Every finding on record at La Paloma Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure the kitchen environment and food handling processes were maintained in a sanitary manner in accordance with accepted standards of practice when:Dishware was stored wet, pitcher lids were cracked and broken, and grime was on the freezer doors and gasket.Cook 1 used a potentially contaminated glove to touch bread rolls. In addition, dietary staff did not take the final temperature of all food to be served during lunch.Dietary Aid (DA) 1 and DA 2 were not wearing beard guards while in the kitchen.Six bottles of grape supplemental protein 30 fluid ounces, three bags of renal tube feeding (formulated food delivered through a feeding tube) formula, and six bottles of carbohydrate-controlled tube feeding formula were stored expired.The Dry Storage room was not within an acceptable temperature range.DA 3 touched the garbage lid with his bare hands, then put gloves on and made a salad without washing his hands. These failures had the potential to cause widespread food contamination and placed residents at risk for food borne illnesses. Findings: 1. On 6/15/26 at 8:13 A.M., a joint observation of the kitchen and interview was conducted with the dietary director (DD). The clean dishware area was observed. There were three 4-quart containers and three 22-quart containers that were wet and stacked. Additionally, there were two pitcher lids that were cracked and broken. The DD stated dishware should not be stored wet and stacked. The DD stated, That's when bacteria grows. The freezer by the clean dishware area was observed. The freezer had visible black, textured residue on the inside of freezer doors and gaskets that wiped off onto a napkin. The DD stated the freezer looked dirty and it should have been clean. A review of the facility's policy titled, Sanitization, revised November 2022, indicated, . All utensils.equipment is kept clean, maintained in good repair and free from breaks.cracks and chipped areas. Plastic ware. that cannot be sanitized or are hazardous because of chips, cracks. are discarded. 2. On 6/16/26 at 12:02 P.M., a joint observation of the kitchen was conducted with the DD. [NAME] 1 was observed wearing a glove on her right hand and repeatedly touching multiple non-food contact surfaces and utensils including plates, lids, ladles, tongs, suction cups used for plates, and an oven mitten that had fallen onto the kitchen floor. [NAME] 1 then used the same right-gloved hand to handle bread intended for meal service. Throughout the meal service, [NAME] 1 continued to alternate between touching the kitchen equipment and the bread with the same gloved hand. The DD observed [NAME] 1 using her gloved hand to touch multiple times non-food contact surfaces and utensils and then handle the bread. The DD stated tongs should have been used when handling bread. At 12:32 P.M., DA 1 was observed plating a hamburger patty, a bowl of soup, and a bowl of broth without obtaining the final food temperatures prior to plating. At 1:15 P.M., DA 1 was observed plating an additional hamburger patty without obtaining the final food temperature prior to plating. After observing that DA 1 did not take the temperature of the hamburger patty before plating, [NAME] 1 checked the temperature of the hamburger patty. The hamburger patty measured 69 degrees Fahrenheit (normal temperature is 155 degrees Fahrenheit for a cooked beef patty). [NAME] 1 instructed DA 1 to continue cooking the hamburger patty until it reached the required temperature. The DD observed food being plated without a final temperature taken and told [NAME] 1 to take all final food temperatures prior to plating. On 6/17/26 at 1:31 P.M., an interview was conducted with [NAME] 1 inside the kitchen. [NAME] 1 stated her gloved hand was contaminated after touching non-food items and she should not have used that gloved hand to serve bread. [NAME] 1 stated that DA 1 should have checked the temperatures for all food items because food that was not at a safe temperature could make the residents sick. [NAME] 1 further stated that the kitchen procedure required the DA preparing the food to obtain and document the temperature prior to plating. On 6/18/26 at 8:11 A.M., an interview was conducted with the DD. The DD stated that [NAME] 1's use of the same gloved hand to touch multiple surfaces, kitchen items, and ready to eat bread was, cross contamination. The DD further stated all food temperatures should have been obtained prior to plating to ensure food remained outside the temperature danger zone and to reduce the risk of foodborne illness. An interview was conducted with the DD. The DD stated that [NAME] 1's use of the same gloved hand to touch multiple surfaces, kitchen items, and ready-to-eat bread was 'cross-contamination.' The DD further stated that all food temperatures should have been obtained prior to plating to ensure food remained outside the temperature danger zone and to reduce the risk of foodborne illness. A review of the facility's undated policy titled, Food Preparation and Service, indicated, . Potentially Hazardous Food (PHF).means food that requires time/temperature control for safety to limit the growth of pathogens (i.e. bacterial or viral organisms capable of causing a disease or toxin formation).Cross contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands). Disposable gloves are single-use items and discarded after each use. 3. On 6/16/26 at 3:30 P.M., a joint observation of the kitchen was conducted with the DD. DA 1 was observed standing at the stove stirring a pot with approximately one-quarter inch of his beard hair exposed. The DD stated DA 1 should have been wearing a beard guard. On 6/17/26 at 11:37 A.M., an observation of the kitchen was conducted. DA 2 entered the kitchen, walked to the dishwashing area, and began washing dishes with approximately one-half inch of his mustache hair exposed. On 6/17/26 at 1:30 P.M., an interview was conducted with DA 2 inside the kitchen. DA 2 stated he should have been wearing a beard guard and forgot. DA 2 stated a beard guard was required anytime staff enter the kitchen with facial hair. On 6/18/26 at 8:11 A.M., an interview was conducted with the DD. The DD stated it was her expectation that all facial hair would be covered anytime staff were in the kitchen. The DD stated facial hair could fall into the food if it was not covered and could contaminate the food. A review of the facility's policy titled, Preventing Foodborne illness- Employee Hygiene and Sanitary Practices, revised November 2022, indicated, .beard restraints are worn while cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. 4. On 6/15/26 at 3:06 P.M., a joint observation of the medication storage room was conducted with the director or nursing (DON). In the cabinets there were: six 30- fluid ounce bottles of grape supplemental protein with an expiration date of 3/11/26; three bags of renal tube feeding formula with an expiration date of 4/2026; and six bottles of carbohydrate-controlled tube feeding formula with an expiration date of 5/1/26. The DON stated there should not have been any expired food products stored in the medication storage room, and that the medication storage room should have been checked weekly for expiration dates. The DON further stated the risk of having expired food products in the medication storage room was that they could have been given to a resident. On 6/18/26 at 9:53 A.M., an interview was conducted with the central supply manager (CSM). The CSM stated it was his responsibility to monitor for expired food products and that expired food products should not have been stored in the medication storage room. The CSM acknowledged that the expired tube feeding formulas and supplemental protein should have been removed from the medication storage room and stated, it was an error on my end. 5. On 6/16/26 at 3:25 P.M., a concurrent observation and interview was conducted with the Maintenance Director (MD) inside the Dry Storage room. The MD utilized a thermocouple (an electrical sensor used to measure temperature) to take the temperature of the dry storage room. The thermocouple indicated the temperature inside the Dry Storage room was 86.5 degrees Fahrenheit (F). The Dry Storage room thermometer indicated the room temperature was 88 degrees F. On 6/18/26 at 8:12 A.M., an interview was conducted with the DD. The DD stated the temperature inside the Dry Storage room should not have exceeded 85 degrees F. The DD stated that temperatures between 86 degrees F and 88 degrees F could spoil the food inside the Dry Storage room. A review of the facility's undated policy titled Storage of Food and Supplies, indicated, .Procedures for Dry Storage 1. Recommended temperature is 50 degrees F - 85 degrees F- if dry food storage goes over 85 degrees F take corrective action. 6. On 6/16/26 at 11:26 A.M., an observation was conducted inside the facility's kitchen. DA 3 was preparing a vegetable salad. DA 3 touched the garbage bin lid with his bare hands. After touching the garbage bin lid, he put gloves on. [NAME] 1 was observed telling DA 3 to wash his hands three times. DA 3 did not wash his hands and proceeded to add the remaining vegetables to the salad. On 6/17/26 at 1:28 P.M., an interview with DA 3 was conducted. DA 3 stated the normal process was to wash hands before putting gloves on. DA 3 stated hand washing should have been done after handling garbage. DA 3 stated he forgot to wash his hands before putting gloves on. DA 3 stated it was important to perform hand washing, especially when handling food because of safety reasons and preventing food contamination. On 6/18/26 at 8:12 A.M., an interview was conducted with the DD. The DD stated kitchen staff were expected to perform handwashing before wearing gloves. The DD stated this was supposed to be done to avoid cross contamination. A review of the facility's undated policy titled Food Preparation and Service, indicated, .General Guidelines.3. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.Food Distribution and Service.7.Gloves are worn when handling food directly and changed between tasks followed by hand hygiene prior to donning new gloves. A review of the facility's policy titled Preventing Foodborne Illness – Employee Hygiene and Sanitary Practices revised November 2022, indicated, .Hand Washing/Hand Hygiene 6. Employees must wash their hands:.h. after engaging in other activities that contaminate the hands.

Based on interview and record review the facility failed to ensure a resident's right to formulate an advance directive (a legal document that outlines your preferences for medical care and treatments if you become incapacitated and unable to communicate) for four out of seven sampled residents (Residents 8, 50, 86, and 92). This failure to communicate advance directive information could have resulted in care being provided that was inconsistent with the resident's expressed healthcare wishes.Findings: A review of Resident 8's admission Record indicated Resident 8 was admitted to the facility on [DATE] with a diagnosis that included hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) following cerebral infarction. A review of the medical record had no documented evidence that the resident was provided with information or whether the resident wished to establish one or declined to do so. A review of Resident 50's admission Record indicated Resident 50 was admitted to the facility on [DATE] with a diagnosis that included fracture of the right lower leg (broken bone). Furthermore, the medical record had no documented evidence showing whether the resident was provided with advance directive information, wished to establish one, or declined to do so. A review of Resident 86's admission Record indicated Resident 86 was admitted to the facility on [DATE] with a diagnosis that included congestive heart failure (a chronic, progressive condition in which the heart's muscle weakens or stiffens). A review of the medical record had no documented evidence that the resident was provided with information, or whether the resident wished to establish one or declined to do so. A review of Resident 92's admission Record indicated Resident 92 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (complete paralysis of one side of the body) and hemiparesis (weakness or partial paralysis on one side of the body) following cerebral infarction. A review of the medical record had no documented evidence that the resident was provided with information, or whether the resident wished to establish one or declined to do so. On 6/16/26 at 11:14 A.M., a concurrent interview and record review was conducted with the Social Service Director (SSD). The SSD reviewed the medical records of Residents 8, 50, 86, and 92 for an Advance Directive. The SSD stated it was not documented whether the residents had refused to develop an advance directive. The SSD stated she only gave information about the Advance Directive when the resident or a family member asked for it. The SSD stated I didn't know it was a thing to offer an Advance Directive to every resident. The SSD stated it was important to complete an Advance Directive for the residents before it was too late and the resident could no longer make their own decisions. On 6/18/26 at 3:13 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectation was that every resident in the facility be offered an Advance Directive and that it be documented whether the resident accepted or refused assistance. A review of the facility's policy titled Advance Directive, dated November 2025, indicated . a. The resident or representative is given the option to accept or decline assistance.b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance 10. The interdisciplinary team (a group of professionals from different fields working together to achieve a shared goal) will review annually with the resident their advanced directives to ensure such directives are still the wishes of the resident. Such reviews will be made during the annual assessment process and recorded in the medical record.

Based on interview and record review, the facility failed to ensure one of five residents, (Resident 2) was free from unnecessary medication when the resident was administered oxycodone (a controlled pain medication) doses for severe pain five times in June 2026 when the resident's pain assessment indicated the resident had no pain or had minimal pain. This deficient practice had the potential for Resident 2 to develop side effects, tolerance and addiction.Findings: A review of Resident 2's admission Record indicated the resident was admitted on [DATE] with diagnoses to include toxic encephalopathy (disease that alters the brain function), right femur fracture and alcoholic cirrhosis. A review of Resident 2's Order Summary Report dated 6/15/26, indicated two orders for oxycodone: 1. Oxycodone Oral Tablet 5 mg (milligram) give one tablet by mouth every four hours as needed for moderate pain rated 4-6 (based off a numeric pain scale where 10 is the highest pain rating and zero is no pain). 2. Oxycodone Oral Tablet 5 mg (milligram) give two tablets by mouth every four hours as needed for severe pain rated 7-10 (based off a numeric pain scale where 10 is the highest pain rating and zero is no pain). A review of Resident 2's Medication Administration Record for June 2026, indicated Resident 2 received two tablets of oxycodone for pain level rated at zero on the following dates: 6/4/26 at 9:59 A.M., 6/7/26 at 10:20 P.M., and 6/14/26 at 8 P.M. The same medication administration record indicated Resident 2 received two tablets of oxycodone for pain level rated one out of 10 on the following dates: 6/2/26 at 12:00 P.M., and at 6/4/26 at 2:19 P.M. On 6/17/26 at 3:21 P.M., an interview and record review was conducted with LN 3. LN 3 stated when a resident rated their pain level at 0-1 and was given oxycodone, that would be an unnecessary medication. LN 3 stated overuse of controlled pain medications could cause side effects like constipation and drug addiction. LN 3 reviewed Resident 2's physician orders for oxycodone and the resident's June 2026 Medication Administration Record. LN 3 stated Resident 2's physician orders were not followed when the resident was administered oxycodone for pain rated at zero or one out of 10. On 6/18/26 at 9 A.M., a joint interview and record review was conducted with LN 4. LN 4 stated if pain level was assessed at zero to one, that meant the resident had no pain or minimal pain. LN 4 reviewed Resident 2's oxycodone order and Medication Administration Record for June 2026. LN 4 stated oxycodone should not have been administered to Resident 2 when the resident rated his pain at zero and one out of 10. LN 4 stated the physician orders should have been followed. LN 4 stated Resident 2 was placed at risk for constipation and addiction when administered the unnecessary oxycodone doses. On 6/18/26 at 1:40 P.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation that staff follow the physician orders and administer pain medications according to the resident's self-rated pain level. The DON stated Resident 2 should not have been administered two oxycodone tablets when the resident rated his pain at zero or one out of 10. The DON stated Resident 2 received unnecessary pain medications.A review of the facility's policy titled, Medication Therapy revised April 2007, indicated, .1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks.1. The resident's clinical record must contain a written order.2. All decisions related to medications shall include.a. adequately detailed assessment.5. The physician will identify situations where medications should be.changed.a. when a medication is being given in excessive doses. A review of the facility's policy titled, Pain Assessment and Management revised April 2025, indicated, .The purposes of this procedure are to help the staff identify pain in the resident.Assessing Pain 1. Assess the resident.

Based on observation, interview, and record review, the facility failed to ensure privacy was provided for two of five residents (Resident 32, 92) during medication administration.This deficient practice had the potential for residents to feel embarrassed and undignified. Findings:A review of Resident 32's admission Record indicated the resident was admitted on [DATE] with diagnoses to include unspecified dementia (loss of memory, thinking and reasoning skills) and muscle weakness.A review of Resident 92's admission Record indicated the resident was admitted on [DATE] with diagnoses to include hemiplegia/hemiparesis (loss of voluntary movement on one side of the body) and cognitive communication deficit.On 6/16/26 at 8:26 A.M., an observation was conducted inside Resident 32's room with licensed nurse (LN) 13. Resident 32 was lying in bed, with her eyes closed. Resident 32's bed was by the door. Resident 32 opened her eyes when LN 13 called her name. Resident 32 mumbled and repeated unintelligible words. LN 13 stated she was going to administer the resident's medications via Resident 32's gastrostomy tube (GT, a tube inserted to the stomach via the abdomen). LN 13 moved Resident 32's right arm, pulled up the resident's gown, and then pulled down the covers to access the resident's GT. Resident 32's abdomen, disposable brief, and right upper thigh were visible from the opened door. LN 13 administered the medications. The privacy curtain was not drawn during the medication administration process, which lasted 35 minutes. Resident 32's door remained open during the whole procedure. On 6/16/26 at 9:56 A.M., another observation was conducted inside Resident 32's room with LN 13. LN 13 was at Resident 32's bedside. LN 13 was observed administering medications for Resident 32. Resident 32's abdomen, disposable brief, and right thigh were uncovered. The privacy curtain was not drawn during the medication administration process which lasted 25 minutes. Resident 32's door remained open during the whole procedure. On 6/17/26 at 8:08 A.M., an observation was conducted inside Resident 92's room with LN 12. Resident 92 was awake and lying in bed. Resident 92's bed was by the door. Resident 92 had a visitor in his room. LN 12 was outside the room preparing Resident 92's medications. LN 12 proceeded to the resident's room. LN 12 stated he would need to place a medicated patch to the resident's left leg. LN 12 uncovered Resident 92 exposing the resident's disposable brief and left leg. The privacy curtain and the door were both open, leaving the resident visible from the hallway. LN 12 placed the medicated patch on the resident's left lower leg. Resident 92's roommate was in a wheelchair at the foot of Resident 92's bed. The roommate looked over and watched LN 12 apply the medicated patch to Resident 92's left lower leg. The visitor in the room also watched the procedure. On 6/17/2026 at 1:34 P.M., an interview was conducted with LN 13. LN 13 stated she was not aware Resident 32's privacy curtain and door were opened during her medication administration on 6/16/26. LN 13 stated the resident's abdomen and right thigh were exposed during the medication administrations. LN 13 stated she should have ensured the resident's privacy was maintained and should have pulled the curtain around before starting the medication administration. On 6/18/26 at 9 A.M., an interview was conducted with LN 4. LN 4 stated the residents' privacy should always be maintained. LN 4 stated privacy curtains should be pulled around for ongoing procedures, brief changes, and GT medication administration to respect the resident's dignity and privacy. LN 4 stated a resident's roommate should not observe any procedures being administered, even if they shared a room. LN 4 stated residents had a right to personal privacy. On 6/18/26 at 10:40 A.M., an interview was conducted with the director of nursing (DON). The DON stated staff should have closed the residents' curtains during procedures and treatment. The DON stated the residents' dignity and privacy should always be maintained. The DON stated, How would one feel if their body is exposed? A review of the facility's policy titled, Dignity revised February 2021, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.1. Residents are treated with dignity and respect at all times.11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored according to acceptable standards of practice when: 1. A resident's insulin pen (device to inject a medication to lower blood sugar level) and a box of silver nitrate applicator sticks (for wound and tissue treatment) were not labeled legibly. 2. An emergency kit containing two Ativan (anti-anxiety medication) vials had a label indicating one vial was in the kit. In addition, two bottles of calcium with vitamin D, a Lantus pen, and a ketorolac emergency kit were found expired. These deficient practices had the potential to affect medication potency and efficacy. Findings: 1. On 6/15/26 at 11:29 A.M., an observation and an interview was conducted with licensed nurse (LN) 1. LN 1 was assigned to the C-Hall medication cart. LN 1 opened the medication cart. Inside the cart, there was a resident's Lantus insulin (medication to control blood sugar levels) pen with an opened date illegibly written. LN 1 stated could not confirm when the insulin pen was first opened. LN 1 stated the labeling was unreadable. LN 1 stated the insulin pen could have been opened in April 2026 but she was not sure. LN 1 stated if the labeling was unclear then she would not know if she was administering an expired medication. LN 1 stated if the insulin pen was opened in April, then the insulin pen should have been discarded and would not be good to use at this time. LN 1 stated the resident would need a new Lantus insulin pen. On 6/15/26 at 11:58 A.M., an observation and interview was conducted with LN 2. LN 2 was assigned to the treatment cart. LN 2 opened the treatment cart and found a tube of silver nitrate applicator sticks inside the cart. The silver nitrate tube was labeled with an opened date of July 2024. The silver nitrate tube's pharmacy label was partly ripped, and the expiration date was rubbed off. LN 2 stated he would not know what the expiration date was. LN 2 stated the expiration date should have been legible. On 6/15/26 at 12:17 P.M., an interview was conducted with the director of nursing (DON). The DON stated medication labels should be clear and legible. A review of the facility's policy titled Medication Labeling and Storage, revised February 2023 indicated, .Medication Labeling .5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days . A review of Lantus insulin pen manufacturer's guidance dated 2022 indicated, .After 28 days throw your opened Lantus pen away-even if still has insulin in it Retrieved https://www.lantus.com 2. On 6/15/26 at 3:07 P.M., a concurrent observation and interview was conducted with the director of nursing (DON) in the medication storage room. The emergency kit #1 had an outside label that indicated there was 1 Ativan vial in the kit. There was a superimposed 2 on top of the 1. The kit was opened by the DON. The kit had two vials of Ativan in it. The DON stated the label for the Ativan vials should have been clarified with the pharmacy. Inside the locked refrigerator, one Lantus pen was found with an expiration date of 3/10/26. The DON stated the Lantus pen should have been removed. The DON stated the resident could have had unmanaged blood sugar if the resident received the expired Lantus. In the cabinet there were two bottles of calcium 600 milligrams with vitamin D 10 micrograms which had an expiration date of 4/2026. There was another emergency kit containing four 15 milliliter vials of ketorolac (pain medication) that had 3 different pharmacy labels on it. The labeling on the vials indicated an expiration date of 11/20/25. However, the top label on the ketorolac emergency kit indicated an expiration date of 3/10/25, and another pharmacy label on the bottom of the ketorolac kit indicated an expiration date of 9/30/25. The DON stated there should not have been any discrepancies in the expirations dates and the pharmacy should have been notified. The DON stated there should not have been any expired medications in the medication storage. A record review of the facility's policy titled Medication Labeling and Storage revised on 2/2023 indicated .3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.10. Only the dispensing pharmacy may label or alter the label on a medication container or package. A review of Lantus insulin pen manufacturer's guidance dated 2022 indicated, .Lantus can be refrigerated until the expiration date. Once the expiration date has passed Lantus should be thrown away Retrieved https://www.lantus.com

Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered and according to acceptable standards of practice for two of five residents (Resident 32, 92) when: 1. Licensed nurse (LN) 13 did not flush water between medications during a gastrostomy tube (GT, tube inserted to stomach for medication administration) medication administration for Resident 32. In addition, the facility's policy for administering medications through an enteral tube (GT) was not followed. 2. LN 12 omitted the administration of an ordered medication for Resident 92. As a result of these deficient practices, there was the potential to place residents at risk for ineffective medical treatments and worsening health conditions.Findings: 1. A review of Resident 32's admission Record indicated the resident was admitted on [DATE] with diagnoses to include dysphagia (difficulty swallowing food or liquids), muscle weakness and unspecified dementia (loss of memory, thinking and reasoning skills). On 6/16/26 at 8:26 A.M., an observation of medication administration was conducted inside Resident 32's room with LN 13. LN 13 was at Resident 32's bedside with six crushed and liquid medications for GT administration. LN 13 added tap water into each crushed medication cup. LN 13 started pouring Resident 32's medications into the barrel of the syringe. LN 13 administered the medications in the following order: Valproic acid (anticonvulsant) 250 milligrams (mg); LN 13 did not flush 15 ml of water after the medication as indicated in the facility's policy.Vitamin C 500 mg; LN 13 did not flush 15 ml of water after the medication as indicated in the facility's policy.Amlodipine (medication to control blood pressure) 5 mg; LN 13 did not flush 15 ml of water after the medication as indicated in the facility's policy.Ativan (anti-anxiety medication) 1 mg; LN 13 did not flush 15 ml of water after the medication as indicated in the facility's policy.Carvedilol 12.5 mg (medication to control blood pressure); LN 13 did not flush 15 ml of water after the medication as indicated in the facility's policy.Tylenol (medication to relieve pain) 500 mg; LN 13 did not flush 15 ml of water after the medication as indicated in the facility's policy.At 9:01 A.M., another medication administration observation was conducted inside Resident 32's room with LN 13. LN 13 was at Resident 32's bedside with two crushed and powdered medications for GT administration. LN 13 added tap water into each medication cup. LN 13 started pouring Resident 32's medications into the barrel of the syringe. LN 13 administered the following medications via GT: Tramadol (pain medication) 50 mg; LN 13 did not flush 15 ml of water after the medication as indicated in the facility's policy.Polyethylene Glycol (a laxative) 17 grams; LN 13 did not flush 15 ml of water after the medication as indicated in the facility's policy.On 6/17/26 at 1:34 P.M., an interview was conducted with LN 13. LN 13 stated when she administered Resident 32's medications she added 30 ml of water to each crushed medication cup. LN 13 stated she considered the water added to the medications as the water flush. LN 13 stated she should have done a separate water flush in between each medication. On 6/18/26 at 10:40 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation that LNs would flush water in between medications during GT medication administration. The DON stated the water flush would ensure the residents received the full dose of the ordered medications and ensured GT patency. A review of the facility's policy titled Administering Medications through an Enteral Tube dated 2001 indicated, .Purpose.The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube.3. Administer each medication separately and flush between medications.13. If administering more than one medication, flush with 10-15 ml room temperature water (or prescribed amount) between medications. 2. A review of Resident 92's admission Record indicated the resident was admitted on [DATE] with diagnoses to include difficulty in walking and generalized muscle weakness. A review of Resident 92's physician order dated 2/17/26, indicated the resident was to receive Multiple Vitamins with Minerals 30 milliliters (ml) to be given at 9 A.M. everyday. On 6/17/26 at 8:08 A.M., a medication administration observation was conducted with LN 12. LN 12 was outside Resident 92's room. LN 12 prepared five oral medications and a medicated patch for Resident 92. LN 12 stated a multivitamin with minerals was due to be given. LN 12 stated the multivitamin was out of stock, and the facility was waiting for a pharmacy delivery. LN 12 administered the prepared medications and the patch to Resident 92. On 6/18/26 at 8:32 A.M., an interview was conducted with LN 12. LN 12 stated he did not administer Resident 92's multivitamin with minerals on 6/16/26. LN 12 stated he did not follow up with the pharmacy regarding the resident's missing multivitamins. LN 12 stated he did not notify the resident's doctor regarding the missed multivitamin dose. LN 12 stated he should have informed the doctor of the missed dose and made a follow-up on the multivitamin availability. On 6/18/26 at 9 A.M., an interview was conducted with LN 4. LN 4 stated all doctor's orders including vitamins and minerals should be followed. LN 4 stated the doctor should be notified for any missed doses.On 6/18/26 at 10:40 A.M., an interview was conducted with the central supply manager (CSM). The director of nursing (DON) was also present. The CSM stated the facility had a stock of multivitamins with minerals liquid that was needed on 6/17/26 for Resident 92. The CSM stated the multivitamin was always kept in the medication room and would not come from the pharmacy. The DON also stated the facility provided the multivitamins and not the pharmacy. The DON stated LN 12 should have checked the medication storage room for the multivitamins. On 6/18/26 at 1:40 P.M., another interview was conducted with the DON. The DON stated LN 12 should have followed the physician's order and Resident 92 should have received the multivitamin dose. A review of the facility's policy titled Administering Medications revised April 2019, indicated, .Medications are administered in a safe and timely manner and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure one of three Licensed Nurses (LN 1) had the appropriate competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform job functions successfully) and skill sets to care for a resident's (Resident 74) dialysis graft (a synthetic tube placed in the arm, used to connect an artery or vein used as pathway during dialysis treatments [procedure done by a trained professional to remove wastes and excess fluids from the body]). This failure had the potential to cause Resident 74 to develop dialysis access complications. Findings: Resident 74 was readmitted to the facility on [DATE] with diagnoses including end stage renal disease (the last stage of kidney disease which the kidneys can no longer support the body's needs) and dependence on renal (kidney) dialysis according to the facility's admission Record. An observation and interview on 6/15/26 at 3:27 P.M. was conducted with Resident 74. Resident 74 was sitting in a wheelchair in his room. Resident 74 stated he had dialysis this morning (6/15/26) and dialysis treatments were done using the dialysis graft on his left arm. Resident 74 stated the graft had a dressing and was removed by facility staff the following day after dialysis. Resident 74 stated facility staff did not check the dialysis graft when they removed the dressing. Resident 74 stated the facility staff did not use a stethoscope to check his graft. During a review of Resident 74's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 5/27/26, section C0500 indicated Resident 74's Brief Interview for Mental Status (BIMS- evaluates cognition, the ability to remember and think clearly) score was 15, intact cognition (thinking ability). A review of physician's orders (POS) in the electronic medical record (EMR) for Resident 74 was conducted. The POS with order date of 5/31/26 indicated, Resident has AV [arteriovenous shunt- connection between an artery and a vein used as an access site for dialysis] Graft located on the LFA [left forearm]. Monitor for the presence of bruit [a sound heard through a stethoscope] (auscultation-listening) and thrill (palpation of vibration) Qshift [every shift]. Notify MD if unable to auscultate or palpate. Monitor QShift for bleeding, drainage, excessive warmth, pain, redness, numbness in fingers, tenderness, or swelling. Check circulation QShift by palpating distal pulses [heartbeat felt in hands and feet], observing capillary refill [a quick test to check how well blood is flowing in the hands, feet and skin], and assessing for numbness, tingling, altered sensation [strange, distorted, unexpected feeling in the body], coldness, and pallor [paleness of skin]. Notify MD of abnormal findings. An interview on 6/17/26 at 2:03 P.M. was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 74 had a dialysis graft on the left arm. LN 1 stated she checked the graft for bruit by placing her hand on the graft site to feel the bruit. LN 1 stated the thrill was felt when touching the dialysis graft to feel strong pulsations (vibrating rhythm). LN 1 did not state she used a stethoscope to check for bruit. During an interview on 6/17/26 at 2:46 P.M. with LN 13, LN 13 stated dialysis grafts were checked for bruit by listening with a stethoscope and feeling the thrill with fingers. During an interview on 6/17/26 at 3:25 P.M. with LN 14, LN 14 stated she checked dialysis grafts by listening for a swooshing sound with a stethoscope and checking the thrill by feeling for pulsation. An interview with the Director of Nursing (DON) was conducted on 6/18/26 at 11:03 A.M. The DON stated a skills fair was completed in February 2026 and the Director of Staff Development (DSD-a licensed nurse certified for staff training) kept the sign-in sheet. During an interview on 6/18/26 at 2:36 P.M. with the DSD, the DSD stated there was no list of topics discussed during the skills fair. The DSD provided the competency skills check for LN 1 dated 2/12/26. The skills check did not have training and evaluation for caring for a resident's dialysis graft. An interview with the Director of Nursing (DON) was conducted on 6/18/26 at 5:08 P.M. The DON stated she expected licensed nurses to check dialysis grafts. The DON stated checking for bruit and thrill was part of the physician's order to ensure patency (being open, clear or unblocked) of the dialysis graft. A review of the facility's policy and procedure (P&P) titled, Hemodialysis Catheters - Access and Care of, dated June 2025 was conducted. The P&P indicated, Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear a whoosh or bruit of blood flow through the access. A review of the facility's P&P titled, End-Stage Renal Disease, Care of a Resident With, dated September 2010 indicated, Education and training of staff in the care of ESRD/dialysis resident may be managed by the contracted dialysis facility or by a clinician with a special training in ESRD and dialysis care.

Based on observation, interview, and record review, the facility failed to ensure one of nine residents (Resident 59) reviewed for Trauma Informed Care (TIC - an intervention and organization approach that focuses on how trauma may affect an individual's life and his or her response to behavioral health), received care and services in accordance with professional standards when Resident 59's diagnosis of PTSD (Post-traumatic stress disorder - a disorder that may occur in people who have experienced or witnessed a traumatic event) was not identified and addressed by the healthcare providers. This failure resulted in the facility's inability to identify possible triggers that could result in re-traumatization (the reactivation of trauma symptoms via thoughts, memories, or feelings related to past torture experience).Findings: Resident 59 was admitted to the facility on [DATE] with diagnoses including PTSD and anxiety disorder (a mental health disorder characterized by worry or fear that interferes with daily functioning). An observation and interview was conducted on 6/15/26 at 10:05 A.M. with Resident 59, who was in bed C. Resident 59 was observed in bed with an air mattress. Resident 59 stated she had been on several motor vehicle accidents and had a diagnosis of PTSD. Resident 59 stated she was beaten by her father when she was a child. Resident 59 stated her roommate in bed B triggered her PTSD when the roommate frequently used the bathroom and left the door open. A review of care plans for Resident 59 was conducted. A care plan initiated on 11/24/25 indicated, .At risk for decreased psychosocial [how the mind interacts with the social environment] well-being related to alleged/suspected PTSD: physical abuse as a child. Internal triggers- thoughts of feeling out of control of the situations, frustration, and feeling vulnerable.External - are situations and people at the facility that remind her of someone from the past and events in the past. An interview was conducted on 6/17/26 at 10:34 A.M. with Certified Nurse Assistant (CNA) 11. CNA 11 stated residents with PTSD experienced traumatic events in the past, which can make them feel endangered because the events can be triggered. CNA 11 stated he was not aware of any residents with PTSD. An interview was conducted on 6/17/26 at 11 A.M. with Licensed Nurse (LN) 1. LN 1 stated residents with PTSD have a history of trauma that can be triggered, causing behaviors such as yelling for no reason. LN 1 stated she was unsure which residents had PTSD. During an interview with CNA 12 on 6/17/26 at 11:16 A.M., CNA 12 stated she did not know the meaning of PTSD. During an interview with CNA 13 on 6/17/26 at 1:23 P.M., CNA 13 stated residents with PTSD have a history of bad experiences that can be triggered in the present time. CNA 13 stated she was not aware of any residents diagnosed with PTSD. During an interview with LN 14 on 6/17/26 at 3:25 P.M., LN 14 stated residents with PTSD experienced traumatic events in the past, such as sexual or financial abuse, or being in the military. LN 14 stated it was important to know which residents had PTSD because these residents may react differently to certain types of care. LN 14 stated without this information, staff could not monitor behaviors properly and might misdiagnose them as anxiety. LN 14 stated she was not aware of residents with PTSD diagnosis. An interview with the Director of Nursing (DON) was conducted on 6/18/26 at 4:55 P.M. The DON stated three residents in the facility have a diagnosis of PTSD. The DON stated staff should know these residents to prevent triggering traumatic events. A review of the facility's policy and procedure(P&P) titled, Trauma Informed Care and Culturally Competent Care, dated August 2022 was conducted. The P&P indicated, Purpose.To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice.To address the needs of trauma survivors by minimizing triggers and/or re-traumatization.Triggers are highly individualized.Identify and decrease exposure to triggers that may re-traumatize the resident.

Based on observation, interview, and record review, the facility failed to ensure one of 20 resident's (Resident 7) care plan was implemented when a divided plate was not provided at lunch service.This failure had the potential to impair Resident 7's ability to self-feed independently and negatively affect adequate nutritional intake. FINDINGS:A review of Resident 7's admission Record, indicated Resident 7 was admitted to the facility on [DATE], with diagnoses to include hemiplegia (unable to move one side of the body) affecting right dominant side, aphasia (difficulty to communicate) following cerebrovascular disease, cognitive communication deficit, and muscle weakness.On 6/15/26 at 12:34 P.M., an observation, interview, and record review was conducted in the dining room. Resident 7's meal ticket indicated Adap. equip. [adaptive equipment]: Divided Plate. Resident 7 was served his lunch on a regular white plate. Resident 7 stated the plate was not a divided plate and he only received a divided plate, a couple times a week. Resident 7 stated it made it more difficult for him to eat when he did not receive a divided plate with every meal.On 6/15/26 at 12:37 P.M., a joint observation, interview, and record review was conducted with restorative nursing assistant (RNA) 21 in the dining room. RNA 21 observed the plate provided to Resident 7 and stated it was not a divided plate. RNA 21 stated the plate served to Resident 7 did not match the adaptive equipment identified on the meal ticket.On 6/18/26 at 1:53 P.M., a joint Interview and record review was conducted with the Infection Preventionist (IP). Resident 7's care plan for Nutritional Risk: Resident is at risk for nutritional imbalance initiated 2/9/26, indicated, Provide adaptive equipment to promote feeding independence; divided plate. The IP stated that when staff did not provide a divided plate to Resident 7, staff did not follow Resident 7's Nutritional Risk care plan. The IP stated it was very important to follow the Nutritional Risk care plan because the divided plate promoted resident-centered care and helped Resident 7 maintain independence during meals. The IP further stated that when Resident 7 did not receive a divided plate with every meal, eating became more difficult and placed Resident 7 at risk for nutritional deficit.On 6/18/26 at 4:23 P.M., an interview was conducted with the director of nursing (DON). The DON stated staff should always follow the resident care plans. The DON stated it was very important for Resident 7 to receive a divided plate with each meal to promote independent eating.A review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, . The Interdisciplinary team (IDT). develops and implements a comprehensive and person-centered care plan for each resident.

Based on interview and record review, the facility failed to ensure the ombudsman was notified in writing of a discharge for one of three residents (Resident 107).This failure resulted in the ombudsman not having an updated resident status. FINDINGS:A review of Resident 107's admission record indicated the resident was admitted to the facility on [DATE]. A review of Resident 107's progress note dated 5/30/26 indicated the resident was discharged home on 5/30/26. On 6/18/26 at 9:50 A.M., an interview was conducted with the Medical Record Director (MRD). The MRD stated there was no documentation of the ombudsman being notified of Resident 107's discharge.On 6/18/26 at 9:53 A.M., an interview was conducted with the social service director (SSD). The SSD stated it was her responsibility to complete written notices of discharge and transfers. The SSD stated the ombudsman was not given a written notice regarding Resident 107's discharge. The SSD stated, I didn't know that I needed to do that. On 6/18/26 at 9:58 A.M., an interview was conducted with the director of nursing (DON). The DON stated she was not aware the ombudsman should have been notified in writing when the residents were discharged home. A review of the facility's policy titled Transfer or Discharge Notices revised in March 2025, indicated .Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long Term Care Ombudsman.

Based on observation, interview, and record review, the facility failed to ensure three of three dietary aids (DA 1, DA 2, DA 3) were competent to carry out the functions of food and nutrition services when:DA 3 touched the garbage lid, put on gloves, and made a salad without washing his hands.DA 1 did not take the final temperature of all food to be served during lunch.DA 1 did not follow a recipe for a lunch menu item.DA 1 and DA 2 were not wearing beard guards while in the kitchen.Competency Test For Cooks and FNS Staff were not consistent among dietary staff. These failures had the potential to result in inconsistent food service practices, increased the risk of dietary staff not implementing facility policies and procedures, and compromised food safety and meal quality. Findings: 1. On 6/16/26 at 11:26 A.M., an observation was conducted inside the facility's kitchen. DA 3 was preparing a vegetable salad. DA 3 touched the garbage bin lid with his bare hands. After touching the garbage bin lid, he put gloves on. [NAME] 1 was observed telling DA 3 to wash his hands three times. DA 3 did not wash his hands and proceeded to add the remaining vegetables to the salad. On 6/17/26 at 1:28 P.M., an interview with DA 3 was conducted. DA 3 stated the normal process was to wash hands before putting gloves on. DA 3 stated that after handling garbage, hand washing should have been done. DA 3 stated he forgot to wash his hands before putting gloves on. DA 3 stated it was important to perform hand washing, especially when handling food because of safety reasons and to avoid contamination. On 6/18/26 at 8:12 A.M., an interview was conducted with the Dietary Director (DD). The DD stated kitchen staff were expected to perform handwashing before wearing gloves. The DD stated this was supposed to be done to avoid cross contamination. 2. On 6/16/26 at 12:32 P.M., a joint observation of the kitchen was conducted with the DD. DA 1 was observed plating a hamburger patty, a bowl of soup, and a bowl of broth without obtaining the final food temperatures prior to plating. At 1:15 P.M., DA 1 was observed plating an additional hamburger patty without obtaining the final food temperature prior to plating. After observing that DA 1 did not take the temperature of the hamburger patty before plating, [NAME] 1 checked the temperature of the hamburger patty. The hamburger patty measured 69 degrees Fahrenheit (normal temperature is 155 degrees Fahrenheit for a cooked beef patty). [NAME] 1 instructed DA 1 to continue cooking the hamburger patty until it reached the required temperature. The DD observed food being plated without a final temperature taken and told [NAME] 1 to take all the final food temperatures prior to plating. On 6/17/26 at 1:31 P.M., an interview was conducted with [NAME] 1 inside the kitchen. [NAME] 1 stated that DA 1 should have checked the temperatures for all food items, because food that was not at a safe temperature could make the residents sick. [NAME] 1 further stated that the kitchen procedures required the DA preparing the food to obtain and document the temperature prior to plating. On 6/18/26 at 8:11 A.M., an interview was conducted with the DD. The DD stated all food temperatures should have been obtained prior to plating to ensure food remained outside the temperature danger zone and to reduce the risk of foodborne illness. 3. On 6/16/26 at 11:25 A.M., the facility's lunch menu and corresponding recipes for 6/16/26 were reviewed. The lunch menu indicated, Curry Lemon Chicken, Garlic Rice, Peas with onions, Wheat Roll and Ice Cream. The recipe for Peas with Onions indicated, frozen peas, pearl onions or chopped fresh onions, melted margarine, and seasoning, dill or tarragon. On 6/16/26 at 12:58 P.M., an observation of the kitchen was conducted. DA 1 was observed boiling plain peas on the stove, draining the peas, and then placing the peas in the plating area without adding onions, margarine, or seasoning as indicated on the recipe for Peas with Onions. At 1:02 P.M., an interview was conducted with DA 1 inside the kitchen. DA 1 stated that he only boiled the peas in water and did not add any ingredients. DA 1 acknowledged that he did not follow the recipe for Peas with Onions. On 6/17/26 at 1:31 P.M., an interview was conducted with [NAME] 1 inside the kitchen. [NAME] 1 stated she had specifically instructed DA 1 to follow the recipe for Peas with Onions. [NAME] 1 stated it was very important to follow all recipes. On 6/18/26 at 8:11 A.M., a joint interview and record review was conducted with the DD. The DD stated it was important to follow the menu recipes because the ingredients add flavor, provide appropriate calories for residents who are calorie dependent, and ensure the residents enjoy the food. 4. On 6/16/26 at 3:30 P.M., a joint observation of the kitchen was conducted with the DD. DA 1 was observed standing at the stove stirring a pot with approximately one-quarter inch of his beard hair exposed. The DD stated DA 1 should have been wearing a beard guard. On 6/17/26 at 11:37 A.M., an observation of the kitchen was conducted. DA 2 entered the kitchen, walked to the dishwashing area, and began washing dishes with approximately one-half inch of his mustache hair exposed. On 6/17/26 at 1:30 P.M., an interview was conducted with DA 2 inside the kitchen. DA 2 stated he should have been wearing a beard guard and forgot. DA 2 stated a beard guard was required anytime staff enter the kitchen with facial hair. On 6/18/26 at 8:11 A.M., an interview was conducted with the DD inside her office. The DD stated it was her expectation that all facial hair would be covered anytime staff were in the kitchen. The DD stated facial hair could fall into the food if it was not covered and could contaminate the food. 5. On 6/18/26 at 8:11 A.M., a joint interview and record review was conducted with the DD inside her office. The Competency Test For Cooks and FNS Staff was reviewed for DA 1, DA 2, and DA 3. The Competency Test For Cooks and FNS Staff for DA 1, dated 3/26/26 did not include an evaluation for the use of beard guards, following the recipes, and checking the temperature of food prior to plating. The Competency Test For Cooks and FNS Staff for DA 2, dated 8/12/25 did not include an evaluation for the use of beard guards. The Competency Test For Cooks and FNS Staff for DA 3, dated 4/24/26 did not include an evaluation for hand hygiene. In addition, DA 2 had 24 questions which included questions about hand hygiene and menu changes, while DA 1 and DA 3 had only 12 questions which did not include the hand hygiene and menu changes. The DD stated that the Competency Test For Cooks and FNS Staff for DA 1, DA 2 and DA 3 should have been universal to ensure regulatory compliance and consistent job performance. The DD stated her kitchen staff should have been competent. A review of the facility's undated policy titled, Demonstrating Food Safety and Job Competency For Food And Nutrition Services Employees, indicated, POLICY: Each Food and Nutrition Service employee must be able to demonstrate competency in the food safety principles and job skills the facility requires.

Based on observation, interview, and record review, the facility failed to ensure a recipe was followed for a lunch menu item.This failure had the potential to negatively affect the taste and consistency of the meal service, which could contribute to residents experiencing decreased food intake and unintended weight loss.Findings:On 6/16/26 at 11:25 A.M., the facility's lunch menu and corresponding recipes for 6/16/26 were reviewed. The lunch menu indicated, Curry Lemon Chicken, Garlic Rice, Peas with onions, Wheat Roll and Ice Cream. The recipe for Peas with Onions indicated, frozen peas, pearl onions or chopped fresh onions, melted margarine, and seasoning, dill or tarragon.On 6/16/26 at 12:58 P.M., an observation of the kitchen was conducted. DA 1 was observed boiling plain peas on the stove, draining the peas, and then placing the peas in the plating area without adding onions, margarine, or seasoning as indicated on the recipe for Peas with Onions.At 1:02 P.M., an interview was conducted with DA 1 inside the kitchen. DA 1 stated that he only boiled the peas in water and did not add any other ingredients. DA 1 acknowledged that he did not follow the recipe for Peas with Onions.On 6/17/26 at 1:31 P.M., an interview was conducted with [NAME] 1 inside the kitchen. [NAME] 1 stated she had specifically instructed DA 1 to follow the recipe for Peas with Onions. [NAME] 1 stated it was very important to follow all recipes.On 6/18/26 at 8:11 A.M., a joint interview and record review was conducted with the DD. The DD stated it was important to follow the menu recipes because the ingredients add flavor, provide appropriate calories for residents who are calorie dependent, and ensure the residents enjoy the food.A review of the facility's policy titled Menus, revised October 2017, did not provide guidance related to following the menu recipes.

Based on observation, interview, and record review, the facility failed to ensure a divided plate was provided to a resident (Resident 7) during meal service as ordered.This failure had the potential to impair the resident's ability to eat independently, increase difficulty with meal consumption, and result in decreased food intake and unintended weight loss.Findings:A review of Resident 7's admission Record indicated Resident 7 was admitted to the facility on [DATE], with diagnoses to include hemiplegia (unable to move one side of the body) affecting right dominant side, aphasia (difficulty to communicate) following cerebrovascular disease, cognitive communication deficit, and muscle weakness.On 6/15/26 at 12:34 P.M., an observation, interview, and record review was conducted in the dining room. Resident 7's meal ticket indicated Adap. equip. [adaptive equipment]: Divided Plate. Resident 7 was served his lunch on a regular white plate. Resident 7 stated the plate was not a divided plate and he only received a divided plate, a couple times a week. Resident 7 stated it made it more difficult for him to eat when he did not receive a divided plate with every meal.On 6/15/26 at 12:37 P.M., a joint observation, interview, and record review was conducted with restorative nursing assistant (RNA) 21 in the dining room. RNA 21 observed the plate provided to Resident 7 and stated it was not a divided plate. RNA 21 stated the plate served to Resident 7 did not match the adaptive equipment identified on the meal ticket.On 6/18/26 at 8:11 A.M., an interview was conducted with the dietary director (DD) inside her office. The DD stated that providing Resident 7 with a divided plate would help Resident 7 eat more effectively, promote independence during meals, and preserve his dignity.On 6/18/26 at 1:53 P.M., an interview was conducted with the Infection Preventionist (IP) at the nursing station. The IP stated that when Resident 7 did not receive a divided plate with every meal, eating became more difficult and placed Resident 7 at risk for nutritional deficit.On 6/18/26 at 4:23 P.M., an interview was conducted with the director of nursing (DON). The DON stated it was very important for Resident 7 to receive a divided plate with each meal to promote independent eating.A review of the facility's policy titled Assistance With Meals, revised March 2022, indicated, .Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them.

Based on interview and record review, the facility failed to ensure complete and accurate resident records for three of nine residents (Resident 10, 6, and 38) reviewed when: 1.Blood sugar readings and insulin were not documented on Resident 10's and Resident 6's medication administration records (MAR), 2. An abuse allegation involving Resident 38 was not documented timely. This failure did not provide an accurate representation of the care provided to residents and had the potential to cause confusion amongst care providers. Findings:1a. Resident 10 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM 2- a long-term condition in which the body has trouble controlling blood sugar) with foot ulcer and absence of left foot according to the facility's admission Record. An observation and interview was conducted with Resident 10 on 6/16/26 at 9:48 A.M. Resident 10 was in bed in his room with a white sheet over his head. Resident 10 pulled down the white sheet and was observed unshaven. Resident 10 stated he had DM and staff administered his insulin.During a review of Resident 10's physician orders in the electronic medical record (EMR), the EMR indicated, Insulin Glargine (a long-acting medication for DM) .inject 10 unit [a standard measurement to count how much medication is needed] subcutaneously (fatty tissue, just under the skin) two times a day for DM II.Insulin Lispro (a fast-acting medication that helps regulate blood sugar levels) .inject as per sliding scale [method of insulin administration where the dose is based on the pre-meal blood sugar result].An interview and joint record review was conducted with Licensed Nurse (LN) 1 on 6/17/26 at 11 A.M. LN 1 reviewed the MAR for Resident 10. LN 1 stated there was no blood sugar and insulin documentation on 6/7/26 at 8 AM and 11:30 AM, and on 6/14/26 at 11:30 AM. LN 1 stated the MAR should be complete to monitor the resident's blood sugar and prevent high or low blood sugar levels. 1b. Resident 6 was readmitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus with foot ulcer and other ophthalmic (eye) complication according to the facility's admission Record.An observation and interview on 6/15/26 at 2:29 P.M. was conducted with Resident 6. Resident 6 was in bed holding a sandwich. Resident 6 stated he did not know what medications he was taking.During a review of Resident 10's physician orders in the EMR, the EMR indicated, Fingerstick blood glucose [blood sugar] check before meals and at bedtime for DM Call MD if BS <(blood sugar less than) 70 or > (greater than) 400.Insulin Glargine.inject 12 unit subcutaneously at bedtime for DM Hold for blood sugar less than 100, notify MD if BS <70 or >400.An interview and joint record review was conducted with Licensed Nurse (LN) 1 on 6/17/26 at 11:07 A.M. LN 1 reviewed the medication administration record (MAR) for Resident 6. LN 1 stated there was no documentation for blood sugar result and insulin on 6/7/26 at 7:30 A.M. and at 11:30 A.M.During an interview on 6/17/26 at 3:25 P.M. with LN 14, LN 14 stated a resident's MAR should be completed to ensure medications were administered timely. LN 14 stated if the MAR did not have documentation, then the medication was not given.During an interview on 6/18/26 at 4:55 P.M. with the Director of Nursing (DON), the DON stated she expected staff to document every shift, check prior to leaving and audit to ensure timely documentation. The DON stated if it was not documented, staff would not know what the resident's blood sugar was and if insulin was given or not. 2. Resident 38 was readmitted to the facility on [DATE] with diagnosis including iron deficiency anemia (condition when the blood lacks enough healthy red blood cells because there's not enough iron) and gastrointestinal hemorrhage (stomach bleed) according to the facility's admission Record.An observation and interview on 6/15/26 at 10:31 A.M. was conducted with Resident 38. Resident 38 was in her room, sitting on the edge of the bed wearing street clothes, hat and sunglasses. Resident 38 showed her seat walker with the seat raised up and open. Resident 38 stated she was going to the bank with the social worker today, 6/15/26, because $2000 was stolen from inside the seat of her walker. During an interview on 6/17/26 at 9:12 A.M. with Resident 38, Resident 38 stated she and the social worker did not go to the bank on Monday, 6/15/26. Resident 38 stated she reported the missing money to the social worker and will go to the bank today, 6/17/26. An interview with the Social Service Director (SSD) was conducted on 6/17/26 at 3:08 P.M. The SSD stated she took Resident 38 to the bank this morning, 6/17/26. The SSD stated Resident 38 used the withdrawn money to visit the casino which was confirmed with Resident 38's responsible party. The SSD stated she was going to interview Resident 38's responsible party to obtain further information.During a follow up interview and joint record review on 6/18/26 at 9:35 A.M. with the SSD, the SSD stated the investigation regarding Resident 38's missing money was completed. The SSD stated the Administrator had the summary of investigation. The SSD reviewed the EMR for Resident 38's progress notes. The SSD stated she did not document the financial abuse allegation in Resident 38's chart. The SSD stated, That's just how it's done; the facility kept a file of abuse allegations in residents' charts. The SSD stated the police came last night (6/17/26) and interviewed Resident 38 but she did not document it in Resident 38's chart. The SSD further stated Resident 38 no longer wanted her friend to be the responsible party. Removal of the friend as the responsible party was also not documented.A review of the facility's Follow-Up Letter Regarding Facility Reported Incident, dated 6/18/26 was conducted on 6/18/26 at 9:46 A.M. The letter indicated, The facility conducted a thorough review of the circumstances surrounding the allegation, including interviews with relevant individuals review of available documentation and records, and evaluation of any contributing factors.An interview on 6/18/26 at 11:03 A.M. was conducted with the Director of Nursing (DON). The DON stated she expected residents' charts to be complete regarding documentation of abuse allegations. The DON stated Resident 38's chart should have a timeline of events, documentation of initial complaint, who was notified, notification to California Department of Public Health (CDPH- state agency that protect the public's health and enforces state and federal laws), ombudsman (advocates for residents of nursing homes), the Administrator, DON, and police visit with a case number.A joint record review of Resident 38's progress notes on 6/18/26 at 4:55 P.M. was conducted with the DON. The DON reviewed Resident 38's progress notes and stated there was still no documentation regarding the abuse allegation. A review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated August 2022 was conducted. The P&P indicated, Policy Statement.All services provided to the resident, progress toward care plan goals, or any changes in the resident's medical, physical, functional or psychosocial [influence of social factors on a person's mind or behavior] condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team [team members with various areas of expertise who work together toward the goals of their residents] regarding the resident's condition and response to care.The following information is to be documented in the resident medical record.Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident.

Based on observation, interview, and record review, the facility failed to follow appropriate infection prevention and control practices when Purified Protein Derivative (PPD) (a test used to determine if a person is infected with tuberculosis (TB- an infectious bacterial disease that primarily attacks the lungs) was not done annually to Resident 9 and Resident 86. As a result of this deficient practice, residents, staff, and visitors, were placed at risk for contracting infections.Findings:1a. A review of Resident 9's admission Record indicated Resident 9 was admitted to the facility on [DATE] with a diagnosis that included Hypertensive Heart Disease (chronic high blood pressure that can cause damage to the heart.)1b. A review of Resident 86's admission Record indicated Resident 86 was admitted to the facility on [DATE] with a diagnosis that included Hypertensive Heart Disease with Heart Failure (uncontrolled blood pressure and has caused damage to the heart) and Diabetes Mellitus type II (uncontrolled high sugar levels in the blood).On 6/17/26 at 10:32 A.M., a concurrent interview and record review was conducted with the Infection Preventionist (IP). The IP reviewed the immunization records for Resident 9 and Resident 86. The IP stated the last PPD test for Resident 9 was on 1/29/24 with no documentation of any PPD test or chest x-ray after 1/29/24. The IP stated the last PPD date for Resident 86 was on 1/17/25, with no documentation that Resident 86 had a PPD or chest x-ray after 1/17/25. The IP stated both Resident 9 and Resident 86 should have received an annual PPD or chest x-ray. The IP stated it was important for all residents to have an annual PPD test to identify and treat anyone who tested positive for TB. The IP stated TB was an airborne contagious disease and if left unidentified, it could put Resident 9 and Resident 86 and other residents at risk of contracting TB.On 6/18/26 at 3:13 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated PPD test was done on admission, and then annually to keep all residents in the facility safe from active TB. The DON stated Resident 9 and Resident 86 should have had an annual PPD test. According to the CDC (Centers for Disease Control- a national health organization) recommendations: Titled Clinical Testing and Diagnosis for Tuberculosis, dated April 17,2025, indicated higher risk of being infected with TB germs, you should get tested. You have a higher risk of being exposed to TB germs if you. People who currently live or used to live in large group settings where TB is more common. or nursing homes. People with diabetes mellitus. A review of the facility's policy titled Tuberculosis Screening Residents for, revised January 2026, indicated .2. Current residents who have risk factors for exposure to TB disease are tested for TB infection.

Based on interview, record review, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded for a resident who discharged to the hospital for 1 (Resident #84) of 3 residents reviewed for closed records. Findings included: A facility policy titled, Certifying Accuracy of the Resident Assessment, revised ,d+[DATE], indicated, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. An Admission Record indicated, the facility admitted Resident #84 on [DATE]. According to the Admission Record, the resident had a medical history that included diagnoses of multiple sclerosis (an autoimmune disease that affects the central nervous system [brain and spinal cord]), urinary tract infection, and sepsis (a life-threatening medical emergency caused by the body's extreme response to an infection, often leading to organ dysfunction and potentially death). Resident #84's Progress notes dated [DATE] indicated a family member reported that Resident #84 seemed uncomfortable and requested a hospital transfer. The notes indicated the nurse found the resident gasping for air despite being on 5 liters of supplemental oxygen. The notes revealed the resident's family member insisted the resident be sent to the hospital. The notes revealed the nurse practitioner was notified and 911 was called. Resident #84's physician's order dated [DATE] revealed May send out Resident to ER [emergency room ] for further Eval [evaluation]. Resident #84's Progress notes dated [DATE] indicated the resident was transferred to the hospital and left the faciity on [DATE] at 2:22 PM. A Hospital History and Physical Reports, dated [DATE], indicated, Resident #84 was admitted to the hospital on [DATE]. Resident #84's Progress notes dated [DATE] indicated, the resident had expired at the hospital on [DATE] at 4:55 AM. A death in facility MDS assessment, with an Assessment Reference Date (ARD) of [DATE], indicated Resident #84 was coded as deceased at the facility. The MDS revealed the assessment was signed by MDS Nurse #1 on [DATE], confirming the accuracy of the information. On [DATE] at 10:49 AM, MDS Nurse #2 stated that she initially opened a discharge assessment with an ARD of [DATE], expecting MDS Nurse #1 to complete it. MDS Nurse #2 stated, however, MDS Nurse #1 later changed it to a death assessment with a new ARD of [DATE]. MDS Nurse #2 was unable to explain why the changes were made. On [DATE] at 6:09 PM, MDS Nurse #1 stated that after reading a progress note indicating the hospital had confirmed Resident #84's death, she assumed the resident had died the same day upon arrival and was not admitted . She stated that based on that assumption, she changed the MDS to a death assessment. According to MDS Nurse #1, this human error caused the MDS to be inaccurate, as it did not clearly reflect Resident #84's correct date and place of death. On [DATE] at 8:52 AM, MDS Nurse #2 stated that staff must ensure their coding and documentation were accurate and that assessments must reflect correct information, such as the date of death and whether the resident was sent to the hospital or passed away at the facility, to ensure the Centers for Medicare and Medicaid Services (CMS) received accurate data. According to MDS Nurse #2, Resident #84's MDS assessment was not accurate. On [DATE] at 9:31 AM, the Director of Nursing (DON) stated that all documentation and coding must be accurate, including the correct date, the resident's condition, and the discharge location, whether the resident was transferred to a hospital or passed away. On [DATE] at 8:55 AM, the Administrator stated the MDS team was expected to double, and triple check all information to avoid erroneous assessments, as MDS accuracy was essential.

Based on interview, observation, record review, and facility policy review, the facility failed to follow physician orders for 1 (Resident #6) of 2 residents reviewed for skin conditions. Specifically, Resident #6 had an order, dated 03/26/2025, to schedule a dermatology appointment. However, no attempts were made to schedule a dermatology appointment until 04/15/2025. Findings included: A facility policy titled, Physician Orders, revised 06/2013, indicated, Physician orders must be given, managed and carried out in accordance with applicable laws and regulations. A facility policy titled, Resident Appointments, revised 03/2025, indicated, 1. [NAME] Clerk shall coordinate/schedule resident appointments. The policy also stated, 4. [NAME] Clerk will document the appointment in the resident's medical record. An Admission Record revealed the facility admitted Resident #6 on 06/11/2022. According to the Admission Record, the resident had a medical history that included diagnoses of Parkinson's disease without dyskinesia (involuntary muscle movements), hypertensive heart disease without heart failure, hyperlipidemia, obsessive-compulsive disorder, bipolar disorder, anxiety disorder, major depressive disorder, and schizoaffective disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) of 9, which indicated the resident had moderate cognitive impairment. Resident #6's Care Plan Report included a problem statement revised on 11/01/2024, that indicated, the resident had a body rash and was at risk for infection, skin breakdown, spreading of the rash, and worsening of the rash. Interventions directed staff to administer treatments as ordered and monitor for effectiveness; avoid use of harsh detergents, soaps, fragrances, or other irritating substances; encourage to avoid scratching; keep hands and body parts free from excessive moisture; laboratory or diagnostic tests as ordered to assist in determining etiology; moisturize dry and flaky skin to rehydrate skin; monitor and record any complaints of pain, itching, or discomfort. Resident #6's Order Summary Report, with active orders as of 04/16/2025, included an order dated 03/26/2025, that directed staff to schedule a dermatology appointment for rash that was not improving. Resident #6's Progress Notes, dated 04/15/2025 at 3:45 PM, indicated, the facility left a detailed voicemail for a dermatology office for Resident #6 to be seen regarding the ongoing rash on their body. The note was written by Central Supply, who was also the [NAME] Clerk. During an observation on 04/14/2025 at 10:56 AM, Resident #6 was noted to have red, inflamed splotches of skin all over their arms. During an interview on 04/15/2025 at 2:34 PM, Central Supply stated that when there was an order for a specialist, he would look at the resident's insurance and check which specialist was in network. He stated he would then reach out to that provider to ensure they were in network and from there, the provider would want a written referral with a doctor's order. Central Supply stated he would also send in pertinent medical information regarding the resident. He stated he might follow up five days later. Central Supply stated that every time he followed up, he documented who he spoke to and what office was contacted. He stated this would be in the progress notes under appointments. During the interview, the record was checked, but there were no notes related to Resident #6's dermatology appointment. Central Supply stated that, ideally, he tried to follow up within seven to 10 days. He stated he had seen Resident #6's order for the dermatology appointment, but he had not gotten to it yet as he had been focused on other orders. During an interview on 04/17/2025 at 10:33 AM, the Director of Nursing (DON) stated that nursing entered orders for residents to see a specialist. The DON stated the scheduler, who was also Central Supply, would then make an appointment. The DON stated that while it may take time to get an appointment scheduled, the specialist should be contacted sooner than two and a half weeks. The DON stated, furthermore, all attempts to contact the specialist should be documented. During an interview on 04/17/2025 at 11:08 AM, the Administrator stated that the [NAME] Clerk, who was also Central Supply, was responsible for making appointments for specialists. The Administrator stated the [NAME] Clerk should make attempts to contact the specialist right after receiving the referral, and he should leave messages right away. The Administrator stated the [NAME] Clerk should also document all contact attempts.

Based on interview, record review, and facility policy review, the facility failed to offer the influenza vaccine and provide education regarding influenza immunizations for 1 (Resident #32) of 5 residents reviewed for immunizations. Findings included: A facility policy titled, Influenza Vaccine, revised 08/2016, indicated, All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. The facility shall provide pertinent information about the significant risks and benefits of vaccines to staff and residents (or residents' legal representatives). The facility policy indicated, 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated or the resident or employee has already been immunized. The policy indicated, 6. A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record. An Admission Record revealed the facility admitted Resident #32 on 02/05/2025. According to the Admission Record, the resident had a medical history that included diagnoses of acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) of 4, which indicated the resident had severe cognitive impairment. Resident #32's Immunization History Report revealed the resident's last influenza vaccination was 02/11/2020. The report revealed there was no other documentation regarding influenza vaccinations. Resident #32's Hospital Discharge Instructions, dated 01/21/2025, revealed the resident refused the influenza virus vaccine at the hospital. During an interview on 04/17/2025 at 9:53 AM, the Director of Staff Development (DSD), who was also the Infection Preventionist (IP), stated that Resident #32 was not offered the influenza vaccination but that it was the facility expectation that the resident be offered one if they were admitted during the influenza season. During an interview on 04/17/2025 at 10:33 AM, the Director of Nursing (DON) stated that, on admission, staff should have asked about influenza vaccinations if the admission was during the influenza season. The DON stated that, the next day, the IP should have arranged those vaccinations. The DON stated that the DSD was not the IP at the time that Resident #32 was admitted , which was probably why the vaccination was missed. During an interview on 04/17/2025 at 11:08 AM, the Administrator revealed he relied on his IP regarding influenza immunizations, and he was unsure of the facility's expectation. During an interview on 04/17/2025 at 12:23 PM, the Case Manager, who is also an IP, stated that when a new resident was admitted , the facility reviewed their record to see what immunizations were received. The Case Manager stated sometimes the facility interviewed the resident in case some immunizations were not available in the medical record. The Case Manager stated if they were unable to find records of an immunization, they re-offered the immunization. The Case Manager stated if the resident wished to receive an immunization, the doctor obtained an informed consent and wrote the order. The Case Manager stated then the facility ordered the vaccine from the pharmacy. The Care Manager stated there was a specific declination form used by the facility and if they saw that an immunization was refused at a hospital, they still obtained the facility declination. The Case Manager stated the reasoning was because the resident may be documented as refusing an immunization for a multitude of reasons and perhaps the immunization was not offered, or the immunization was not explained properly, or the resident did not want an immunization in an acute-care setting. The Case Manager stated it was still the facility's obligation to re-offer an immunization if there was no record that the resident received that immunization.

Based on interview, record review, and facility policy review, the facility failed to follow the pharmacist's recommendations for 1 (Resident #6) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Regimen Reviews, revised 05/2019, indicated, The Consultant Pharmacist reviews the medication regimen or each resident at least monthly. The policy revealed the section titled, Policy Interpretation and Implementation included 1. The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medication. Further review revealed, 8. Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physician for each resident identified as having a non-life threatening medication irregularity. The section further revealed, 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. An Admission Record revealed the facility admitted Resident #6 on 06/11/2022. According to the Admission Record, the resident had a medical history that included diagnoses of obsessive-compulsive disorder, bipolar disorder, anxiety disorder, major depressive disorder, and schizoaffective disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident received an anticonvulsant medication during the assessment's lookback period. Resident #6's Care Plan Report included a problem statement revised 02/14/2025, that indicated the resident was at risk for social isolation, mood problems, and ineffective coping related to obsessive compulsive disorder, anxiety, depression, schizoaffective disorder, and bipolar disorder. Interventions directed staff to administer medications as ordered, assist the resident in identifying strengths and positive coping skills, behavioral health consults as needed, and observing for signs and symptoms of mania or hypomania, irritability, or mood changes. Resident #6's Order Summary Report, with active orders as of 04/16/2025, included an order dated 12/04/2024, for Depakote 250 milligrams (mg), with instructions to give two tablets by mouth two times a day for seizures; a total of 500 mg twice a day. A Consultant Pharmacist's Medication Regimen Review, dated 11/16/2024, revealed that the consultant pharmacist recommended a clarification of the indication for Resident #6's Depakote. The review revealed if the medication was to be given for seizure control, then therapeutic levels of the medication would be necessary. The review revealed if they were giving the medication for behaviors, the indication would need to be changed in the Medication Administration Records (MARs). The review revealed the only written response was no. The review revealed the provider did not provide a clinical rationale or further explanation of the response. A Consultant Pharmacist's Medication Regimen Review, dated 01/25/2025, revealed that the consultant pharmacist recommended an adjustment of Resident # 6's valproic acid (Depakote) dosage, as the resident's levels were still sub-therapeutic for seizures. The review revealed the only written response was no. The review revealed the provider did not provide a clinical rationale or further explanation of the response. During an interview on 04/16/2025 at 8:48 AM, the Director of Nursing (DON) stated that a pharmacist came in monthly to make recommendations. The DON stated the recommendations went to her and the Case Manager. The DON stated the Case Manager was the one who followed up with the pharmacy recommendations. She stated that Resident #6's primary diagnosis for the Depakote was bipolar disorder. She stated that Nurse Practitioner (NP) #5 was the one who followed up with pharmacy recommendations. During an interview on 04/16/2025 at 9:12 AM, the Case Manager stated that the pharmacist came in and reviewed the residents' medications monthly. The Case Manager stated the pharmacist submitted his recommendations in a large packet. The Case Manager stated that once she received those packets, she separated the packets by provider and submitted them to the relevant physician or nurse practitioner. She stated if there was no new order, then there was no further documentation made beyond what the provider offered. During an interview on 04/162025 at 10:01 AM, Pharmacist #7 stated that the forms used for medication regimen review recommendations depended on the facility and their DON, and how they preferred to do those recommendations. Pharmacist #7 stated that because providers generally did a good job following his minor recommendations, he entered them on the nursing recommendation report. Pharmacist #7 stated more serious recommendations, or recommendations that were directed at psychiatry, may be on their own forms. Pharmacist #7 stated that when he saw Resident #6's low dosage of Depakote, he suspected that it was for psychiatric purposes and not seizures. He stated he made the recommendation (on 11/16/2024) to clarify the medical record. Pharmacist #7 stated when the physician documented that they would not follow the recommendation, he recommended an increase in the dosage to treat seizures. He stated that he had followed up in January (2025) about his recommendations. During an interview on 04/17/2025 at 10:33 AM, the DON stated that the physician should document their clinical rationale for not following a pharmacist's recommendation. She stated she did not know why NP #5 did not document her clinical rationale regarding the Depakote. She stated she did not know why the facility did not follow up with the recommendation. During an interview on 04/17/2025 at 11:38 AM, NP #5 stated she understood she should have documented the clinical rationale for not following a pharmacist's recommendation as opposed to only writing no. She stated that she documented that the Depakote was for mood and not seizures in her notes, but she confirmed that the pharmacist would not necessarily see that documentation, so it was more prudent to document on the medication regimen review forms for the pharmacist to see.

Based on interview and record review, the facility failed to honor resident ' s preference for one of three sampled residents (Resident 1) when Resident 1 was showered despite his refusal. This failure had the potential to affect Resident 1 ' s emotional well-being. Findings: A review of Resident 1 ' s admission record indicated he had diagnoses of hemiplegia (weakness to one side of the body), hypertension (elevated blood pressure). A review of Resident 1 ' s minimum data assessment (MDS, an assessment tool) Section C Cognitive Patterns dated 7/19/23 indicated Resident 1 ' s cognition was intact. An interview was conducted on 8/9/23 at 12:31 P.M with Resident 1. Resident 1 stated on 7/31/23 at approximately 7:00 A.M. - 8:00 A.M., certified nursing assistant (CNA) 1 offered him a shower. He (Resident 1) told CNA 1 he did not want to have a shower. Resident 1 instead agreed to a bed bath. Resident 1 was surprised when CNA 1 and a rehabilitation personnel (RP) assisted him up to a shower chair from his bed and was brought to the shower room. A phone interview was conducted with CNA 1 on 8/9/23 at 1:30 P.M. CNA 1 stated on 7/31/23 at approximately 7:00 A.M. - 8:00 A.M., Resident 1 informed her, he did not want to have a shower. CNA 1 stated she and RP transferred Resident 1 from his bed to a shower chair and went to the shower room. CNA 1 further stated she should have respected Resident 1 ' s right to refuse shower. An interview was conducted on 8/9/23 at 1:45 P.M. with licensed nurse (LN 2). LN 2 stated, facility staff should honor resident ' s right to refuse shower to maintain their dignity. During an interview on 8/9/23 at 3:07 P.M. with the Director of Nursing (DON), the DON stated residents ' preferences should be respected and honored by the facility staff to preserve residents ' honor and dignity. A review of the facility ' s policy Residents Rights (undated) indicated, Rights to self - determination. To reside and receive services with reasonable accommodation by the facility of individual needs and preferences .

Based on observation, interview, and record review, the facility failed to ensure fall safety interventions for two of six residents (Resident 35 and Resident 23) reviewed for accidents were provided when: Resident 35's chair/bed silent alarm (an alarm used to help warn staff when a resident is changing position or getting up) was not implemented consistently; In addition, Resident 35's falls were not thoroughly investigated to ensure that all fall preventative measures were implemented. Resident 23's wheechair was placed in an area that was not within the resident's reach. In addition, the facility was not secured during the night when a visitor's entrance was left open and unlocked. As a result, Resident 35 fell eight times while at the facility. One of Resident 35's fall resulted in a laceration on the forehead which required suturing. Resident 23 had the potential to fall and become injured. Furthermore, not securing the facility from potential intruders put the safety of all residents's at risk. Findings: Resident 35 was admitted to the facility on [DATE] with diagnoses that included heart failure per the undated Resident Face Sheet. A review of Resident 35's Fall Risk Assessment, dated 2/11/2021, indicated Resident 35 was At Risk for falls. A review of Resident 35's physician orders, dated 2/21/2021, indicated an order for Silent bed alarm to wheelchair/bed to alert staff of solo transfers. A joint observation of Resident 35 was conducted with the Assistant Director of Nursing (ADON) on 5/26/2021 at 3:30 P.M. Resident 35 sat on her wheelchair without a silent alarm. A review of Resident 35's nursing progress notes from February 2021 thru May 2021 indicated that Resident 35 fell on ,d+[DATE], 2/15, 2/26, 4/8, 4/10, 4/24, 5/13, and 5/21/2021. The nursing progress notes indicated the following: On 2/14/2021 at 8:50 P.M., Resident 35 was found on the floor. According to the record, CNA (certified nursing assistant) heard yelling from the room and went to check, found resident on the floor . The progress note also indicated Resident 35 was asked what she was trying to do and the resident replied, I wanted to use the wheelchair. On 2/15/2021 at 10:29 P.M., Resident 35 was found sitting on the bathroom floor. According to the progress note, CNA found her (Resident 35) sitting on the floor leaning to the BR (bathroom) door. On 2/26/2021 at 4:15 P.M., Resident 35 was found on the floor on the right side of the bed with the resident's foot caught on the wheelchair. According to the record, Resident 35 sustained a skin tear on the right knee measuring 3 centimeters (cm.) by 3 cm. Per the progress note, Resident 35 could not describe what she was doing prior to the fall. On 4/8/2021 at 9:43 A.M., Resident 35 was found on the floor in the bathroom of room #111. According to the record, Resident 35 was sitting on the floor next to the toilet. Per the progress note, Resident 35 sustained a skin tear on the right leg. On 4/10/2021 at 8:10 P.M., Resident 35 fell to the floor from the wheelchair in front of the nurse's station. On 4/24/2021 at 6:57 P.M., Resident 35 was found on the floor by the reception area and nurse's station. Per the progress note, Resident 35 was asked what happened and resident replied, I slid from the wheelchair when I'm trying to move myself. The progress note indicated Resident 35 sustained a skin tear on her right index finger (second finger). On 5/13/2021 at 8:47 P.M., Resident 35 attempted to stand up and slid out of her wheelchair onto the floor. Per the progress note, Resident 35 stated, Had to go pee. On 5/21/2021 at 9: 51 P.M., Resident 35 was found on the floor in her room. According to the progress note, Resident 35 sustained a laceration to the forehead measures approximately 3 cm. x (by) 0.3 cm. with moderate amount of blood noted on forehead and floor. Resident reports pain only to her head. On 5/21/2021 at 10:23 P.M., Resident 35 was transferred to the hospital via 911. On 5/22/2021 at 9:10 A.M., Resident 35 returned to the facility from the hospital. According to the progress note, the hospital impression was, fall, Head Trauma (head injury), Staples. A review of Resident 35's care plan related to the fall incidents was conducted. According to Resident 35's fall care plan, the following fall prevention interventions were initiated after each fall incidents: After the fall on 2/14/2021 (found on the floor), fall interventions were initiated on 2/15/2021, one day after the fall, which included Room change to A bed to more visible to staff and RNA (restorative nursing assistant - strengthening exercises) program. After the fall on 2/15/2021 (found on the floor in the bathroom), a fall intervention was initiated on 2/18/2021, three days after the fall, which indicated, Silent bed/wheelchair alarm to alert staff of solo transfers (regular alarm until silent alarm arrives a t the facility). After the fall on 2/26/2021 (found on the floor), there was no new fall preventative intervention written on Resident 35's care plan. After the fall on 4/8/2021 (found on the bathroom floor in room #111), a fall intervention was initiated on 4/9/2021, one day after the fall, which indicated, Move resident to A bed to be more visible to staff. After the fall on 4/10/2021 (fell at the nurse's station), a fall intervention was initiated on 4/13/2021, three days after the fall, which indicated, (Brand of non-skid mat) to wheelchair to reduce risk for falls. After the fall on 4/24/2021 (found on the floor by the reception area and nurses' station), a fall intervention was initiated on 4/27/2021, three days after the fall, which indicated, (Brand of non-skid mat) on top of wheelchair pad to reduce risk for falls. After the fall on 5/13/2021 (got up needing to use the bathroom), a fall intervention was initiated on 5/18/2021, five days after the fall, which indicated, Encourage resident to go to bed before 8 P.M. to prevent falls h/o (history of) falls after 8 P.M. and encourage resident to use restroom before going to bed. After the fall on 5/21/2021 (found on the floor with laceration on the forehead), fall interventions were initiated on 5/25/2021, four days after the fall with injury, which included Place mattress on the right side of the bed. Allow resident to sleep on the mattress on the floor and Place resident in supervised area and continue to redirect. An interview with CNA 50 was conducted on 5/26/2021 at 3:10 P.M., to discuss Resident 35's fall incident on 5/21/2021. CNA 50 stated she passed by Resident 35's room and saw the resident on the floor. CNA 50 stated she saw blood on Resident 35's head. A telephone interview with the Assistant Director of Nursing (ADON) was conducted on 6/1/2021 at 11 A.M. to discuss Resident 35's fall incident on 4/8/2021. The ADON stated she was at the nurse's station when she heard Resident 35 yelled for help from room #111. The ADON stated the box for Resident 35's chair alarm was at the nurse's station and that she could not recall whether the silent alarm went off when Resident 35 fell in room #111. An observation of Resident 35 was conducted on 7/8/2021 at 5:30 A.M. Resident 35 sat on her wheelchair without the silent chair alarm. An interview with CNA 51 was conducted on 7/8/2021 at 7:09 A.M. CNA 51 stated Resident 35 was a fall risk. CNA 51 stated Resident 35 did not use any device to help prevent the resident from falling. An interview with licensed nurse (LN) 50 was conducted on 7/8/2021 at 3:10 P.M. to discuss Resident 35's fall incident on 5/21/2021. LN 50 stated she was in the A Hall when she was informed by a CNA that Resident 35 was found on the floor in her room. LN 50 stated the box for Resident 35's silent alarm was placed on top of her medication cart. LN 50 stated she did not hear the alarm go off. Resident 35's silent alarm was checked and it was set on the lowest volume setting. When the silent alarm was tested under the low volume setting, the sound was not easily heard when the environment was noisy. The silent alarm's volume setting was changed to the loudest setting. The sound was loud and easily heard. LN 50 stated, I did not hear that sound. An interview and joint record review with the Director of Nursing (DON) was conducted on 7/9/2021 at 10:31 A.M. The DON reviewed Resident 35's nursing progress notes, care plans and the Interdisciplinary (IDT - team members from different disciplines working collaboratively) notes related to the fall incidents. The DON confirmed that Resident 35 had eight falls from 2/14/2021 thru 5/21/2021. The DON stated Resident 35's fall on 5/21/2021 resulted in a laceration on the forehead, which required staples. The DON stated the IDT met after each of Resident 35's fall incident to find out the cause of the fall and to ensure appropriate fall preventative interventions were initiated. The DON acknowledged that the Post Fall IDT notes did not indicate that the IDT questioned whether the silent chair/bed alarm was used when Resident 35 fell repeatedly. The DON reviewed the nursing progress notes and confirmed that the nursing progress notes related to Resident 35' falls did not indicate that an audible sound or alarm were heard prior to finding Resident 35 on the floor. The DON acknowledged that to initiate an appropriate fall preventative intervention, a thorough root cause of the fall should be conducted. The interviews with CNA 1, the ADON, and LN 1 were shared with the DON. The DON could not explain why CNA 1, the ADON, and LN 1 did not hear the alarm go off prior to finding Resident 35 on the floor. The DON could not explain why the IDT did not question the use of the silent alarm during their discussion of Resident 35's repeated falls. The DON stated that fall preventative interventions should be consistently implemented to help prevent falls. A review of the facility's policy and procedure titled Falls and Fall Risk, Managing, revised on March , was conducted. The policy indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Resident-Centered Approaches to Managing Falls and Fall Risk .6. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.9. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routine of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. 2. Resident 23 was readmitted to the facility on [DATE] with diagnoses to include [CONDITION(S)] (paralysis on one side of the body) and [CONDITION(S)] (weakness on one side of the body) following nontraumatic intracerebral hemorrhage (brain bleed/stroke) affecting left non-dominant side, per the facility's Resident Face Sheet. A review of Resident 23's clinical record was conducted. The resident's clinical record indicated Resident 23 had been found on the floor on 2/16, 2/17, and 2/26/21. The three incidents of being found on the floor had been classified as falls. The IDT (interdisciplinary team) note dated 2/26/21 , indicated, .[Resident 23] fall on 2/22/21 . Resident was found on the bathroom floor on his right side . Resident states that he didn't have his wheelchair so he crawled to the bathroom . New interventions implemented .wheelchair next to resident so resident can assist himself to restroom PRN [as needed] A review of Resident 23's physician orders dated 2/26/21, indicated, Keep wheelchair open, locked, and in reach of resident at all times for resident to assist himself to bathroom. Special Instructions: (Fall prevention/safety) Every shift On 7/7/21 at 8:39 A.M. a joint observation and interview was conducted with Resident 23 inside the resident's room. Three residents resided in the room. Resident 23 was in Bed A located nearest to the door. A wheelchair was not observed at Resident 23's bedside. Resident 23 stated he could usually assist himself to the wheelchair if it were placed on the right side of his bed nearest to the door. On 7/7/21 at 9:16 A.M., an observation was conducted of Resident 23 inside the resident's room. Resident 23 was observed in bed. A wheelchair was not observed at Resident 23's bedside. On 7/7/21 at 3:15 P.M., an observation was conducted of Resident 23 inside the resident's room. Resident 23 was observed in bed. A wheelchair was not observed at Resident 23's bedside. On 7/7/21 at 4:47 P.M. an observation was conducted of Resident 23 inside the resident's room. Resident 23 was observed in bed. A wheelchair was not observed at Resident 23's bedside. On 7/7/21 at 5:29 P.M., a joint observation, interview, and record review was conducted with LN 22. LN 22 reviewed Resident 23's physician order dated 2/26/21 for the resident's wheelchair to be open, locked, and within the resident's reach. LN 22 then observed Resident 23 in bed in his room and the resident's wheelchair folded and placed against the wall. LN 22 stated Resident 23's wheelchair had not been open, locked, and within the resident's reach. LN 22 stated the physician order to prevent further falls had not been followed. LN 22 stated Resident 23 could get injured trying to get to the bathroom without his wheelchair. On 7/9/21 at 9:43 A.M., an interview was conducted with the director of nursing (DON). The DON stated the physician order for Resident 23's wheelchair to be kept open, locked and within the resident's reach had not been followed. The DON stated the physician order was first, a fall prevention measure and second, to facilitate the resident being able to access the bathroom. The DON stated it was her expectation for Resident 23's fall prevention intervention to be in place at all times. The facility's policy titled Falls and Fall Risk, Managing revised March 2018, indicated, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .1. The staff, with input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls 3. On 7/8/21 at 3:58 A.M., an observation was conducted of the main entrance to the facility. The double door main entrance was closed. A sliding glass door, adjacent to the double door main entry, was opened approximately three inches. This led into an open room used for visitors and from there into the whole building. Four surveyors entered the facility through the sliding glass door of the visitors' room, and were able to access different areas of the building. The four surveyors were not immediately noticed by staff. On 7/8/21 at 4:03 A.M., an interview was conducted with licensed nurse (LN) 4. LN 4 stated all points of entry into the facility should have been checked at the start of the night shift (11 P.M.). LN 4 stated this was to be done to keep the residents safe. LN 4 stated the room used for visits adjacent to the double door main entry should have been checked and locked after 5 P.M. the night before. On 7/8/21 at 7:22 A.M., an interview was conducted with LN 30. LN 30 stated as the charge nurse for the night shift, it was her responsibility to check the points of entry to the facility at the start of the shift and to make sure they were locked. LN 30 stated she did check the points of entry to ensure they were locked at the start of her shift. LN 30 stated she had not checked the entrance to the visiting room that was adjacent to the double door main entry. LN 30 stated, I should have checked. LN 30 stated having an unsecured point of entry into the facility at night was not safe. On 7/9/21 at 9:15 A.M., an interview was conducted with the director of nursing (DON). The DON stated it was her expectation for all points of entry into the facility to be secured at night so that unauthorized persons could not enter. The DON stated staff who worked nights were trained on how and when to check that the building was secured and that included the visitor entrance adjacent to the main double door. The DON further stated there was no policy that addressed securing the facility entrances.