors from assessments, history of falls, and other fall risk determinants. The DON and DSD will re-educate the nursing staff about the Falling Star Program which will include the frequency of monitoring the residents and interventions to minimize injuries from a potential fall. a. Medical record review for Resident 1 was initiated on 10/1/25. Resident 1 was admitted to the facility on [DATE]. Resident 1 had diagnoses which included diffuse traumatic brain injury (a disruption in the normal function of the brain that can be caused by a bump, blow or jolt to the head), history of falling, and anoxic brain damage (a condition where the brain was deprived of oxygen for a period of time). In addition, Resident 1 was hospitalized on [DATE], and returned to the facility on 9/25/25. Review of Resident 1's H&P examination dated 4/24/25, showed Resident 1 was nonverbal and had no capacity to make medical decisions. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 was dependent on the facility staff assistance to roll from lying on his back, to the left and right sides, and return to lying on his back on the bed. Further review of Resident 1's MDS assessment showed to code the resident dependent when the resident did not provide any effort to complete the activity, or the assistance of two or more helpers were required for the resident to complete the activity. In addition, the MDS assessment showed Resident 1 had an impairment on both upper and lower extremities that interfered with daily functions. Review of Resident 1's Grievance / Complaint Report Form dated 9/16/25, showed the department manager would investigate the allegations and submit a written report of the findings to the Administrator within five working days of receiving the grievance. Resident 1's grievance form showed Resident 1's family member complained regarding the resident's legs positioned towards the edge of the bed and informing a CNA to reposition the resident. Under the sections for witnesses and employees to describe the incident and to describe the findings of the incident showed N/A was documented. Under the Recommendations/Corrective Action Taken section showed an in-service was initiated for the licensed nurses and CNAs on 9/17/25, about proper positioning in bed. However, further review of Resident 1's medical record failed to show documentation the facility monitored and/or provided additional interventions to prevent the resident from falling after the grievance from the resident's family member was filed. Review of Resident 1's eINTERACT Change in Condition Evaluation - V 5.1 dated 9/18/25, showed Resident 1 had an unwitnessed fall incident, where he was found lying on the floor near the right side of his bed. Resident 1 was noted to have a bump on the right side of his forehead. Resident 1 was on an anticoagulant (blood thinner) medication and the physician ordered to transfer Resident 1 to the acute care hospital for an evaluation and treatment. Review of Resident 1's admission H&P note from Acute Care Hospital A dated 9/18/25, showed Resident 1 fell around two feet from the bed onto the ground and striking his head. The CT of the head (computed tomography scan of the head is an imaging test that uses X-rays to create detailed cross-sectional images of the brain, skull, and sinuses) result showed a small 2 mm (size) right frontal subdural hematoma. b. Review of the facility's P&P titled Falls - Clinical Protocol revised 3/2018 showed the staff will identify the resident's risk factors for falls and history of falling. The nurse shall assess the resident and document the resident's vital signs, musculoskeletal function, and observe for change in normal range of motion. In addition, the staff will identify, monitor, and document the interventions related to the residents' risk of falls and re-evaluate the current approaches as needed to prevent subsequent falls. Review of the facility's P&P titled Charting and Documentation revised 7/2017 showed documentation in the medical record will be objective, complete, and accurate. Review of Resident 1's IDT (Interdisciplinary Team) Conference Record-RNA Follow Up dated 4/5/25, showed Resident 1 was bed bound. Review of Resident 1's Quarterly MDS assessment dated [DATE], showed Resident 1 was dependent on the facility staff assistance on toileting hygiene, and was always incontinent with the urinary and bowel continence. Review of Resident 1's MAR for July 2025 showed Resident 1 was administered with the following medications:- from 7/1 to 7/31/25, Resident 1 was administered amlodipine (used to treat high blood pressure)10 mg one tablet via GT in the morning for hypertension (high blood pressure);- from 7/1 to 7/31/25, Resident 1 was administered 5 ml of levetiracetam (anticonvulsant) 100 mg/ml oral solution via GT one time a day for seizures (a sudden burst of electrical activity in the brain);- on 7/17/25 at 2218 hours, Resident 1 was administered Ativan (antianxiety) 2 mg/ml intravenously every four hours as needed for seizure disorder. Review of Resident 1's N Adv - Fall Risk Evaluation dated 7/24/25 at 1604 hours, showed the following:- For the ambulation and elimination status, the documentation showed Resident 1 was chairbound/incontinent; however, Resident 1 was bedbound and incontinent.- For medications, the documentation showed Resident 1 was taking one to two of these medication classes (anesthetics, antihistamines, antihypertensives, antiseizure, benzodiazepines, cathartics, diuretics, hypoglycemics, narcotics, psychotropics, sedatives/hypnotics) within the last seven days; however, Resident 1 was taking three of the medication classes (antihypertensive, antiseizure, and psychotropic medication) . The Fall Risk Evaluation further showed if the total score was 10 or greater, the resident would be considered at high risk for potential falls and preventions should be initiated immediately and documented on the care plan. Review of Resident 1's progress notes correlating with the N Adv - Fall Risk Evaluation dated 7/24/25 at 1604 hours, showed the resident's fall risk score was nine. On 10/2/25 at 1256 hours, a follow up interview and concurrent medical record review for Resident 1 was conducted with LVN 1. LVN 1 verified the Fall Risk Evaluation was inaccurate and based on the resident's MAR, the fall risk score would be higher than nine, to show Resident 1 would be at a high risk for fall. c. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed the care plan interventions are implemented after careful data gathering of the resident's problem areas and their causes. In addition, the assessments of the residents are ongoing, and care plans are revised as information about the residents change. Review of Resident 1's plan of care initiated 12/10/24, and revised 10/1/25, showed a care plan problem addressing the resident's risk for falls. The interventions included to anticipate and meet the resident's needs, review information on past falls and attempt to determine the cause of the falls, record the possible roots cause, remove potential causes (for the falls) if possible, initiate the Falling Star Program, apply the yellow wrist band on the resident, place a yellow star by the door next to the resident's name, place the resident's bed in the lowest position and place the call light within reach. The care plan failed to show a new intervention was added or modified to prevent fall after the grievance of the resident's family member regarding the resident's episode of resident's legs positioned towards the edge of the bed or the behavior of dangling his legs over the bed. Further review Resident 1's care plan showed interventions were added to the resident's care plan on 9/20/25, after the resident's fall on 9/18/25, which included providing frequent visual checks, positioning the resident in the middle of the bed, and putting pillows on the resident's sides. On 10/1/25 at 1600 hours, an interview was conducted with LVN 1. LVN 1 stated on 9/18/25 at around 0840 hours, she found Resident 1 on the floor near the right side of his bed. LVN 1 stated she assessed Resident 1 and saw a bump on his forehead, before placing him back on his bed with CNA 1's assistance. LVN 1 stated the physician ordered to transfer Resident 1 to the acute care hospital for an evaluation. When asked if LVN 1 was aware of Resident 1's behavior of dangling his legs over the bed, LVN 1 stated the resident would cross his legs near the edge of his bed and slide down on the bed, when he was on the low air loss mattress. On 10/2/25 at 1020 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 1 would cross his legs all the time during his scheduled shifts. CNA 1 added the resident's legs would hang over the bed, and the resident would slide down on the low air loss mattress. CNA 1 stated he had informed the licensed nurses about Resident 1's behavior but was not aware if interventions were implemented for Resident 1 regarding the behavior of hanging his legs over the bed. On 10/2/25 at 1233 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated she filed a grievance on 9/16/25, with the facility, because Resident 1's legs were hanging off the bed and he was close to falling from the bed. Family Member 1 stated the facility staff informed her they would speak to the DON to address Resident 1's behavior and come up with a plan. On 10/2/25 at 1256 hours, a follow up interview and concurrent medical record review for Resident 1 was conducted with LVN 1. LVN 1 stated she did not document Resident 1's ability to cross his legs in his medical record and verified there was no documentation in Resident 1's progress notes regarding his ability to cross or move his legs over the bed. LVN 1 further stated she would have initiated a care plan for Resident 1's behavior of hanging his leg over the bed so the facility staff would be aware of any interventions implemented. LVN 1 reviewed Resident 1's N Adv - Fall Risk Evaluation dated 7/24/25, and Resident 1's MAR for 7/2025. LVN 1 verified the Fall Risk Evaluation was inaccurate and based on the resident's MAR, the fall risk score would be higher and show Resident 1 would be at a high risk for fall. On 10/2/25 at 1548 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated when a grievance was filed, the SSD should notify the responsible staff who oversaw the department, interview the facility staff involved, and update the resident's care plan. The DON verified she only updated Resident 1's care plan regarding the grievance after the resident's fall incident. On 10/8/25 at 0957 hours, an interview was conducted with the Interim DSD. The Interim DSD stated the SSD spoke to her regarding Family Member 1's grievance about Resident 1's legs dangling off the bed and their concern of Resident 1 falling out of bed. The Interim DSD stated she provided an in-service to the facility staff about repositioning the residents. When asked if the Interim DSD implemented any additional interventions for Resident 1's risk for falls, the Interim DSD stated just the intervention to reposition the resident. On 10/8/25 at 1045 hours, an interview and concurrent facility document review of Resident 1's Grievance Form was conducted with the SSD. The SSD stated she was responsible for investigating the facility's grievances. When asked how the SSD investigated the grievance from Family Member 1, the SSD stated she informed the Interim DSD about Family Member 1's concern and the Interim DSD agreed to do an all-facility staff in-service about positioning the residents. The SSD verified she did not interview any facility staff members about Resident 1's behavior of hanging his legs over the bed. On 10/8/25 at 1156 hours, a follow-up interview and concurrent facility document review for Resident 1 was conducted with the DON. The DON stated based on Resident 1's Grievance Form, the documented N/A on the form showed the grievance was not investigated because the facility staff were not interviewed. In addition, the DON stated the facility should have implemented interventions for Resident 1 regarding Family Member 1's grievance. The DON verified Resident 1's fall risk evaluation was inaccurate and stated if the correct assessment was conducted, Resident 1's fall risk score would have increased to show the resident was high risk for fall. On 10/10/25 at 1607 hours, a telephone interview was conducted with the DON and Medical Records Director. The DON and Medical Records Director were informed and acknowledged the above findings.

Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) attained or maintained their highest practicable physical well-being. * Resident 1 was found with a deep laceration to her left hand which was covered with a dressing. CNA 1, who was providing care to Resident 1 when the laceration was sustained, covered the laceration with a dressing and failed to report the incident to the licensed nurses. This failure resulted in Resident 1's transfer to the acute care hospital and required sutures to repair the left-hand laceration. Findings: Medical record review for Resident 1 was initiated on 2/28/22. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE], showed Resident 1 required total assistance on staff for bed mobility, transfers, dressing, bathing, and personal hygiene. Review of the Nurses Notes dated 2/18/22 at 1710 hours, showed at 1430 hours, the resident was noted with a left thumb dressing with blood. The dressing was removed, and Resident 1 was noted to have a laceration between the left thumb and left index finger, measuring 5.0 cm (length) x 1.0 cm (width) x 0.05 cm (depth). Review of the Nurses Notes dated 2/18/22 at 1735 hours, showed at 1537 hours, the physician was informed of Resident 1's change of condition, and a new order was obtained to transfer the resident to the acute care hospital emergency department for further evaluation of the laceration sustained in between the left thumb and left index. Review of the acute care hospital's history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . The documentation showed Resident 1 was found to have a left hand laceration, which required suturing. Further review of the hospital history and physical examination [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the SNF's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/28/22 at 0930 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 1 was non-verbal and required one-person total assistance with ADL care. CNA 3 stated she worked on 2/18/22, but was not assigned to Resident 1. CNA 3 stated when the licensed nurses were assessing Resident 1, she observed a big cut on Resident 1's left hand. CNA 3 stated CNA 1 was assigned to Resident 1 and CNA 1 did not request for assistance when providing care to Resident 1. On 2/28/22 at 0942 hours, a telephone interview was conducted with CNA 1. CNA 1 stated he was assigned to Resident 1 on the day of the incident (2/18/22). CNA 1 stated Resident 1 required one-person total assistance with ADL care and repositioning. When asked to provide details of the incident, CNA 1 stated he could not provide any information, other than the cut was . already there when his shift started. On 2/28/22 at 1007 hours, an observation and concurrent interview was conducted with Resident 1 and her family member (Family Member 1). Resident 1 was observed sitting up in bed watching television. Resident was non-verbal and a bandage was observed to the left hand. Family Member 1 stated the Resident could not speak and required assistance with ADL care. Family Member 1 stated he visited the resident daily, normally between the hours of 1000 and 1100. Family Member 1 stated the facility notified him on 2/18/22 at approximately 1600 hours, regarding Resident 1's needs to be transferred to the acute care hospital for a hand injury. Family Member 1 stated on 2/18/22, he noticed Resident 1's bilateral arms and hands were underneath the blanket. Family Member 1 stated normally her hands were draped and uncovered. Family Member 1 stated he thought Resident 1 was cold and did not remove her arms and hands from underneath the blanket. On 2/28/22 at 1020 hours, an interview was conducted with the Receptionist. The Receptionist stated Family Member 1 visited Resident 1 approximately at the same time daily and stayed in the facility for 30 to 40 minutes. On 2/28/22 at 1045 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 1 sustained a hand laceration and required wound care treatments. On 2/28/22 at 1050 hours, an observation of the Resident 1's wound was conducted with LVN 2. LVN 2 removed Resident 1's bandage. Resident 1 was observed with five sutures between the left thumb and index finger. On 2/28/22 at 1121 hours, an interview was conducted with LVN 3. LVN 3 stated she worked the day Resident 1 sustained the hand laceration. LVN 3 stated she was the desk nurse on 2/18/22. LVN 3 stated on 2/18/22 at 1430 hours, LVN 4, who was the charge nurse assigned to Resident 1 observed a wet bloody bandage on the left hand of Resident 1. On 2/28/22 at 1359 hours, an interview was conducted with the DSD. The DSD stated LVN 4 discovered Resident 1's wound during her rounds on 2/18/22, because Resident 1's blanket had a red colored stain which looked like blood on her blanket. The DSD stated CNA 1 did not report a change of condition to any licensed nurses. The DSD stated the CNAs were to conduct the skin checks when care was provided to the residents and report any changes immediately to the licensed nurses. On 2/28/22 at 1415 hours, an interview was conducted with the DON. The DON stated she was notified by RN Supervisor 1, Resident 1 sustained an injury to the left hand on 2/18/22. The DON stated when LVN 4 and RN Supervisor 1 assessed Resident 1, they discovered Resident 1 had a bandage covering the laceration to the left hand. The DON stated LVN 4 and RN Supervisor 1 denied treating the wound and laceration to the left hand. The DON stated during the facility's investigation of the injury, CNA 1 admitted to placing the bandage on Resident 1's hand and failed to report the injury/change of condition to the licensed nurses. On 2/28/22 at 1557 hours, an interview was conducted with Administrator 1. Administrator 1 stated during the facility's investigation regarding Resident 1's injury to the left hand, CNA 1 was interviewed multiple times and his story kept changing. Administrator 1 stated during the facility's investigation, she reviewed the facility's surveillance videos, and CNA 1 was observed leaving Resident 1's room and retrieved gauze, tape, and bandages from the treatment cart. Administrator 1 stated CNA 1 admitted the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrator 1 stated CNA 1 failed to report the injury immediately. Administrator 1 stated Resident 1 needed an evaluation by a physician based on the severity of the laceration. On 3/16/22 at 1027 hours, a telephone interview was conducted with RN Supervisor 1. RN Supervisor 1 stated LVN 4 reported Resident 1's hand laceration to her and asked her to assess Resident 1's hand. RN Supervisor 1 stated she was very shocked and surprised when no one other than LVN 4 had reported the cut because it was a very deep cut. RN Supervisor 1 stated Resident 1 was sent to the acute care hospital to be evaluated. RN Supervisor 1 stated Family Member 1 reported the resident's arms and hands were underneath the blanket when the family visited that morning. RN Supervisor 1 stated CNA 1 did not report any injuries that Resident 1 might have sustained on the day the laceration was discovered. RN Supervisor 1 stated the CNAs should report immediately if they noticed any changes to the resident's skin or anything different with the resident. On 3/16/22 at 1051 hours, a telephone interview was conducted with LVN 4. LVN 4 stated Resident 1 did not speak and was not able to communicate. LVN 4 stated she was assigned to Resident 1 on 2/18/22. LVN 4 stated when she assessed Resident 1, prior to the medication administration between 0800 to 0900 hours, she did not observe a bandage on Resident 1's hand. LVN 4 stated there was no endorsement from the night shift regarding Resident 1 sustaining an injury. LVN 4 stated after the medication administration, she rounded on Resident 1 and observed Resident 1's bilateral arms and hands were underneath the blanket. LVN 4 stated when she rounded on Resident 1 between 1400 to 1430 hours, she discovered a wound dressing on Resident 1's left thumb and saw visible blood outside of the wound bandage and blanket. LVN 4 stated she proceeded to open the saturated bandage and observed a cut on the left hand and saw visible blood. LVN 4 stated she applied a temporary wound dressing and immediately reported to the RN Supervisor 1. LVN 4 stated the assigned CNA to Resident 1 was CNA 1. LVN 4 stated CNA 1 did not report a change of condition or any injuries Resident 1 sustained during the shift. LVN 4 stated when she questioned CNA 1, he stated the injury occurred on the night shift. LVN 4 stated CNA 1 continued to deny the injury was sustained during care of Resident 1. LVN 4 stated she was informed by Administrator 1, CNA 1 confirmed Resident 1 sustained a laceration during repositioning and admitted he placed the bandage on Resident 1's hand to cover up the wound. LVN 4 stated CNA 1 should have reported the incident immediately instead of trying to hide it.

Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) attained and/or maintained their highest practicable physical well-being. The facility failed to ensure the daily wound care treatment was provided to Resident 1's right heel diabetic ulcer as ordered by the physician. In addition, the facility failed to obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, Resident 1 was transferred to the acute care hospital for the right heel wound infection and required surgical intervention. Findings: Review of the facility's P&P titled Wound Care revised October 2010 showed preparation is included to verify if there is a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review for Resident 1 was initiated on 4/9/21. Resident 1 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 1 had no cognitive impairment. Review of the Non-Pressure Sore Skin Problem Report dated 1/16/21, showed Resident 1 was noted with a diabetic ulcer on the right heel, which was described as dry and stable eschar (dead tissue) measuring 3 cm x 3 cm. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's Treatment Record for March 2021 showed the wound treatment to the right heel diabetic ulcer was scheduled daily on the 0700 to 1500 hour shift, with a stop date of 3/28/21. However, the wound care was not signed as provided on 3/6, 3/7, 3/13, 3/14, and 3/20/21. Further review of the Treatment Record failed to show the wound care was provided to Resident 1's right heel diabetic ulcer after 3/28/21. Review of Resident 1's right heel diabetic ulcer Weekly Progress Report showed the weekly wound assessments from 1/29 to 3/26/21. The wound was assessed as dry, stable eschar, measuring 3 cm x 3 cm, with no signs and symptoms of infection. On 4/2/21, the documentation showed the right heel diabetic ulcer was dry stable eschar, measuring 3 cm x 3cm, but was noted to have foul odor and drainage. However, review of the medical record failed to show documentation Resident 1's attending physician was notified of the changes in Resident 1's right heel diabetic ulcer. Review of the Departmental Notes dated 4/5/21, showed Resident 1's right heel diabetic ulcer was noted with wound edge opening and a strong foul odor. The documentation showed the NP was notified and ordered [MEDICATION(S)] (antibiotic) 100 mg by mouth twice a day for right heel wound infection. Review of the medical record failed to show a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of NP 1's progress notes dated 4/5/21, showed LVN 3 reported Resident 1's right heel diabetic ulcer had a foul odor and drainage. Resident 1 would be sent out to the acute care hospital for further treatment and evaluation. On 5/10/21 at 1531 hours, a telephone interview was conducted with Resident 1. Resident 1 stated the care he was receiving from the facility included wound treatment on his right heel. Resident 1 was asked what treatment was he receiving for the wound on his right heel. Resident 1 stated the nurse applied iodine on the wound on his right heel, and covered with a dressing. Resident 1 stated the nurse did not apply the iodine on the wound everyday. Resident 1 stated a few days before he was transferred to the acute care hospital, nothing was done for his right heel wound. On 5/21/21 at 1425 hours, a telephone interview was conducted with LVN 3. LVN 3 acknowledged the Treatment Record was a documentation for wound care/treatments administered to Resident 1. LVN 3 verified the above findings. LVN 3 was asked what the check marks and initials meant on the Treatment Record of Resident 1. LVN 3 stated the the check marks and the initials meant the treatment was administered to Resident 1. LVN 3 verified there was no documentation to show wound care was administered on 3/6, 3/7, 3/13, 3/14, and 3/20/21. On 6/1/21 at 1215 hours, a telephone interview was conducted with the DON. The DON verified the above findings. The DON verified a renewal order was not obtained from Resident 1's physician after the last day of the wound care treatment on 3/28/21. The DON stated an order should have been obtained because the wound was not healed. The DON verified the wound care treatment was not provided to Resident 1's right heel diabetic ulcer from 3/29 to 4/5/21. Review of the acute care hospital's ED (emergency department) Provider Notes dated 4/5/21, showed Resident 1 presented to the ED with chief complaint of pain, including right heel pain with a history of wound ulcer. Review of the acute care hospital's Orthopedic Surgery consult notes dated 4/5/21, showed on examination, Resident 1 had a large 8 x 8 cm ulceration over the plantar (sole of the foot) aspect of the right heel with active purulent (with pus) drainage with abscess (swollen area within the body tissue containing an accumulation of pus). Review of Resident 1's medical record from the acute care hospital titled Operative Note dated 4/7/21, showed Resident 1 underwent right below the knee amputation on 4/7/21, with preoperative diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross reference to F580.

Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide an environment free from potential for serious accident hazards for two of two sampled residents (Residents 1 and 2) and 10 nonsampled residents (Residents A, B, C, D, E, F, G, H, I and J). * The facility failed to ensure the safe smoking practices were followed for seven of seven residents (Residents 1, 2, C, G, H, I, and J) who smoked in the facility. The residents were not thoroughly assessed to determine if they required supervision while smoking, and there were no individualized care plan problems developed addressing safe storage and use of smoking materials. * The facility failed to ensure residents and facility staff were aware of the designated smoking area in the facility. This resulted in residents smoking in areas not designated for smoking, smoking in the areas close to the residents' rooms who were receiving oxygen. These failures posed the risk of fire and serious injury to the residents. On 5/8/19 at 1406 hours, the Administrator and DON were informed an IJ was identified regarding the following deficient practices: * The facility failed to follow their P&P on smoking by failing to thoroughly assess all residents who smoked in the facility and determine if they were safe to smoke and if they required supervision while smoking. * The facility failed to develop individualized care plan problems addressing safe storage and use of smoking materials. * The facility failed to ensure safety measures were followed by allowing residents to smoke in a designated and marked area for smoking. On 5/9/19 at 1530 hours, the IJ was abated after the facility had submitted the following plan of corrective actions: * Conducted thorough smoking assessments to all residents who smoked in the facility. * Identified and marked the designated smoking area. * Updated the residents' plans of care to include safe storage and use of smoking materials. * Provided a locked box to the residents who were determined to be safe to keep their smoking materials in their rooms. * In-serviced all staff on the facility's smoking P&P and safety measures related to smoking. Findings: According to the facility's P&P titled Smoking by Residents revised 9/2018, showed the resident will be assessed by the IDT initially when they verbalize the desire/interest to smoke. The assessment is to determine if the resident is able to smoke safely and not harm themselves or others. The resident's attending physician shall be notified of the resident's desire to smoke. The resident's care plan will be updated to address smoking and to include smoking activity and any restrictions, special equipment or instructions required, if any. The resident shall be informed about any limitation of smoking, including designated smoking areas and the extent to which the facility can accommodate their smoking, and this shall be documented on their medical record. 1. Review of the List of Residents Who Smoke provided by the facility on 5/8/19, showed there were seven residents (Residents 1, 2, C, G, H, I, and J) who currently smoked in the facility. On 5/8/19 at 1150 hours, an observation was conducted at the facility's courtyard patio (the patio was surrounded by glass doors and walls of the facility). The glass doors surrounding the patio were observed with NO SMOKING signs which faced out to the patio. There was no visible sign of the designated smoking area; however, there were ashtrays and cigarette butts on the ground. On the patio wall between Rooms A and B, there was a fire extinguisher, smoking aprons, and a smoking blanket observed. Adjacent to these items (on the right) was a NO SMOKING sign. The sliding glass door to Room C was observed to be slightly open. The resident in this room had an oxygen concentrator which noted to be even though the resident was not in the room. An ashtray had been placed right outside Room C. On 5/8/19, review of Residents 1, 2, C, G, H, I, and J's medical records was initiated and showed the following: a. Review of a Resident Smoking Assessment for Residents 1, 2, C, G, H, I, and J failed to show the IDT had met to determine if each resident needed supervision while smoking. On 5/8/19 at 1210 hours, an interview was conducted with Resident 1. Resident 1 stated he smoked with supervision because he could not get out of bed on his own. Resident 1 stated he kept his smoking paraphernalia in his room. The resident pointed to his cigarette box sitting on his over bed table. Resident 1 stated he had two buddies (Residents H and I) who smoked with him, and if they ran out of cigarettes, he shared his cigarettes with them. On 5/8/19 at 1215 hours, an interview was conducted with Resident 2. Resident 2 stated she smoked independently and smoked whenever she wanted to. Resident 2 stated she did not have a schedule to follow. On 5/8/19 at 1225 hours, an interview was conducted with Resident I. Resident I stated she was a smoker and smoked independently. When asked if a staff member was present in the courtyard patio while she smoked, Resident I stated .not all the time. When asked where the designated smoking area was, Resident I stated they could smoke in any area of the courtyard patio, but, they usually sat where the umbrella was. Resident I stated that last week the umbrella was located by Room C, but now it's by Room D. On 5/8/19 at 1235 hours, an interview was conducted with Resident C. Resident C stated he kept his own cigarettes in his room. He pulled a pack of cigarettes from his pocket. When asked if a staff member supervised him while he smoked, Resident C stated .not all the time. Resident C stated when it was raining they would smoke under the covered area by the door (this is where the subacute rooms were located and many of the residents required supplemental oxygen). On 5/8/19 at 1240 hours, an observation was conducted at the facility's courtyard patio. Residents 2, G, H, and I were observed smoking at the courtyard patio by Room D. Resident G was observed smoking without supervision. Resident G was not observed wearing a smoking apron. Resident G was holding the cigarette in her left hand. Resident G's hands were noted to be shaking and her jacket was observed with a small circular burn hole on the left side. A few moments later, CNA 7 was observed to approach Resident J. CNA 7 stated she was here to supervise Resident J and showed she had Resident's J's smoking materials. CNA 7 stated all the other residents were independent smokers and do not need supervision. On 5/8/19 at 1315 hours, an interview was conducted with Resident G. Resident G stated she smoked and was able to self propel her wheelchair out to the courtyard patio whenever she wanted to. When asked if a facility staff supervised her when she smoked, Resident G stated, .it depends. Resident G stated she kept her cigarettes in her room. b. Review of Residents 1, 2, C, G, H, and J's plans of care identified each resident had a care plan problem to address the risk for injury related to smoking. However, there were no interventions to identify if they were safe to smoke independently or required supervision. There were no interventions to identify whether it was appropriate or safe for the residents to have smoking paraphernalia (i.e. cigarettes, lighters, matches) in their possession or if the staff were required to keep the smoking paraphernalia for the residents. Review of Resident G's had a care plan problem dated 4/3/19, to address the risk for injury related to smoking. The interventions included to offer and encourage Resident G to use a smoking apron. Review of Resident I's care plan problem dated 10/9/17, to address the risk for injury related to smoking and identified Resident I needed to be supervised when smoking. The interventions also included for the smoking materials (cigarettes, lighter, match) to be kept by the staff at the nurses' station. On 5/8/19 at 1304 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified above findings and stated the IDT did not meet to determine whether these seven residents need supervision while smoking or not. The DON verified Residents 1, 2, C, G, H, and J's plans of care failed to identify if the residents required supervision when smoking and failed to identify whether it was appropriate or safe for the residents to have smoking paraphernalia in their possession. When asked if the residents were allowed to keep their own smoking materials, the DON stated no, because these residents were not assessed if they could keep their own smoking materials. On 5/8/19 at 1349 hours, the DON was called to the courtyard patio. The DON verified there was no sign as to where the designated smoking area was. The DON stated the designated smoking area was by Room A, however, this was not the area where the residents currently smoked. On 5/8/19 at 1545 hours, Resident 2 was observed smoking unsupervised at the courtyard patio. Resident 2 was ambulatory. 2. On 4/4/19 at 0[AGE]0 hours, Resident 1 was observed smoking independently on the smoking patio. Medical record review for Resident 1 was initiated on 4/4/19. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's physician's orders [REDACTED]. Review of the medical record failed to show a smoking assessment was completed for Resident 1. 3. Medical record review for Resident C was initiated on 4/4/19. Resident C was readmitted to the facility on [DATE]. Review of Resident C's physician's orders [REDACTED]. to smoke. There was no documentation to show a smoking assessment was completed for Resident C. Review of the plan of care failed to show a care plan problem was developed to address Resident C's smoking. 4. Medical record review for Resident F was initiated on 4/4/19. Resident F was admitted to the facility on [DATE]. Review of Resident F's physician's orders [REDACTED]. to smoke. There was no documentation to show a smoking assessment was completed for Resident F. Review of the plan of care failed to show a care plan problem was developed to address Resident F's smoking. 5. On 4/4/19 at 1[AGE]0 hours, Resident E was observed smoking on the back patio. There were no staff members present to supervise the resident. Medical record review for Resident E was initiated on 4/4/19. Resident E was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident E's Physician order [REDACTED]. to smoke. There was no documentation to show a smoking assessment was completed for Resident E. Review of the plan of care failed to show a care plan problem was developed to address Resident E's smoking. On 4/4/19 at 1[AGE]6 hours, an interview was conducted with RN 1. RN 1 verified Resident D and E were smoking in the smoking patio with no staff members present to supervise the residents. On 4/4/19 at 1622 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 could not locate any documentation the physician was notified of Residents C, D, E, F's desires to smoke. LVN 1 failed to show Residents 1, D, C, E and F's smoking assessments and care plan problems to address Residents 1, D, C, E and F's smoking. 6. On 4/4/19 at 1[AGE]0 hours, Resident D was observed smoking on the back patio. There were no staff members present to supervise the resident. Medical record review for Resident D was initiated on 4/4/19. Resident D was admitted to the facility on [DATE]. Review of Resident D's Physician order [REDACTED]. to smoke. There was no documentation to show a smoking assessment was completed for Resident D. Review of the plan of care failed to show a care plan problem was developed to address Resident D's smoking. On 4/4/19 at 1648 hours, an interview and concurrent medical record review for Resident D was conducted with RNs 2 and 3. RNs 2 and 3 could not locate any documentation the physician was notified of Resident D's desire to smoke. RNs 2 and 3 failed to show Resident D's smoking assessment and care plan problem to address Resident D's smoking.

Based on interview and clinical record review, the facility failed to ensure medications were necessary for two of 18 sampled residents (Residents 12 and 11). The facility failed to show nonpharmacological interventions were attempted for Resident 12, and were ineffective prior to the initiation of [MEDICATION NAME] acid (a medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder). The facility failed to document clinical justification to continue [MEDICATION NAME] acid for Resident 12 in the presence of the elevated liver enzyme test results and an enlarged liver. The facility failed to follow their P&P, related to [MEDICATION NAME] acid use, by not documenting Resident 12's behaviors for a three day period prior to the initiation of [MEDICATION NAME] acid. Resident 12 received [MEDICATION NAME] acid for 8 months and, during this time, had abnormal liver function tests, abnormally high ammonia levels, which required treatment, and an enlarged liver. The facility failed to document clinical justification to [MEDICATION NAME](a medication used to induce sleep) beyond the manufacturer's directions for Resident 11. This has the potential for dependency and adverse reactions for the resident. Findings: 1. According to Abbott Laboratories, a manufacturer of [MEDICATION NAME] acid, [MEDICATION NAME] acid carries a FDA (Food and Drug Administration) black box warning, the highest cautionary warning issued by the US Food and Drug Administration. [MEDICATION NAME] acid can cause life threatening hepatotoxicity (liver failure) and pancreatitis (inflammation of the pancreas). Review of the facility's P&P titled Medications - [MEDICAL CONDITION] dated May, 2009, showed it is the policy of the facility, no medication to treat behaviors will be initiated until after 72 hour monitoring for the behavior has been conducted. According to Mayo Clinic (www.mayoclinic.org) Mayo foundation for Medical Education and Research, Understanding [MEDICAL CONDITION], 2008, showed a person with a [MEDICAL CONDITION] may experience changes in behavior. These changes include difficulty with self control, self awareness and response to social situations. It is common for a person with a [MEDICAL CONDITION] to be impulsive, have poor judgment, lack of inhibition and make inappropriate comments. According to the National Institutes of Health, a service of the US National Library of Medicine, increased levels of ALT ([MEDICATION NAME] transaminase) and AST ([MEDICATION NAME] aminotransferase), enzymes found in the liver, often mean liver disease is present. An elevated ammonia level and enlarged liver may also indicate liver disease and damage. On 11/16/11, clinical record review for Resident 12 was initiated. The history and physical dated 3/15/11, showed Resident 12 had a [MEDICAL CONDITION]. The MDS dated [DATE], showed Resident 12 is cognitively impaired and is dependent on staff for ADLs. The physician's orders [REDACTED]. On 11/17/11 at 0805 hours, during an interview and clinical record review with LVN 1, when asked what the specific behaviors were to justify the use of the [MEDICATION NAME] acid, the LVN stated the care plan did not specify the behaviors. The LVN showed a care plan problem titled Behavioral Patterns dated March, 2009. LVN 1 stated there was another care plan problem titled Behavioral Patterns dated 3/2/11, which showed Resident 12 removes his sheets and exposes himself unintentionally. An intervention listed showed staff would replace the sheets as needed. The LVN was unable to explain why replacing the sheet was ineffective. The LVN stated staff would document nonpharmacological interventions attempted prior to the use of the [MEDICATION NAME] acid on the MAR. However, review of the MAR dated March, 2011, showed no nonpharmacological interventions were attempted. The LVN stated there were none documented on the MAR. Review of the Behavioral Management Follow Up form dated 5/27/11 and 9/2/11, showed Resident 12 was receiving [MEDICATION NAME] acid for a behavior, but nonpharmacological interventions listed on the form were not specific to the behavior being treated by the [MEDICATION NAME] acid. The pharmacist's Consultation Report for Resident 12 dated 9/23/11, showed Resident 12 continued to receive [MEDICATION NAME] acid in the presence of elevated liver enzymes. The pharmacist documented [MEDICATION NAME] acid is hepatotoxic and is contraindicated in patients with hepatic disease or significant hepatic dysfunction. Use with extreme caution in patients with a prior history of hepatic disease. Hepatotoxicity has been fatal and may more commonly occur in the first 6 months of treatment. The pharmacist recommended the physician re-evaluate the risks versus benefits of administering these medications to Resident 12. On 11/17/11 at 1100 hours, during an interview and clinical record review with the DON, the DON was unable to show Resident 12's medications were re-evaluated by the physician and clinical justification documented to continue the medication in the presence of adverse reactions. Review of the clinical record showed a laboratory report form dated 4/20/11, showing Resident 12's ALT level was 194 U/L (normal range is between 7 U/L to 52 U/L). The laboratory noted these results were high. The laboratory report form dated 5/23/11, showed Resident 12's AST level was 143 U/L (normal range is between 13 U/L to 39 U/L) and his ALT level was 143 U/L. The laboratory noted these results were high. The laboratory report form dated 6/29/11, showed Resident 12's AST level was 121 U/L and his ALT level was 95 U/L. The laboratory noted these results were high. The resident's kidney function was normal. The laboratory report form dated 9/2/11, showed Resident 12's AST level was 150 U/L and his ALT level was 107 U/L. The laboratory noted these results were high. The laboratory report form dated 9/21/11, showed Resident 12 had a fatty enlarged liver of moderate degree. The laboratory report form dated 9/29/11, showed Resident 12's ammonia level was 78.1 umol/L (normal range is between 9 umol/L to 35 umol/L). The laboratory noted this result was high. The physician's orders [REDACTED]. Review of the laboratory report form dated 10/4/11, showed Resident 12's AST level was 167 U/L and his ALT level was 149 U/L. The laboratory noted these results were high. The resident's kidney function was normal. A physician's orders [REDACTED]. The laboratory report form dated 10/19/11, showed Resident 12's AST level was 143 U/L and the residents ALT level was 122 U/L. The laboratory noted these results were high. The laboratory report form dated 11/17/11, showed Resident 12's ammonia level was 88 umol/L (normal range is between 9 umol/L and 35 umol/L). The laboratory noted this result was high. (Cross-Reference F154, #1 and F428, #1) 2. According to Sanofi-Aventis U.S., LLC, a manufacturer of Ambien,[MEDICATION NAME] used for the short term treatment of [REDACTED]. Adverse reactions include abnormal thoughts and behavior, drowsiness and dizziness. The resident should be evaluated for use beyond seven to 10 days. On 11/15/11, clinical record review for Resident 11 was initiated. The Psychotherapeutic Drug Summary Sheet dated 11/11/08, showed Resident 11 was [MEDICATION NAME] before 3/26/09. The physician's orders [REDACTED]. However, the record showed no physician justification documented for the use of [MEDICATION NAME] seven to 10 days. The pharmacist's Consultation Report dated 10/11/11, showed there was no [DIAGNOSES REDACTED]. The pharmacist made a recommendation for the physician to re-evaluate the need for continued use [MEDICATION NAME] Resident 11, and to document clinical justification. On 11/16/11 at 0740 hours, during an interview and clinical record review with MDS Coordinator 1, she was unable to show physician documentation to continue the use [MEDICATION NAME] Resident 11. (Cross-Reference F428, #2)