Every finding on record at Lake Balboa Care Center

Based on interview and record review, the facility failed to complete the facility's admission packets including admission agreements and the facility orientation packets upon admission per its policy and procedure (P&P) for three of four sampled residents (Resident 1, Resident 3, and Resident 4). This failure had the potential to result in the residents and residents' responsible parties (RP - an individual who signs a facility's admission agreement to manage a resident's care, administrative tasks, and billing arrangements) not being able to exercise their rights including a resident's continued stay in the facility with Medi-Cal (Medicaid - a public health insurance program funded by the government that provides free or low-cost medical care to people with low incomes and limited resources, and Medi-Cal is the specific name used in California) benefits.Findings: During a record review of the facility's Medi-Cal Certificate, dated 2/1/2023, the Medi-Cal Certificate indicated, Your Medi-Cal certification is effective from the date specified above and continues as long as the provider maintain compliance with State and Federal law, rules and regulations, as determined by annual survey. During a record review of the California Department of Public Health (CDPH) letter issued 3/22/2024 that was provided by the facility, the CDPH letter indicated, This letter and your enclosed certificate verify your facility's participation in the Medi-Cal program and should be retained in your records. 1. During a review of Resident 1's Face Sheet (admission Record), the Face Sheet indicated that the facility originally admitted Resident 1 on 5/25/2026 and re-admitted the resident on 6/6/2026 with diagnoses including encephalopathy (damage or disease that affects the brain), acute (sudden, intense flare-up) respiratory failure with hypoxia (a severe deficiency of oxygen in the blood and tissues), end stage renal disease (ESRD - irreversible kidney failure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed). The Face Sheet further indicated that Resident 1 had a Medicaid number. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/9/2026, the MDS indicated that Resident 1's cognition (ability to think, understand, and make decisions) was severely impaired. The MDS also indicated Resident 1 was dependent on staff for transferring and required maximum assistance from staff for toileting/personal hygiene, showering, lower body dressing, and bed mobility (movement). During a review of Resident 1's admission packet that included the facility orientation packet and the admission agreement, the admission packet indicated that on 7/17/2026, the Admissions Assistant 1 (AA 1) wrote Refused indicating Resident 1's RP (RP 1) refused to sign the acknowledgment portion of the document. During a phone interview on 7/21/2026 at 12:02 p.m., with RP 1, RP 1 stated that the facility informed RP 1 the facility did not provide Medi-Cal custodial care (MCC - non medical help with everyday life, such as bathing, dressing, and eating, provided in a nursing home when you have low income and limited assets) so RP 1 needed to transfer Resident 1 to another facility that could bill to Medi-Cal, but when RP 1 checked the website (a digital location on the internet made up of a collection of connected pages), the facility was eligible to provide the services for Medicare and Medi-Cal beneficiaries. RP 1 further stated that Resident 1 was old and not easy to transfer and adjust to a new environment. During a concurrent interview and record review on 7/22/2026 at 10:29 a.m., with Admissions Assistant 1 (AA 1), AA 1 stated that tried to complete the admission packets by obtaining a resident's or family's signature upon admissions or at least on the following business day. AA 1 reviewed Resident1's admission packet and stated that the facility admitted Resident 1 initially on 5/25/2026, transferred to hospital on 5/31/2026, then readmitted on [DATE], the first contact was to complete the admission packet with RP 1 on 6/19/2026, but AA 1 did not receive the response from RP 1 until 7/17/2026, so AA 1 documented as refused as of 7/17/2026.2. During a review of Resident 3's Face Sheet, the Face Sheet indicated that the facility admitted Resident 3 on 7/6/2026 with diagnoses including acute respiratory failure with hypoxia and acute pulmonary edema (PE - fluid in the lungs).During a review of Resident 3's MDS dated [DATE], the MDS indicated that Resident 3's cognition was moderately impaired. The MDS also indicated Resident 3 required moderate assistance from staff for toileting hygiene, showering, lower body dressing, and transferring, required supervision or touching assistance for oral/personal hygiene, upper body dressing and bed mobility (movement). During a concurrent interview and record review on 7/22/2026 at 10:50 a.m., AA 1 stated the facility admitted Resident 3 on 7/6/2026, and on 7/9/26, AA 1 left the message to Resident 3's RP to complete the admission packet, but there was no response, so Resident 3's admission packet was not completed as of that day (7/22/2026). AA 1 stated there was no documented evidence the AA 1 made attempts to contact either Resident 3's RP or Resident 3. AA 1 further stated that in general if a resident or family asked AA 1 regarding Medi-Cal benefits while reviewing the admission packets, then AA 1 would refer them to the Business Office. 3. During a review of Resident 4's Face Sheet, the Face Sheet indicated that the facility admitted Resident 4 on 5/8/2026 with diagnoses including right hip fracture (broken bone), history of fall, and bilateral (both sides) primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of knee. During a review of Resident 4's MDS dated [DATE], the MDS indicated that Resident 4's cognition was moderately impaired. The MDS also indicated Resident 4 required maximum assistance from staff for shower transfers and required moderate assistance from staff for toileting/personal hygiene, showers, upper/lower body dressing, and bed mobility. During a review of Resident 4's admission packet that included the facility orientation packet and the admission agreement, the admission packet indicated that on 7/15/2026 a word Refused was written. During a concurrent interview and record review on 7/22/2026 at 10:45 a.m., AA 1 reviewed Resident 4's admission packet and stated the facility admitted Resident 4 on 5/8/2026 and AA 1 approached Resident 4 on 5/11/2026 to complete the admission packet, but Resident 4 stated that the resident was going to sign it later because it was too long. AA 1 stated AA 1 documented on the acknowledgment portion of the document as refused on 7/15/2026, but AA 1 was not able to provide documented evidence the attempts to complete the admission packet with Resident 4, so AA 1 could not tell when Resident 4 was approached and why the document was not completed. During an interview on 7/22/2026 at 10:58 a.m., with the Administrator (ADM), the ADM stated that the residents' admission packets should be completed within 72 hours after admitting the residents to the facility and if anyone refused to sign the forms, the facility staff should document because if not documented, the facility could not tell the facility tried to complete the residents' admission packets in a timely manner. During a review of the facility's P&P titled, Administrative Manual for Admission, last reviewed on 4/21/2026, the P&P indicated that the admission agreement and legal papers and consents necessarily for the clinical/medical record, will be completed at the time of admission by the resident if capable of giving consent or a designated representative or based on conservatorship as authorized to action on behalf of the resident. The P&P also indicated that the resident, legal or authorized representative will give written, signed, dated consent (confirmation of consent) for (See admission Packet for details). During a review of the facility's P&P titled, Resident Rights, last reviewed on 4/21/2026, the P&P indicated, It is the policy of this facility to inform the resident both orally and in writing of their rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during their stay in the facility. Procedure: Prior to or upon admission, a representative of the admitting office will provide the resident with a written copy of resident rights and a copy of all rules and regulations governing the resident's conduct and responsibilities during their stay in the facility. The resident will also be provided with a State developed notice of Medicaid rights and obligations, if any.

Based on interview and record review, the facility failed to notify a resident's responsible party (RP - an individual who signs a facility's admission agreement to manage a resident's care, administrative tasks, and billing arrangements) for one of four sampled residents (Resident 1) that the facility had the Medi-Cal (Medicaid - a public health insurance program funded by the government that provides free or low-cost medical care to people with low incomes and limited resources, and Medi-Cal is the specific name used in California) certificate and was eligible to provide the care and services for the Medi-Cal beneficiaries when the Medicare (an official government health insurance program mainly for people age [AGE] and older, as well as some younger people with disabilities) skilled benefits end. This failure had the potential to result to Resident 1 and Resident 1's RP not being able to exercise their rights to file with Medi-Cal benefits. Findings: During a record review of the facility's Medi-Cal Certificate dated 2/1/2023, the Medi-Cal Certificate indicated, Your Medi-Cal certification is effective from the date specified above and continues as long as the provider maintain compliance with State and Federal law, rules and regulations, as determined by annual survey. During a record review of the California Department of Public Health (CDPH) letter issued 3/22/2024 that was provided by the facility, the CDPH letter indicated, This letter and your enclosed certificate verify your facility's participation in the Medi-Cal program and should be retained in your records. During a review of Resident 1's Face Sheet (admission Record), the Face Sheet indicated that the facility originally admitted Resident 1 on 5/25/2026 and re-admitted the resident on 6/6/2026 with diagnoses including encephalopathy (damage or disease that affects the brain), acute (sudden, intense flare-up) respiratory failure with hypoxia (a severe deficiency of oxygen in the blood and tissues), end stage renal disease (ESRD - irreversible kidney failure), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed). The Face Sheet further indicated that Resident 1 had a Medicaid number. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/9/2026, the MDS indicated that Resident 1's cognition (ability to think, understand, and make decisions) was severely impaired. The MDS also indicated Resident 1 was dependent on staff for transferring and required maximum assistance from staff for toileting/personal hygiene, showering, lower body dressing, and bed mobility (movement). During a review of Resident 1's Interdisciplinary Team (IDT - a group of people with different types of training and skills - such as doctors, nurses, and social workers who work closely together to reach a shared goal) Care Plan Review notes dated 6/6/2026, the discharge plan summary indicated that Resident 1 was admitted for short term rehabilitation and nursing services, the Social Services Director (SSD) explained Resident 1's RP (RP 1) that the facility could not bill to Medi-Cal beyond Medicare skilled days due to facility Medi-Cal de-certifying process, RP 1 verbalized understanding, and the SSD could assist Resident 1's transfer to another facility if requested. During a phone interview on 7/21/2026 at 12:02 p.m., with RP 1, RP 1 stated that the facility informed RP 1 the facility did not provide Medi-Cal custodial care (MCC - non medical help with everyday life, such as bathing, dressing, and eating, provided in a nursing home when you have low income and limited assets) so RP 1 needed to transfer Resident 1 to another facility that could bill Medi-Cal, but when RP 1 checked the website (a digital location on the internet made up of a collection of connected pages), the facility was eligible to provide the services for Medicare and Medi-Cal beneficiaries. RP 1 further stated that Resident 1 was old and not easy to transfer and adjust to a new environment. During an interview on 7/22/2026 at 8:35 a.m., with the SSD, the SSD stated that RP 1 informed Resident 1 had to wait for six months to one year to be admitted to another facility if approved. When the SSD was asked if the SSD provided the information to RP 1 that the facility provided Medi-Cal custodial care and could bill to Medi-Cal while waiting, the SSD stated that the SSD explained verbally but was not able to provide documented evidence that SSD provided the information to RP 1. During a concurrent interview and record review on 7/23/2026 at 10:48 a.m., with the Assistant Director of Nursing (ADON) and the SSD, Resident 1's IDT Care Plan Review notes dated 6/6/2026 were reviewed. The SSD stated that Resident 1's summary of discharge plan indicated that the SSD explained to RP 1 that the facility could not bill Medi-Cal due to facility undergoing Medi-Cal decertifying process, RP 1 verbalized understanding, and the SSD could assist lateral transfer to another facility if requested. The SSD stated that this was mistakenly documented and that she did not provide that information to RP 1 because at that time the SSD was informed that the facility could bill Medi-Cal. When the SSD was asked if the SSD provided the information to RP 1 and documented that the facility could provide the Medi-Cal custodial care under Medi-Cal benefits when Medicare skilled benefits end, the SSD stated that there was no documented evidence that it was discussed with RP 1 not until the morning of 7/23/2026 (documentation was done after it was brought to the facility's attention by the surveyor). During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed on 4/21/2026, the P&P indicated that it was the policy of this facility to inform the resident both orally and in writing of their rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during their stay in the facility. And the P&P further indicated that prior to or upon admission, a representative of the admitting office will provide the resident with a written copy of resident rights and a copy of all rules and regulations governing the resident's conduct and responsibilities during their stay in the facility. The resident will also be provided with a State developed notice of Medicaid rights and obligations, if any.

Based on interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) by: 1.Failing to ensure a care plan was developed for three of five sampled residents (Resident 7, 15 and 35) investigated during review of the Infection Control task when Residents 7, 15, and 35 refused Coronavirus Disease 2019 (COVID-19,respiratory illness that spreads easily through respiratory droplets from coughs, sneezes, or talking) pneumonia (an infection/inflammation in the lungs), influenza (an infection of the nose, throat and lungs) and respiratory syncytial virus (RSV-a common respiratory virus. It usually causes mild, cold-like symptoms but it can cause serious lung infections, especially in infants, older adult) vaccinations (medications used to prevent diseases usually given by injection or by mouth) 2. Failing to ensure a care plan was developed for one of five sampled residents (Resident 33) investigated during review of the Infection Control task when Resident 33 refused pneumonia and RSV vaccination. These failures had the potential for the residents to not receive necessary care and services related to vaccination refusal, placing the residents at risk for respiratory diseases such as COVID-19, pneumonia, influenza, and RSV. 3. Failing to ensure a care plan was developed for a resident's use of Seroquel (an antipsychotic medication) and clonazepam (medication that acts as a central nervous system depressant) for one of five residents (Resident 8) reviewed for unnecessary medications. This deficient practice increased the risk that Resident 8 may have experienced adverse effects (unwanted or dangerous medication side effects) of psychotropic medication therapy leading to an overall negative impact on their physical, mental, and psychosocial well-being. Findings: 1a. During a review of Resident 7's Face Sheet, the Face Sheet indicated the facility admitted Resident 7 on 3/15/2026, with diagnoses that included acute pyelonephritis (a bacterial infection causing inflammation of the kidneys), urinary tract infection (UTI- an infection in the bladder/urinary tract) and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities). During a review of Resident 7's Resident Consent for influenza, Pneumococcal (caused by bacteria that can infect different parts of the body), and COVID-19 Vaccination (the Consent), dated 3/15/2026, the Consent indicated Resident 7's Family Member 2 (FM 2) refused influenza, pneumococcal, and COVID-19 vaccine. During a review of Resident 7's Resident Vaccination Consent, dated 3/15/2026, the Resident Vaccination Consent indicated FM 2 refused RSV vaccine. During a review of Resident 7's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 3/16/2026, the H&P indicated Resident 7 had fluctuating capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS-a resident assessment tool), dated 3/18/2026, the MDS indicated Resident 7's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. During an interview on 4/11/2026, at 7:37 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated Resident 7 had refused vaccine for influenza, pneumococcal, COVID-19, and RSV. The IPN stated the facility does not develop a care plan for residents' refusal for vaccination. 1b. During a review of Resident 15's Face Sheet, the Face Sheet indicated the facility admitted Resident 15 on 10/16/2025, with diagnoses that included unspecified elevated white blood cell count (WBC-the immune system cells that fight infections), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (HTN-high blood pressure). During a review of Resident 15's Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination (the Consent), dated 3/21/2026, the Consent indicated Resident 15's FM 3 refused influenza, pneumococcal, and COVID-19 vaccine. During a review of Resident 15's Resident Vaccination Consent, dated 3/21/2026, the Resident Vaccination Consent indicated FM 3 refused RSV vaccine. During a review of Resident 15's MDS dated [DATE], the MDS indicated Resident 15's cognitive skills for daily decisions were intact. During an interview on 4/11/2026, at 7:39 a.m., with the IPN, the IPN stated Resident 15 had refused the vaccine for influenza, pneumococcal, COVID-19, and RSV. 1c. During a review of Resident 35's Face Sheet, the Face Sheet indicated the facility admitted Resident 35 on 3/26/2026, with diagnoses that included unspecified multiple sclerosis (MS-a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), UTI and essential HTN. During a review of Resident 35's Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination (the Consent), dated 3/26/2026, the Consent indicated Resident 35 refused influenza, pneumococcal, and COVID-19 vaccine. During a review of Resident 35's Resident Vaccination Consent, dated 3/26/2026, the Resident Vaccination Consent indicated Resident 35 refused RSV vaccine. During a review of Resident 35's H&P, dated 3/30/2026, the H&P indicated Resident 35 had the capacity to understand and make decisions. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35's cognitive skills for daily decisions were intact. During an interview on 4/11/2026, at 7:35 a.m., with the IPN, the IPN stated Resident 35 had refused the vaccine for influenza, pneumococcal, COVID-19, and RSV. 2. During a review of Resident 33's Face Sheet, the Face Sheet indicated the facility admitted Resident 33 on 2/23/2026, with diagnoses that included unspecified asthma (a chronic [long-term] disease that causes inflammation, swelling, and narrowing of the airways, making it difficult to breathe), unspecified fall and weakness. During a review of Resident 33's Resident Consent for Influenza, Pneumococcal, and COVID-19 Vaccination (the Consent), dated 2/23/2026, the Consent indicated Resident 33's FM 4 refused influenza, pneumococcal, and COVID-19 vaccine. During a review of Resident 33's Resident Vaccination Consent, dated 2/23/2026, the Resident Vaccination Consent indicated Resident 33 refused RSV vaccine. During a review of Resident 33's H&P, dated 2/25/2026, the H&P indicated Resident 33 had the capacity to understand and make decisions. During a review of Resident 33's MDS, dated [DATE], the MDS indicated Resident 33's cognitive skills for daily decisions were moderately impaired. During an interview on 4/11/2026, at 7:42 a.m., with the IPN, the IPN stated Resident 33 had refused the vaccine for pneumococcal and RSV. The IPN stated the facility does not develop a care plan for refusal for vaccination unless there was a change in the resident's condition. During an interview on 4/11/2026, at 4:55 p.m., with the IPN, the IPN stated that they (licensed nurses) do not develop a care plan for residents' refusal of vaccinations. The IPN stated vaccines are used to protect the residents from influenza, pneumococcal, COVID-19, and RSV. The IPN stated the facility did not develop an individualized care plan addressing the residents' refusal of vaccinations which included goals and interventions to prevent respiratory diseases. During an interview on 4/11/2026, at 5:12 p.m., with the DON, the DON stated care plans are developed to address residents' problems and needs which include resident goals and specific interventions. The DON stated not developing a care plan for Resident 7, 15, and 35's refusal of vaccinations could potentially place Residents 7, 15, and 35's at risk for developing COVID-19, pneumonia, influenza and RSV, and Resident 33 at risk for pneumonia and RSV. During a concurrent interview and record review on 4/11/2026, at 5:15 p.m., with the DON, facility's policy and procedure (P&P), titled, Comprehensive Resident Centered Care Plan, dated 11/2016, and last reviewed on 2/2026, the P&P indicated, It is the policy of this facility that the interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The DON stated the facility's P&P was not specific to resident refusal, but the P&P indicated the care plan should have a measurable objective and timeframes to meet a resident's medical, nursing, mental and psychosocial needs. The DON stated vaccination is a resident's medical need so a care plan should be developed when a vaccination is refused. During a review of facility's P&P, titled, Immunizations-Residents, dated 9/2017, and last reviewed on 2/2026, the P&P indicated, It is the policy of this facility to offer and administer influenza, pneumococcal, and COVID-19 immunization to eligible residents after providing education on the risks and potential side effects of the vaccine(s) and obtaining consent. Eligibility to receive the vaccines may include, but is not limited to current vaccine status, season/time of year, medical contraindications, or resident preference/choice. To minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza, pneumococcal disease, or COVID-19 by ensuring that each resident is informed about the benefits and risks of immunizations; and has the opportunity to receive the influenza, pneumococcal, or COVID-19 vaccine(s), unless medically contraindicated, declined or already immunized. 3. During a review of Resident 8's Face Sheet, the Face Sheet indicated the facility admitted Resident 8 on 1/26/2026 with diagnoses including dementia, bipolar (a disorder associated with episodes of mood swings ranging from depressive [period of feeling sad, hopeless or empty] lows to manic [being in a state of extreme, elevated energy and emotion] highs), and anxiety. During review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 42 has moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and mostly dependent (helper does all the effort) for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS indicated Resident 8 was taking antipsychotic, antianxiety and antidepressant medications. During a review of Resident 8's Order Summary Report as of 4/12/2026, the Order Summary Report indicated an order dated 2/1/2026 for the following medications: -Seroquel 25 milligram (mg-unit of measurement), give three tablets by mouth at bedtime for bipolar disorder as evidenced by verbalization that someone is constantly pushing her. -Clonazepam 1 mg by mouth at bedtime for anxiety manifested by verbalization of feeling anxious. During a concurrent interview and record review on 4/12/2026 at 1:10 p.m., with Registered Nurse 2 (RN 2). Resident 8's care plans were reviewed. There was no care plan Resident 8's Seroquel use and anxiety disorder behavior as manifested by verbalization of feeling anxious requiring the use of clonazepam. RN 2 validated the missing care plans. RN 2 stated that it is important for Resident 8 to have individualized care plans so the facility can provide the proper care to meet Resident 8's needs. During a review of facility's P&P, titled, Comprehensive Resident Centered Care Plan, reviewed on 3/17/2026, the P&P indicated, Facility shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on interview and record review, the facility failed to ensure licensed nurses practiced professional standards of practice while administering insulin (hormone that regulates the amount of glucose [sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin injections sites for one of one sampled resident (Resident 2) investigated under the care area insulin. This failure had the potential to result in bruising, pain, and/or lipodystrophy (lump or accumulation of fatty tissue under skin) to Resident 2. Cross reference to F760.Findings: During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility admitted Resident 2 on 6/1/2023 and readmitted the resident on 2/24/2026 with diagnoses that included, but not limited to type two (2) diabetes mellitus (DM - a chronic condition that affects the way the body processes blood glucose [sugar]) and Parkinson's disease (a movement disorder of the nervous system that worsens over time). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 3/2/2026, indicated the Resident 2 had the capacity to make himself understood and understand others. The MDS indicated Resident needed substantial (helper does more than half the effort) on facility staff for dressing and bathing. During a review of Resident 2's Order Summary Report, active as of 4/12/2026, the Order Summary Report indicated an order for Novolog (a brand of insulin) Flex pen 100 units per milliliters (unit/ml, a unit of fluid volume) inject per sliding scale (progressive increase in the insulin dosage, based on pre-defined blood glucose ranges) subcutaneously (SQ - in the fatty layer of the skin) before meals and at bedtime, dated 3/4/2026. During a review of Resident 2's Medication Administration Record (MAR- a report detailing the medications administered to a resident by the licensed nurse in the facility) from 3/8/2026 to 3/23/2026, the MAR indicated the following for Novolog Flexpen 100 unit/ml solution: - 3/8/2026 - administered: abdomen - left upper quadrant (LUQ) - 3/9/2026 - administered: abdomen - LUQ - 3/16/2026 - administered: arm - left arm - 3/17/2026 - administered: arm - left arm - 3/22/2026 - administered: abdomen - left lower quadrant (LLQ) 3/23/2026 - administered: abdomen - LLQ During a review of Resident 2's DM Care Plan (CP, a document that summarizes a resident's needs, goals, and care/treatment), the CP indicated an intervention to administer medication as ordered. During a concurrent interview and record review on 4/12/2025 at 2:27 p.m., with the Director of Nursing (DON), reviewed Resident 2's MAR dated 3/2026. The DON stated the expectation is for her licensed nurses to follow directions and rotate injection sites. The DON stated there were multiple instances where Resident 2's injection sites of insulin were not rotated in 3/2026. The DON stated the sites of insulin administration should be rotated to prevent damage to the skin tissues of the resident and medication errors. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed on 3/17/2026, the P&P indicated to administer medication in accordance with prescriber's orders. During a review of the facility-provided FDA Label for Novolog insulin, last revised 2/2023, it indicated to rotate the injection sites from one injection to the next to reduce the risk of lipodystrophy and to not use the same spot for each injection.

Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors by failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin (hormone that regulates the amount of glucose [sugar] in the blood) injections sites for one of one sampled resident (Residents 2) investigated under the care area insulin. This failure had the potential to result in bruising, pain, and/or lipodystrophy (lump or accumulation of fatty tissue under skin) to Resident 2 and for Resident 2 to not get the appropriate amount of medication.Findings: During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility admitted Resident 2 on 6/1/2023 and readmitted the resident on 2/24/2026 with diagnoses that included, but not limited to type two (2) diabetes mellitus (DM - a chronic condition that affects the way the body processes blood glucose [sugar]) and Parkinson's disease (a movement disorder of the nervous system that worsens over time). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool) dated 3/2/2026, indicated the Resident 2 had the capacity to make himself understood and understand others. The MDS indicated Resident needed substantial (helper does more than half the effort) on facility staff for dressing and bathing. During a review of Resident 2's Order Summary Report, active as of 4/12/2026, the Order Summary Report indicated an order for Novolog (a brand of insulin) Flex pen 100 units per milliliters (unit/ml, a unit of fluid volume) inject per sliding scale (progressive increase in the insulin dosage, based on pre-defined blood glucose ranges) subcutaneously (SQ - in the fatty layer of the skin) before meals and at bedtime, dated 3/4/2026. During a review of Resident 2's Medication Administration Record (MAR- a report detailing the medications administered to a resident by the licensed nurse in the facility) from 3/8/2026 to 3/23/2026, the MAR indicated the following for Novolog Flexpen 100 unit/ml solution: - 3/8/2026 - administered: abdomen - left upper quadrant (LUQ) - 3/9/2026 - administered: abdomen - LUQ - 3/16/2026 - administered: arm - left arm - 3/17/2026 - administered: arm - left arm - 3/22/2026 - administered: abdomen - left lower quadrant (LLQ) 3/23/2026 - administered: abdomen - LLQ During a review of Resident 2's DM Care Plan (CP, a document that summarizes a resident's needs, goals, and care/treatment), the CP indicated an intervention to administer medication as ordered. During a concurrent interview and record review on 4/12/2025 at 2:27 p.m., with the Director of Nursing (DON), reviewed Resident 2's MAR dated 3/2026. The DON stated there were multiple instances where the injection sites of insulin were not rotated in 3/2026. The DON stated the sites of insulin administration should be rotated to prevent damage to the skin tissues of the resident and medication errors. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed on 3/17/2026, the P&P indicated to administer medication in accordance with prescriber's orders. During a review of the facility-provided FDA Label for Novolog insulin, last revised 2/2023, it indicated to rotate the injection sites from one injection to the next to reduce the risk of lipodystrophy and to not use the same spot for each injection.

Based on observation, interview, and record review, the facility failed to observe infection control guidelines by failing to: 1. Ensure one of one sampled ice machines did not have black substances inside the ice compartment bin. This deficient practice had the potential to result in contamination of the ice which could lead to waterborne diseases (illnesses caused by pathogenic microorganisms, bacteria, viruses, and parasites transmitted through contaminated water) for 48 of 50 residents in the facility. 2. Ensure Certified Nursing Assistant 1 (CNA 1) wore an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) while turning and reposition one of one sampled resident (Resident 7) who was on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes). 3. Ensure one of one sampled resident (Resident 62), who was admitted with a Peripherally Inserted Central Catheter (PICC-a long, thin flexible tube inserted into a large vein in the upper arm, extending to a central vessel near the heart), was placed on EBP. These deficient practices had the potential to result in the spread of MDRO and/or infection to residents. 4. Ensure a soiled toilet seat cover was removed from the toilet riser in one of one sampled resident's (Resident 27) bathroom during a random observation. This deficient practice placed residents and staff at risk of exposure and possibly contracting infectious microorganisms. Findings: 1. During a concurrent observation and interview on 4/11/2026 at 6:20 a.m., with the Dietary Supervisor (DS), observed the iced machine in the kitchen. Upon wiping the inside of the ice compartment where the door was latched using a paper towel, the paper towel collected black substances which adhered to the paper towel. The DS stated that the black substances should have been wiped away and cleaned during the regular cleaning. The DS stated that if the black substances get into the ice and are ingested, it can cause foodborne illnesses. During an interview on 4/11/2026 at 2:05 p.m., with the Director of Nursing (DON), the DON stated she exercised oversight of all department in the facility including the dietary department. The DON stated that cleanliness in the kitchen is maintained to ensure food and beverages that are served from the kitchen are safe for the residents of the facility. The DON stated ice machine should be regularly cleaned and maintained to ensure the ice is not contaminated by any pathogens (tiny organisms that can make you sick if they get inside your body). The DON stated that dirt build up in the ice machine can potentially make the resident sick. During a review of the facility's policy and procedure (P&P) titled, Ice Machine Cleaning Procedures, last reviewed on 3/7/2026, the policy indicated, The ice machine needs to cleaned and sanitized monthly.clean inside the machine with sanitizing agent per the manufacturer's instructions. 2. During a review of Resident 7's Face Sheet, the Face Sheet indicated the facility admitted Resident 7 on 3/15/2026 with diagnoses including toxic encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition-such as viral infection or toxins in the blood), sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), and urinary tract infection (UTI-infection in the urinary system). During review of Resident 7's Minimum Data Set (MDS - a resident assessment tool) dated 3/18/2026, the MDS indicated Resident 7 has severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and substantial/maximal assistance (helper does more than half the effort) to dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). During a review of Resident 7's Order Summary Report (OSR) as of 4/12/2026, the OSR indicated Resident 7 had a physician order for EBP: PPE required for high resident contact care activities due to MDRO urine, ordered 3/16/2026. During a concurrent observation and interview on 4/11/2026 at 7:42 a.m., with CNA 1, inside Resident 7's room, observed CNA 1 turn and reposition Resident 7 without wearing an isolation gown. CNA 1 stated that according to the signage in front of the room, Resident 7 was on EBP. CNA 1 also stated that she (CNA 1) was supposed to wear an isolation gown when touching Resident 7 due to possible contamination and high risk of infection. During an interview on 4/11/2026 at 12:24 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated that staff must wear gowns and gloves for residents that are on EBP when doing any high close contact such as touching, repositioning, and cleaning residents due to prevent infection. During a review of facility's policy and procedure (P&P) titled, IPCP Standard and Transmission-Based Precautions, reviewed on 3/17/2026, the P&P indicated, EBP used in conjunction with standard precautions and expand the use of PPE though the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. 3. During a review of Resident 62's Face Sheet, the Face Sheet indicated the facility admitted Resident 62 on 4/10/2026 with diagnoses including reduced mobility, dysphagia (difficulty swallowing), and need for assistance with personal care. During a review of Resident 62's OSR as of 4/12/2026, the OSR indicated Resident 62 had no physician order for EBP. The OSR also indicated on 4/10/2026, Resident 62 had a physician order for a right upper arm PICC line intravenous (IV-means giving fluids, medications, or nutrients directly into a vein using a needle or tube) site check for any signs and symptoms of complications from IV medications. During a concurrent observation and interview on 4/11/2026 at 7:49 a.m., inside Resident 62's room, with CNA 1, observed CNA 1 reposition and change Resident 62. CNA 1 stated that Resident 62 was not on EBP. During an interview on 4/11/2026 at 8:00 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 62 does not need to be on EBP. During an interview on 4/11/2026 at 12:25 p.m., with the IPN, the IPN stated that Resident 62's PICC line does not place Resident 62 on EBP. During an interview on 4/12/2026 at 10:08 a.m., with Registered Nurse 3 (RN 3), RN 3 stated that Resident 62 has a PICC line, placing him (Resident 62) on high risk for infection. RN 3 stated that Resident 62 needs to be on EBP for infection prevention. During a concurrent interview and record review on 4/12/2026 at 10:31 a.m., with the DON, reviewed the facility's P&P, titled, IPCP Standard and Transmission-Based Precautions, reviewed on 3/17/2026. The P&P indicated, PPE: the use of gown and gloves for high-contact resident care activities is indicated for nursing home residents with wounds and/or indwelling medical devices regardless of known MDRO infection or colonization. Indwelling medical devices include, but are not limited to .PICC lines. The DON stated that Resident 62, who has a PICC line, should be on EBP due to high risk of infection. 4. During a review of Resident 27's Face Sheet, the Face Sheet indicated the facility admitted Resident 27 on 1/27/2026 with diagnoses including urinary tract infection, sepsis, and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 27's MDS dated [DATE], the MDS indicated Resident 27 could make herself understood and understood others and required substantial assistance (helper does more than half the effort) from facility staff for toileting and personal hygiene. During a concurrent observation and interview on 4/6/2026 at 8:31 a.m., in Resident 27's room and bathroom, Resident 27 was lying in bed, which was in front of the open bathroom door. Resident 27 asked if the door to the bathroom could be shut because she did not want to look into the bathroom, especially because there was a dirty toilet seat cover on the toilet riser. Resident 27 stated it should have been thrown away. During a concurrent observation and interview on 4/6/2026 at 8:31 a.m., in Resident 27's room and bathroom with Certified Nursing Assistant 5 (CNA 5), CNA 5 pointed to the soiled toilet seat cover and stated the cover should have been removed right after it was used to prevent the spread of infections. During an interview on 4/9/2026 at 12:41 p.m., with the DON, the DON stated facility staff must remove soiled toilet seat covers once they are used/soiled, not only to make it aesthetically pleasing, but also to prevent the spread of germs. During a review of the facility's policy and procedure (P&P) titled, Infection Control, last reviewed and revised on 3/17/2026, the P&P indicated that the facility must implement infection control measures to prevent the spread of communicable diseases. The P&P further indicated if common use of equipment for multiple residents is unavoidable, clean and disinfect it prior to use on another.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor, appearance and palatability for lunch when roast beef was served dry and too tough to chew for two of three residents (Resident 2, 37) during a lunch dining observation. This failure had the potential to place Resident 2 and 37 at risk of unplanned weight loss, a consequence of poor food intake, from receiving food from the kitchen. Findings: a. During a review of Resident 2's Face Sheet, the Face Sheet indicated the facility admitted Resident 2 on 6/1/2023 and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM - a disease that occurs when the glucose, also called blood sugar, is too high) and moderate protein calorie malnutrition (a potentially fatal condition caused by a severe lack of dietary protein and/or energy [calories]). During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/2/2026, the MDS indicated the Resident 2 had the capacity to make himself understood and understand others. The MDS indicated Resident 2 needed substantial (helper does more than half the effort) on facility staff for dressing and bathing and set-up assistance (helper sets up/cleans up; resident does the effort) with feeding. During a review of Resident 2's Order Summary Report, active as of 4/12/2026, there was an order dated 2/24/2026 for: - CCHO (consistent carbohydrate diet- diabetes management plan diet) NAS (no added salt) diet Regular – Level 7 texture (no texture restrictions). During an observation on 4/12/2026 at 12:48 P.M. in the dining room during lunch service, Resident 2 was sitting up in his wheelchair next to his family member (FM1). FM 1 was trying to cut Resident 2's roast beef in a vigorous motion, repeatedly into tiny pieces. Resident 2 ate the other food items but did not eat the roast beef. During a concurrent observation and interview on 4/12/2026 at 12:51 p.m. in the dining room with FM 1, FM 1 stated the roast beef was way too tough, hard to cut, stated where was the juice or gravy because it was dry and it looked terrible. FM 1 stated Resident 2 could not chew the meat, and it should have never been served, especially to the population at the facility. During a concurrent observation and interview on 4/12/2026 at 12:55 P.M. with Registered Nurse (RN 2) in the dining room, RN 2 looked at Resident 2's meat and stated it looked very dry and tough, and she should have noticed it sooner to offer a substitute. RN 2 stated it would be hard for the residents in the facility to eat even with a regular texture diet and should have never been served. During a concurrent observation, interview and record review with the Dietary Supervisor (DS) on 4/12/2026 at 12:50 p.m., a review of facility's menu indicated that on 4/12/2026, roast beef au jus (French for with juice) was served during lunch. The DS was observed testing and chewing the roast beef au jus for about a minute before swallowing. DS stated and validated missing au jus on the roast beef and added meat was dry and tough. The DS also stated the meat should not have been served to the residents. During a review of the facility's Policy and Procedure (P&P) titled Mealtime Observation for Food Acceptance & Food Replacement, last reviewed 3/17/2026, the P&P indicated any staff member that observes a resident experiencing problems with chewing must be referred to the Director of Nursing (DON). The P&P further indicated staff must offer a food substitute if they notice poor intake. During a review of the facility's P&P titled In-Room Dining, last reviewed 3/17/2026, the P&P indicated meals will be presented attractively. b. During a review of Resident 37's Face Sheet, the Face Sheet indicated the facility admitted Resident 37 on 8/15/2025 and was readmitted on [DATE] with diagnoses including dehydration (not having enough water in the body), dysphagia (difficulty swallowing food or liquid) and protein calorie malnutrition. During a review of Resident 37's MDS, dated [DATE], MDS indicated Resident 37 had moderately impaired cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 37 needed supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with eating while dependent (helper does all the effort) on the other activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS also indicated Resident 37 had some difficulty or pain while swallowing. During a review of Resident 37's Order Summary Report, active as of 4/12/2026, the Order Summary Report indicated an order on 10/29/2025 for a consistent carbohydrate diet (CCHO-diabetes management plan diet). During a concurrent dining observation and interview with Resident 37 on 4/12/2026 at 12:48 P.M. in the dining room during lunch service, Resident 37 was seated at the dining table, and observed having a hard time cutting the meat into pieces. Resident 37 stated he is unable to eat due to meat being too tough like a shoe leather. During a concurrent observation, interview and record review with the Dietary Supervisor (DS) on 4/12/2026 at 12:50 p.m., a review of facility's menu indicated that on 4/12/2026, roast beef au jus (French for with juice) was served during lunch. The DS was observed testing and chewing the roast beef au jus for about a minute before swallowing. DS stated and validated missing au jus on the roast beef and added meat was dry and tough. The DS also stated the meat should not have been served to the residents. During a review of the facility's Policy and Procedure (P&P) titled Mealtime Observation for Food Acceptance & Food Replacement, last reviewed 3/17/2026, the P&P indicated any staff member that observes a resident experiencing problems with chewing must be referred to the DON. The P&P further indicated staff must offer a food substitute if they notice poor intake. During a review of the facility's P&P titled In-Room Dining, last reviewed 3/17/2026, the P&P indicated meals will be presented attractively.

Based on observation, interview, and record review, the facility failed to ensure the Quaternary Ammonium Solution (QUAT- a class of disinfectant ingredients commonly used in household, healthcare, and commercial cleaning products) had a holding concentration of 200 parts per million (ppm-unit of measure). This deficient practice had the potential to result in ineffective sanitization of work surfaces against bacteria and viruses in the kitchen which could lead to resident consuming food that are contaminated and result to foodborne illnesses. Findings: During a concurrent kitchen observation and interview on 4/11/2026 at 6:20 a.m., with the Dietary Supervisor (DS), observed a red bucket containing a clear liquid solution. The DS sated that the red bucket contained the Quat solution used to sanitize work and food preparation surfaces. The DS stated that they maintained a testing log to ensure the quat solution has a concentration of 200 ppm per manufacturer's guidelines. The DS stated that the 200 ppm concentration will ensure that the solution is effective in preventing bacteria and viruses from contaminating food items that are prepared in these work surfaces. The DS stated that this bucket had already been tested since the Sanitizer Dispenser Log had already been filled up for the breakfast testing and the next test will be during lunch preparation. The DS then obtained a test strip to test the bucket which would indicate if the solution contained the amount of ppm which is supposed to be 200 ppm based on the color diagram according to the DS. The DS then dipped the test strip in the red bucket containing the quat solution and the test strip turned orange, equivalent to 100 ppm (200 ppm is green). The DS replaced the red bucket with a fresh quat solution and retested by dipping the test strip which again resulted in the test strip turning orange. The DS then discarded the red bucket and stated she will call up the supplier/manufacturer to replace the quat solution. The DS stated that the quat solution in the red bucket won't be able to effectively disinfect the work surfaces which could potentially risk contamination of the food prepared in these work surfaces which could lead to foodborne illnesses. During a review of the facility's policy and procedure (P&P) titled, Quaternary Ammonium Log Policy, last reviewed on 3/17/2026, the P&P indicated, The concentration of the ammonium in the quaternary sanitizer will be tested to ensure the effectiveness of the solution.the quaternary solution used for sanitizing clean work surfaces in the kitchen, will be made according to the instruction on the product container or dispensing device set up for the specific quat product.the solution will be replaced when the reading is below 200 ppm.

Based on observation, interview, and record review, the facility failed to dispose garbage and waste properly when: 1. One of one black dumpster (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) was not completely closed due to overfilling of bagged trash and empty cartons. 2. There were eight transparent trash bags containing soiled diapers, gloves, empty glove boxes, and other unidentifiable trash piled on the concrete near the dumpster. These failures had the potential to attract insects, pests, and rodents and potentially spread infection to 50 of 50 residents living in the facility. Findings: During a concurrent observation and interview on 4/12/2026 at 7:11 a.m., with the Director of Staff Development (DSD) at the back of the main facility building close to the parking lot, observed an overfilled black dumpster and eight transparent trash bags laying on the concrete floor in the enclosure designated for the dumpster. The DSD stated that the dumpster should be completely closed and any other trash should be placed in the bins. The DSD stated it can potentially attract pests, insects, and rats and it's not sanitary for trash to be strewn in the garbage area enclosure. The DSD took a photo of the overfilled dumpster and multiple transparent trash bags containing soiled diapers, gloves, and unidentified trash. During a concurrent interview and record review on 4/11/2026 at 2:05 p.m., with the Director of Nursing (DON), reviewed the photo image of the dumpster and bags of transparent trash bags strewn on the floor near the dumpster. The DON stated that the dumpster should be covered and any other waste must be placed in bins with lids. The DON stated that the dumpster is used for kitchen waste and other trash. The DON stated that it can endanger the resident if trash disposal is unsanitary due to potential pest infestations that can result in any form of illnesses from pest contamination. During a review of the facility's policy and procedure (P&P) titled, Environmental-Exterior Trash Bin, last reviewed on 3/17/2026, the P&P indicated, It is the policy of the facility to maintain all outside trash and waste disposal areas clean, sanitary, safe, and compliant manner in accordance with federal, state, and local regulations, including infection control and environmental safety standards. Proper management of outside trash bins is essential to prevent odors, pest infestation, contamination, and safety hazards.avoid overfilling bags or bins.

Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of eight sampled residents (Resident 15) failing to ensure the Infection Preventionist Nurse (IPN) documented when the physician initially ordered to discontinue Resident 15's Vancomycin (a strong antibiotic [medication used to treat infections] used primarily to treat severe infections) on 3/24/2026, after the physician was made aware that vancomycin use did not meet the criteria for Resident 15's antibiotic use. This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate medical care information and the potential to result in confusion in the care and services for Residents 15 Findings: During a review of Resident 15's Face Sheet , the Face Sheet indicated the facility admitted Resident 15 on 10/16/2025, with diagnoses including unspecified elevated white blood cell count (WBC-the immune system cells that fight infections), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (HTN-high blood pressure). During a review of Resident 15's Physician Order, dated 3/21/2026, the Physician order indicated an order for vancomycin hydrochloride oral suspension (a liquid medication where solid particles of the drug are mixed into a liquid but do not fully dissolve) 125 milligram (mg- metric unit of measurement, used for medication dosage and/or amount)/ five milliliter (ml-unit of measurement) by mouth daily for clostridium difficile (C-diff, a highly contagious bacteria that causes severe diarrhea) prophylaxis (treatment or actions taken to prevent a disease) for 14 days. During a review of Resident 15's Minimum Data Set (MDS-a resident assessment tool) dated 3/23/2026, the MDS indicated Resident 15's cognitive skills for daily decisions were intact. During a review of Resident 15's Antibiotic Time Out, dated 3/24/2026, the Antibiotic Time Out indicated Resident 15 did not have an active infection and had culture (a test to find germs that can cause an infection) result positive for vancomycin resistant enterococci (VRE- a type of antibiotic-resistant bacteria often acquired in healthcare settings). The Antibiotic Time Out indicated the Infection Preventionist Nurse (IPN) notified Family Member 3 (FM 3), but FM 3 wanted the vancomycin to be continued until completed. During a review of Resident 15's MAR, dated 3/2026, the MAR indicated Resident 15 received the vancomycin from 3/22/2026, to 3/31/2026. During an interview on 4/11/2026, at 7 a.m., with the IPN, the IPN stated Resident 15 had VRE and had an order for vancomycin for C-diff prophylaxis. The IPN stated since Resident 15 had VRE, Resident 15's vancomycin would not be effective, and he (Resident 15) should not be on vancomycin. The IPN stated Resident 15 did not meet the criteria for the use of vancomycin. The IPN stated she (IPN) called the physician on 3/24/2026, and the physician initially discontinued the vancomycin but after notifying FM 3, FM 3 wanted the vancomycin to be continued so she (IPN) had called the physician and the physician agreed to continue the vancomycin. The IPN stated she (IPN) did not document that the physician initially discontinued the vancomycin. The IPN stated she (IPN) should have documented in Resident 15's medical record the complete physician conversation. The IPN stated the failure was to not completely document physician conversation. During an interview on 4/11/2026, at 9:17 a.m., with the Director of Nursing (DON), the DON stated IPN should have documented in Resident 15's medical record the entire conversation with the physician that the physician initially discontinued the vancomycin and was continued due to FM 3's request. The DON stated Resident 15's medical record should be complete and accurate. During a review of facility's policy and procedure (P&P), titled, Charting and Documentation, dated 12/2025, and last reviewed on 3/17/2026, the P&P indicated, The purpose of this procedure is to provide: 1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, as well as the progress of the resident's care. 2. Guidance to the physician in prescribing appropriate medications and treatments. 3. The facility, as well as other interested parties, with a tool for measuring the quality of care provided to the residents. 4. Nursing service personnel with a record of the physical and mental status of the residents. 5. Assistant in the development of a Plan of Care for each resident. 6. The elements of quality medical nursing care. 7. A legal record that protects the resident, physician, nurse, and the facility. 8. A source of all resident charges. Charting Requirement: . Attempted and/or completed communication with physician.

Based on observation, interview, and record review, the facility failed to ensure at least 80 square (sq.) feet (ft.) per resident was provided for ten (10) of 23 resident rooms (room [ROOM NUMBER], 103, 105, 107, 110, 112, 115, 117, 119, and 121). This deficient practice had the potential to result in inadequate useable living space for all the residents and inadequate working space for the health caregivers. Findings: During the recertification survey from 4/11/2026 to 4/12/2026, the residents residing in rooms 101, 103, 105, 107, 110, 112, 115, 117, 119, and 121 were observed with sufficient amount of space for residents to move freely inside the rooms. There was adequate room for the operation and use of wheelchairs, walkers, or canes. The room variance did not affect the care and services provided by nursing staff for the residents. During a review of the Request for Room Variance Waiver letter dated 4/11/2026, submitted by the Administrator (ADM), the letter indicated the rooms (101, 103, 105, 107, 110, 112, 115, 117, 119, and 121) did not meet the 80 sq. ft. requirement per federal regulation. The letter indicated that no residents in the rooms are hindered, nor adversely affected by the limited room size. During a review of the document titled, Client Accommodations Analysis dated 4/11/2026, submitted by the facility, indicated the following rooms with their corresponding measurements: Room # No. # of beds Total sq. ft./total sq. ft. per resident 101 2 155/ 77.5 103 2 155/ 77.5 105 2 155/ 77.5 107 2 155/ 77.5 110 4 310/77.5 112 4 310/77.5 115 2 157/78.5 117 2 157/78.5 119 2 157/78.5 121 2 157/78.5 During the resident council (a group of nursing home residents who meet regularly to discuss their rights, quality of care, and quality of life) meeting on 4/11/2025 at 1:30 p.m., no concerns were brought up by the residents regarding the size of the rooms. During multiple room observations conducted in rooms 101, 103, 105, 107, 110, 112, 115, 117, 119, and 121 from 4/11/2026 to 4/12/2026, between the hours of 7:00 a.m. to 6:30 p.m., it was observed that nursing staff had adequate space to provide care to the residents. During a review of facility's policy and procedure (P&P) titled, Resident Rooms, reviewed on 3/17/2026, P&P indicated that it is a policy of the facility that a resident room must. measure at least 80 sq. ft per resident in multiple resident bedrooms, and at least 100 sq. ft in a single resident room.

Based on interview and record review, the facility failed to ensure the facility's Registered Dietitians (RD) conducted a nutrition-focused physical assessment (a physical exam that RDs perform to assess nutritional status or evaluate malnutrition [lack of sufficient nutrients in the body]) by not speaking to residents or residents' family members/representatives and by not physically assessing residents during the Nutrition Evaluation and Registered Dietician Nutritionist (RDN) Review for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential to result in inaccurate nutrition assessments, and ineffective nutrition intervention and goals for Resident 1 and Resident 2 who are on hemodialysis (a life-saving medical procedure that filters waste, toxins, and excess fluid from the blood when kidneys [organs located in the lower back that act as the body's primary filtration system] have failed).Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/29/2025 with diagnoses that included end stage renal disease (ESRD- kidneys have severely deteriorated and can no longer function adequately to filter waste products and excess fluid from the blood), type two (2) diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), moderate protein- calorie malnutrition (a nutritional disorder occurring when a person does not consume enough protein and calories to meet their body's needs), and dependence on renal dialysis (hemodialysis- a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/4/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the sense) was moderately impaired. The MDS indicated Resident 1 required set up or clean up assistance from staff with eating, required supervision or touching assistance with oral hygiene and personal hygiene, and required substantial/maximal assistance with toileting hygiene. During a review of Resident 1's care plan (a document that summarizes a resident's needs, goals, and care/treatment) for risk for nutrition problem or potential nutritional problem related to chronic kidney disease (kidneys are damaged and gradually lose their ability to filter waste and extra fluid from your blood over a long period, usually months or years) with hemodialysis, ESRD, DM, and moderate protein-calorie malnutrition, initiated on 10/29/2025, the care plan indicated an intervention for the Registered Dietician (RD) to evaluate and make diet change recommendations as needed (PRN). During a concurrent interview and record review on 3/11/2026 at 2:50 p.m., with the Dietary Supervisor (DS), reviewed Resident 1's Nutrition Evaluation and Registered Dietician Nutritionist (RDN) Review dated 10/31/2025 timed at 8:57 a.m. The DS stated that residents' dietary evaluations are done within seven days of admission. The DS stated that the Nutrition Evaluation is conducted in two parts. The DS stated that within the first three days of the resident's admission, the DS will interview the resident to obtain the resident's food likes and dislikes, allergies, and what residents prefer for breakfast, lunch, and dinner. The second part of the evaluation is when the Registered Dietician does their part of the evaluation and writes their recommendations based on the information gathered by the DS. The DS reviewed Resident 1's Nutrition Evaluation and RDN Review dated 10/31/2025 timed at 8:57 a.m. and stated that the DS performed the Dietary Evaluation portion and Registered Dietician 1 (RD 1) conducted the RDN Nutritional Assessment/Evaluation portion of the review. The DS stated that RD 1 does not meet and speak with the residents to perform a nutrition focused physical assessment. During an interview on 3/12/2026 at 10:25 a.m., with RD 1, RD 1 stated that she is one of the contracted RDs of the facility. RD 1 stated that she conducts her assessments through a thorough chart review reviewing residents' diagnosis, orders, medication, lab results, oral intake, height and weight. RD 1 stated that she does not enter the facility because she works remotely. RD 1 stated that RD 2 is the RD that visits the facility every Thursday. RD 1 continued to state that RD 1 does not perform nutrition focused physical assessments with the residents in the facility and that RD 1 conducts her assessments and evaluations based on the information gathered by the DS since the DS meets and speaks to the residents. RD 1 stated that she does not speak to the residents or residents' family nor does she physically see residents in the facility. RD 1 further stated that RD 1's assessment and evaluations are solely based on record review. b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/27/2026 with diagnoses that included ESRD, DM, and dependence on renal dialysis. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognition was moderately impaired. The MDS indicated Resident 2 required set up or clean up assistance from staff with eating, required supervision or touching assistance with oral hygiene, and required substantial/maximal assistance with toileting hygiene. During a review of Resident 2's care plan for nutrition problem or potential nutritional problem related to diabetes and chronic kidney disease with hemodialysis, revised on 3/10/2026, the care plan indicated an interventions for the RD to evaluate and make diet change recommendations PRN. During an interview on 3/12/2026 at 11:22 a.m., with the Administrator (ADM), the ADM stated that the facility's RDs are contracted and RD 2 is the RD that comes to the facility every Thursday. During a follow-up interview on 3/12/2026 at 12:11 p.m., with RD 1, RD 1 stated that she (RD 1) does not come into the facility to conduct nutritional-focused physical assessments because RD 1's contract indicates that she is to do remote work only. RD 1 stated that RD 2 goes into the facility every week and if the facility needs a registered dietician, the DS is in the facility to inform RD 1 or RD 2 of any concerns. RD 1 continued to state that a face-to-face nutrition-focused physical assessment is not necessary because RD 1 goes through nursing notes, lab results, and oral intake which gives RD 1 an overall picture of the resident. RD 1 stated that it will not make a difference whether RD 1 is in the facility or working remotely. RD 1 continued to state that during a record review of residents' medical records, if there is anything that concerns RD 1, she will inform RD 2 or the DS so that RD 2 or the DS can check on it. When asked if RD 1 should check on concerns herself, RD 1 stated that it is not necessary because there are people there in the facility to check for her. During a concurrent interview and record review on 3/12/2026 at 3:03 p.m., with RD 2, reviewed Resident 2's Nutrition Evaluation and RDN Review dated 2/28/2026 timed at 12:41 p.m. RD 2 stated that she (RD 2) is a contracted RD that comes into the facility every Thursday. RD 2 stated on Thursdays when RD 2 arrives at the facility she will receive a list of new admissions. RD 2 stated that she will go through the list of new admissions and will prioritize high risk residents such as residents on tube feeding (a form of nutrition that is delivered into the digestive system as a liquid) or on dialysis. RD 2 stated that she does a thorough record review of the residents' medical record, reviewing residents' diets, lab results, medical diagnosis, any weight gain or weight loss and RD 2 will discuss with the Interdisciplinary Team (IDT- a group of healthcare professionals from different disciplines who work together to plan and provide care for a resident) to come up with a suitable plan for the resident. RD 2 continued to state that residents in the facility do not stay long term anyway and it is not necessary for RD 2 to do a face-to-face assessment with the residents. RD 2 stated that the DS is there five days per week, and if there are any concerns that the DS cannot address then the DS reports to RD 1 or RD 2. When asked how RD 1 is able to do an assessment remotely, RD 2 stated that RD 1 knows exactly what RD 1 is doing because she is highly educated and she does not need to do a face-to-face assessment. RD 2 reviewed Resident 2's Nutrition Evaluation and RDN Review dated 2/28/2026 timed at 12:41 p.m. RD 2 stated that Resident 2 is on dialysis and should have been seen and evaluated by RD 2. When asked if RD 2 has seen and assessed Resident 2, RD 2 stated that RD 2 has not assessed Resident 2 because Resident 2 is on dialysis every Tuesday, Thursday, and Saturday and when RD 2 is at the facility on Thursdays, Resident 2 is not in the facility. When asked if Resident 2 will be seen by RD 2 because Resident 2 is a high risk resident on dialysis, RD 2 did not answer. RD 2 stated that RD 1 assessed Resident 2 and documented on the Nutrition Evaluation and RDN Review dated 2/28/2026. When asked about the standards of practice of a registered dietitian and what entails a nutrition-focused physical assessment, RD 2 did not answer. During an interview on 3/12/2026 at 3:51 p.m., with the Director of Nursing (DON), the DON stated that RD 1 works remotely and RD 2 comes to the facility every Thursday. The DON stated that RD 2 is expected to check on and assess newly admitted residents. The DON stated that ideally an assessment should be done in person to get the best clinical picture of the resident. The DON continued to state that residents in the facility are short term residents and they don't have too many health problems, so for the DON it is ok that RD 1 assesses residents remotely through a thorough record review. During a follow-up interview on 3/12/2026 at 4:30 p.m., with the DS, the DS stated that it is important to conduct a nutrition-focused physical assessment because is important for the RD to see how a resident eats, how the resident chews, observes skin integrity, and to give the RD an overall clinical picture of the residents. During a review of the facility's policy and procedure (P&P) titled, Nutrition Care Management, reviewed 2/17/2026, the P&P indicated under purpose: to provide care and services including assessing the resident's nutritional status and the factors that put the resident at nutrition/hydration risk; Defining and implementing interventions for maintaining or improving nutritional hydration status that are consistent with resident needs, goals, and recognized standards of practice. Under Clinical Evaluation.: 1. Nutritional Assessment may include: Functional status (assistive devices, cues, hand-overhand, extensive assistance); Oral health (oral cavity lesions, mouth pain, decayed teeth, poorly fitting dentures); Chewing and swallowing problems; Affective and behavioral disorders; Hypermetabolic states (continuous wandering, skin breakdown) During a review of the facility's job description titled, Dietician, dated 12/27/2021, the job description indicated the primary purpose of the job description position is to plan organize develop and direct the overall operation of the dietary department in accordance with current federal state and local standards guidelines and regulations governing the facility and as may be directed by the administrator to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean safe and sanitary manner. Visit residents periodically to evaluate the quality of meals served, likes and dislikes, etc. Encourage the resident/family to participate in the development and review of residents plan of care. During a review of the facility's contract with the Registered Dieticians titled, Independent Service Agreement, dated 2/19/2025, the contract indicated service provider will prepare complete records of all services with complete, legible, and accurate progress notes and observations in accordance with the requirements of all applicable federal and state agency requirements and by Facility policies and procedures. During a review of the Academy of Nutrition and Dietetics' Nutrition Care Process titled, NCP Step 1: Nutrition Assessment, the document indicated, Nutrition assessment is a systematic approach to collect, classify, and synthesize important and relevant data (indicator) needed to identify nutrition-related problem and their causes. This step also includes reassessment for comparing and re-evaluating data from previous interaction to the next and collection of new data that may lead to new revised nutrition diagnoses based on the client status or situation. Finding Nutrition Assessment Data: For individuals, data can come directly from the client through interview, observation and measurements, a health record, and the referring health care provider. During a review of the Academy of Nutrition and Dietetics' Nutrition Care Process titled, NCP Step 3: Nutrition Intervention, the document indicated, Nutrition intervention goals, ideally, developed collaboratively with the client, provide the basis for monitoring progress and measuring outcomes. Planning the nutrition intervention involves: Collaborating with the client to identify goals of the intervention for each diagnosis. Implementation is the action phase and involves: Collaborating with the client to carry out the plan of care. During a review of the Academy of Nutrition and Dietetics' Nutrition Care Process titled, NCP Step 4: Nutrition Monitoring and Evaluation, undated, the document indicated, During the first interaction, appropriate outcomes/indicators are selected to be monitored and evaluated at the next interaction with the client. During subsequent interactions, these outcomes /indicators are used to demonstrate the amount of progress made and whether the goals or expected outcomes are being met.

Based on interview and record review, the facility failed to implement the facility's policy on intake and output (I &O- the tracking of all fluids that enter (intake) and leave (output) a resident's body over a set period, usually 24 hours) by failing to monitor and ensure residents on fluid restrictions (a medically prescribed diet limiting total daily liquid consumption) did not exceed their fluid restriction volume for two of three sampled residents (Resident 2 and resident 3). This deficient practice had the potential to cause fluid overload (condition where you have too much fluid volume in your body) for Resident 2 and Resident 3. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/27/2026 with diagnoses that included end stage renal disease (kidneys have severely deteriorated and can no longer function adequately to filter waste products and excess fluid from the blood), type two (2) diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 3/5/2026, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the sense) was moderately impaired. The MDS indicated Resident 2 required set up or clean up assistance from staff with eating, required supervision or touching assistance with oral hygiene, and required substantial/maximal assistance with toileting hygiene. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated an order for 1,500 milliliters (mL- unit of measurement) fluid restrictions. Breakdown as follows: AM/ Nursing: 360 mL; AM/ Dietary: 240 mL; PM/ Nursing: 360 mL; Lunch Meal Dietary: 120 mL; Noc (11:00 p.m.-7:00 a.m.)/ Nursing: 180 mL; Dinner/ Dietary: 240 mL, order date 2/27/2026. During a review of Resident 2's care plan (CP-a document that summarizes a resident's needs, goals, and care/treatment) for dialysis, revised on 3/10/2026, the CP indicated under intervention for 1,500 mL fluid restrictions. Breakdown as follows: AM/ Nursing: 360 mL; AM/ Dietary: 240 mL; PM/ Nursing: 360 mL; Lunch Meal Dietary: 120 mL; Noc/ Nursing: 180 mL; Dinner/ Dietary: 240 mL, order date 2/27/2026. During a concurrent interview and record review on 3/12/2026 at 9:00 a.m., with the Assistant Director of Nursing (ADON), reviewed Resident 2's physician's orders, Resident 2's CNA fluid intake documentation from 3/1/2026-3/11/2026, and Resident 2's Intake and Output Record from 3/1/2026-3/11/2026. The ADON stated that when residents are on fluid restrictions, licensed nurses and Certified Nursing Assistants (CNAs) will monitor all fluids consumed by residents. The ADON stated the licensed nurses will document residents' fluid consumption that the licensed nurses provided on an Intake & Output Record and CNAs will document fluids that CNAs provided on the CNA tasks, under fluid intake on the electronic health record. The ADON stated that fluids given by both licensed nurses and CNAs should be added together at the end of each shift and should be equal to or less than the amount of the fluid restriction in a 24-hour period. The ADON reviewed Resident 2's physician's orders and stated that Resident 2 is on a 1,500 mL fluid restriction daily. The ADON reviewed Resident 2's CNA fluid intake documentation from 3/1/2026-3/11/2026 and stated that on the following days Resident 2 received the following mLs of fluid from CNAs:- 3/1/2026: 1,800 mL- 3/2/2026: 1,300 mL- 3/3/2026: 1,100 mL- 3/4/2026: 920 mL- 3/5/2026: 1,350 mL- 3/6/2026: 550 mL- 3/7/2026: 1,400 mL- 3/8/2026: 1,850 mL- 3/9/2026: 2,200 mL- 3/10/2026: 1,180 mL- 3/11/2026: 915 mLThe ADON reviewed Resident 2's Intake and Output Record from 3/1/2026-3/11/2026 and stated that on the following days Resident 2 received the following mLs of fluid from licensed nurses:- 3/1/2026: 1,300 mL- 3/2/2026: 1,300 mL- 3/3/2026: 850 mL- 3/4/2026: 1,400 mL- 3/5/2026: 800 mL- 3/6/2026: 1,100 mL- 3/7/2026: 850 mL- 3/8/2026: 850 mL- 3/9/2026: 1,100 mL- 3/10/2026: 980 mL- 3/11/2026: 1,100 mLThe ADON stated that in a 24-hour period Resident 2 received a total of:- 3,100 mL on 3/1/2026.- 2,600 mL on 3/2/2026.- 1,950 mL on 3/3/2026.- 2,320 mL on 3/4/2026.- 2,150 mL on 3/5/2026.- 1,650 mL on 3/6/2026.- 2,250 mL on 3/7/2026.- 2,700 mL on 3/8/2026.- 3,300 mL on 3/9/2026.- 2,160 mL on 3/10/2026.- 2,015 mL on 3/11/2026. During a follow-up interview on 3/12/2026 at 9:46 a.m., with the ADON, the ADON stated that fluids provided by licensed nurses and from the kitchen should be the only fluids offered to residents on fluid restrictions. The ADON continued to state that CNAs should be informing license nurses prior to offering or providing fluids to residents with fluid restrictions for proper monitoring. The ADON stated that the facility failed to monitor Resident 2's intake per physician's order. The ADON further stated that licensed nurses should be communicating with one another, especially during huddle to remind CNAs on which residents are on fluid restrictions to accurately monitor fluid intake. b. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 2/3/2026 with diagnoses that included but not limited to end stage renal disease, dependence on renal dialysis, and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). During a review of Resident 3's Minimum Data Set, dated [DATE], the MDS indicated Resident 3 had moderately intact cognitive skills for daily decision making. The MDS indicated Resident 3 required supervision with oral hygiene and partial/moderate assistance with personal hygiene and substantial/maximal assistance with toileting and showering. During a review of Resident 3's Order Summary Report, active as of 3/11/2026, the Order Summary Report indicated an order for 1,000 mL fluid restriction broken down into breakfast, lunch, and dinner. During a review of Resident 3's CP, initiated 2/27/2026, the CP indicated Resident 3 was on dialysis related to ESRD. The CP indicated an intervention for 1,000 mL fluid restriction broken down into breakfast, lunch, and dinner. During a review of Resident 3's Dietary Evaluation dated 2/6/2026, the Dietary Evaluation indicated Resident 3 was on fluid restriction of 1,000 mL broken down into breakfast, lunch, and dinner and that Resident 3's PO (by mouth) intakes were monitored. During a review of Resident 3's CNA tasks dated 2/11/2026 to 3/11/2026, the CNA tasks indicated Resident 3's daily fluid intake was over the 1,000 mL fluid restriction on the following dates:- On 2/12/2026, total of 1,150 mL- On 2/13/2026, total of 1,100 mL- On 2/14/2026, total of 1,050 mL- On 2/17/2026, total of 1,200 mL- On 2/18/2026, total of 1,050 mL- On 2/19/2026, total of 1,150 mL- On 2/20/2026, total of 1,050 mL- On 3/2/2026, total of 1,220 mL- On 3/5/2026, total of 1,050 mL During a concurrent interview and record review on 3/12/2026 at 2:03 p.m., with the ADON, reviewed Resident 3's CNA fluid intake record from 2/11/2026 to 3/11/2026. The ADON stated that Resident 3 received more fluids than Resident 3 should have consumed on 2/12/2026, 2/13/2026, 2/14/2026, 2/17/2026, 2/18/2026, 2/19/2026, 2/20/2026, 3/2/2026, and 3/5/2026. The ADON stated licensed nurses should have monitored Resident 3's fluid intake to not exceed 1,000 ml. The ADON stated that it is important to ensure all residents on fluids restrictions are monitored to ensure complications do not happen such as shortness of breath and fluid overload, and to avoid unwanted transfers to the hospital. The ADON stated proper monitoring, and documentation should have been done. During a review of the facility's policy & procedure (P&P) titled, Intake and Output, reviewed 2/17/2026, the P&P indicated it is the policy of this facility to maintain an intake and output record when needed to monitor residents for adequate fluid balance intake and output shall be recorded by each shift. Purpose: to provide an accurate record of the resident's fluid intake and output. Measuring Intake: Place daily I & O sheet in resident's room. Nursing assistants will document fluids (in cubic centimeters [cc- unit of measurement]) consumed in appropriate area of I & O sheet for each shift. Monitor and record fluid from diet trays and from water pitcher at bedside. Licensed staff will document all fluids (in cc's) consumed by resident while taking medications in the I & O sheet. Documentation: 3-11 shift will collect all I & O sheets at the end of shift and replace with a new one for the next day. Data recorded on the I & O sheets from the bedside will be recorded on the resident's permanent I&O sheet in their medical record. Intake for a twenty-four (24) hour period shall be totaled by the 3-11 shift each day.

Based on observation, interview, and record review, the facility failed to follow proper food handling and storage practices by failing to ensure: 1. A clear plastic bag containing a cup of food brought by family member for a resident was labeled with a date for when it was brought into the facility. 2. A clear plastic container of strawberries did not have visible black/green discoloration consistent with mold-like (type of fungus) substance present on several strawberries stored inside one of three sampled refrigerators (Refrigerator 2). 3. An opened package of hamburger buns was labeled with an open date stored inside one of three sampled refrigerators (Refrigerator 3).These deficient practices had the potential to place 45 of 45 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).Findings: During a concurrent observation and interview on 3/11/2026 at 10:00 a.m., with the Dietary Supervisor (DS), observed the following in the facility' s kitchen: - An undated clear plastic bag containing a cup for food brought by family, labeled with a resident's room number stored on the bottom shelf inside Refrigerator 2. - A clear plastic container of strawberries dated 2/27/2026 with visible black/green discoloration consistent with mold-like (type of fungus) substance present on several strawberries stored inside Refrigerator 2.- An opened package of hamburger buns without an open date indicated on the package stored inside Refrigerator 3.The DS stated that food brought for residents was being stored in a closed container inside Refrigerator 2. The DS stated food prepared and cooked by family members for residents was also being stored inside the refrigerator and should be discarded after 24 hours for the safety of the residents. The DS stated the strawberries were not checked for any spoilage or mold. The DS stated staff should check that food items are fresh and safe to use and if not, should be discarded. The DS stated the hamburger buns did not have an open date label and stated that food items should have an open date label to follow guidelines on when to use the food item by. During a review of the facility's policy and procedure (P&P) titled, Foods brought by family or visitor, revised 1/26/2024, the P&P indicated, Perishable prepared foods will be checked by the designee dietary staff and discarded after 24 hours of storage. Resident food shall be stored in the facility kitchen. Resident food stored in the facility kitchen will be easily distinguishable from facility food. All foods shall be labeled with the resident name, location and date. During a review of the facility's P&P titled, Storing Produce, undated, the P&P indicated, Check boxes of fruit and vegetables for rotten, spoiled items. Throw away spoiled items upon delivery. During a review of the facility's P&P titled, Labeling and dating of foods, undated, the P&P indicated, For foods that are commercially processed, ready to eat and intended to be stored cold greater than 24 hours will be marked with a use by date.The use by date signifies the date in which food must be consumed or discarded.

Based on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 2) with meals that accommodated their food preferences. This deficient practice resulted in Resident 2's food preferences not being honored and had the potential to result in decreased meal intake which could lead to weight loss and malnutrition (lack of sufficient nutrients in the body).Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/27/2026 with diagnoses that included end stage renal disease (kidneys have severely deteriorated and can no longer function adequately to filter waste products and excess fluid from the blood), type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 3/5/2026, the MDS indicated Resident 2's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and sense) was moderately impaired. The MDS indicated Resident 2 required set up or clean up assistance from staff with eating, required supervision or touching assistance with oral hygiene, and required substantial/maximal assistance with toileting hygiene. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated an order for consistent carbohydrate diet (CCHO - helps control blood sugar levels)/renal diet (designed for individuals with chronic kidney disease [a condition where the kidneys gradually lose their ability to filter waste products and excess fluid from the blood]) regular/thin liquid consistency with meals, ordered 2/27/2026. During a review of Resident 2's care plan (a document that summarizes a resident's needs, goals, and care/treatment) for nutrition problem or potential nutritional problem related to diabetes and chronic kidney disease with hemodialysis, revised on 3/10/2026, the care plan indicated an intervention to honor resident rights to make personal dietary choices. During a review of Resident 2's meal card, the meal card indicated added food for lunch: soup. During a review of Resident 2's Nutrition Evaluation and Registered Dietician Nutritionist (RDN) Review dated 2/28/2026 timed 12:41 p.m., the Nutrition Evaluation and RDN Review indicated under preference, Resident 2 likes soup for lunch. During a concurrent observation, interview, and record review on 3/11/2026 at 12:48 p.m., with the Director of Nursing (DON) in Resident 2's Room, observed Resident 2's lunch tray. The DON stated that Resident 2 does not have soup served. The DON reviewed Resident 2's meal card and stated that Resident 2 should have soup served because Resident 2's meal card indicated that Resident 2 should have soup for lunch. During an interview on 3/12/2026 at 2:50 p.m. with the Dietary Supervisor (DS), the DS stated that kitchen staff are supposed to follow what is on residents' meal tickets at all times. The DS stated it is important to follow what is on residents' meal tickets because kitchen staff need to follow and honor residents' preferences and choices. The DS continued to state that the facility failed to honor Resident 2's food preference by failing to serve Resident 2's soup during lunch. The DS continued to state that by not serving Resident 2's preference of soup, the kitchen staff did not honor Resident 2's rights. During a review of the facility's policy and procedure (P&P) titled, Food Preferences, last reviewed 2/17/2026, the P&P indicated resident's food preferences will be adhered to within reason. Food preferences will be obtained as soon as possible through the initial resident screen. The screening must be completed within seven (7) days of admission by the Food & Nutrition Service (FNS) Director.

Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) confidential personal information was protected when a copy of Resident 1's Discharge Summary and Post-Discharge Plan of Care was given to Resident 2. This deficient practice violated Resident 1's rights and resulted in the unauthorized exposure of Resident 1's confidential information.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 10/22/2025 and readmitted the resident on 11/13/2025 with diagnoses that included sepsis (a potentially life-threatening condition that occurs when the body's extreme response to an infection causes injury to its own tissues and organs), Non-Hodgkin lymphoma (a type of blood cancer originating in white blood cells within the immune system, often causing swollen lymph nodes, fever, night sweats, and weight loss), and hypotension (low blood pressure). During a review of Resident 1's Admitting Evaluation History and Physical dated 11/14/2025, the Admitting Evaluation History and Physical indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/19/2025, the MDS indicated Resident 1 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a review of Resident 1's Discharge Summary and Post-Discharge Plan of Care dated 12/23/2025, the Discharge Summary and Post-Discharge Plan of Care contained the following information:- Resident 1's full name, date of birth , and dates of admission to the facility.- A recapitulation of Resident 1's stay that included the reason for admission, treatment provided, discharge date , reason for discharge, and final diagnosis.- The final summary of Resident 1's status that included cognitive status, physical function, nutritional status, and Resident 1's height and weight.- The post discharge plan of care that included Resident 1's home address, phone number, physician name and phone number, home health agency name and phone number, and medical equipment ordered. During a review of a facility letter sent to Resident 1 dated 12/31/2025, the facility letter indicated that on 12/24/25, the facility was made aware that Resident 1's discharge summary and discharge plan of care was mistakenly given to another discharging resident. The facility letter further indicated the information included Resident 1's full name, date of birth , admission date, address, discharge date , diagnosis, phone number, reason for admission to the facility, physician order for home health, height, weight, and reason for discharge. During an interview on 1/26/2026 at 9:50 a.m., with the Patient Concierge (PC), the PC stated on 12/24/2025 she received a phone call from Resident 2's husband. The PC stated that Resident 2's husband called to inform her (PC) that Resident 1's discharge papers were included with Resident 2's discharge paperwork. The PC stated she immediately reported the information to the medical records department. During an interview on 1/26/2026 at 10:08 a.m., with the Medical Records Assistant (MRA), the MRA stated that on 12/24/2025 she was informed by the PC that Resident 1's discharge paperwork was accidentally given to Resident 2. The MRA stated the medical records department does not print the discharge paperwork for discharges, the nurses print the discharge paperwork themselves. During an interview on 1/26/2026 at 10:50 a.m., with the Infection Prevention Nurse (IP), the IP stated that on 12/24/2025 she was working as the Registered Nurse (RN) supervisor for the 7:00 a.m. to 3:00 p.m. shift because the RN supervisor who was supposed to work that shift had called off. The IP stated part of her job duties that day included discharging several residents. The IP stated that the night shift usually prepares and prints out the discharge paperwork for the discharges scheduled for the following day and will place the printed discharge papers in the residents' physical charts. The IP stated when she was discharging Resident 2, she pulled out the discharge papers from Resident 2's physical chart and only reviewed the first few pages and ensured that the face sheet and medication list matched Resident 2's name. The IP stated she did not check all of the pages of the discharge paperwork and was unaware that Resident 1's discharge paperwork was part of the paperwork given to Resident 2. The IP stated she should have reviewed each document carefully to ensure the right documents were given to the right resident. The IP stated that by accidentally giving Resident 1's discharge paperwork to Resident 2, she violated patient confidentiality and disclosed Resident 1's private health information to Resident 2. During an interview on 1/26/2026 at 11:16 a.m., with the Director of Nursing (DON), the DON stated the IP accidentally included Resident 1's Discharge Summary and Post-Discharge Plan of Care with Resident 2's discharge paperwork. The DON stated that the IP should have checked every document to ensure all of the documents being provided to Resident 2 were actually for Resident 2. The DON stated that giving Resident 1's Discharge Summary and Post-Discharge Plan of Care to Resident 2 was a Health Insurance Portability and Accountability Act (HIPAA - a federal law designed to protect the privacy and security of patient health information) violation. During a review of the facility's undated policy and procedure titled, Resident/Patient Confidentiality, the policy indicated it is the policy of the facility to ensure all resident health information is confidential and protected by HIPAA Law. The policy and procedure further indicated all staff, volunteers, and vendors must not disclose any medical information about a resident, either verbally, written or electronically and that only legal authorization allows any medical information to be released.

Based on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure Physical Therapist 1 (PT 1) wore an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) while providing physical therapy (PT) services in bed for one of one sampled resident (Resident 1) who was on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes).This deficient practice had the potential to increase the risk of spreading infection to other residents and staff. Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 11/19/2025 with diagnoses including right femur (thigh bone) fracture (broken bone), urinary tract infection (UTI - an infection in the bladder/urinary tract), and extended spectrum beta-lactamase (ESBL - enzymes [proteins that help speed up metabolism] produced by bacteria that make them resistant to antibiotics). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 11/22/2025, the MDS indicated that Resident 2 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and Resident 2 was dependent on staff with toileting hygiene, shower/bathe, upper/lower body dressing, bed mobility (movement), and transfer.During a record review of Resident 2's Order Summary Report, the Order Summary Report indicated the following:- EBP: PPE required for high resident contact care activities. Indication - Indwelling catheter (a thin flexible tube inserted into the urethra to drain the bladder)/MDRO urine, ordered 11/20/2025.- Indwelling catheter care every shift for obstructive uropathy (OU - a condition in which the flow of urine is blocked), ordered 11/19/2025.- Skilled PT orders: PT evaluation and treatment daily five times per week for four weeks to address difficulty walking. Resident may receive therapeutic exercises and therapeutic activities, ordered 11/20/2025.During a concurrent observation and interview on 12/5/2025 at 2 p.m., with PT 1, observed EBP signage on the wall next to Resident 2's room door. Observed Resident 2 lying in bed, and PT 1 stated that he (PT 1) was going to provide range of motion (ROM - the full movement potential of a joint, or a series of joints, in any direction) exercise to Resident 2. PT 1 started to provide ROM exercise to Resident 2, but PT 1 wore gloves and a surgical face mask only and did not wear an isolation gown.During a concurrent observation and interview on 12/5/2025 at 2:07 p.m., with the Infection Preventionist (IP), observed the EBP signage for Resident 2 and observed PT 1 inside Resident 2's room and providing PT services to Resident 2. The IP stated that PT 1 should wear an isolation gown while providing PT services for Resident 2.During an interview on 12/5/2025 at 2:10 p.m., with PT 1, PT 1 stated that he (PT 1) provided ROM exercises to Resident 2 and then repositioned Resident 2's body. When PT 1 was asked what PPE he should wear before starting PT services for Resident 2, PT 1 stated that he was supposed to wear an isolation gown and gloves, but PT 1 did not wear the gown. When PT 1 was asked why staff should follow and wear the required PPE with EBP signage, PT 1 stated it was to prevent spreading germs and to protect the residents and staff. During an interview on 12/5/2025 at 4:29 p.m., with the Director of Nursing (DON), the DON stated that staff should wear isolation gowns and gloves when providing services that required high contact with residents on EBP to prevent spreading germs around. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention Control Program (IPCP) Transmission-Based Precautions (TBP - used to help stop the spread of germs from one person to another), last reviewed 4/2025, the P&P indicated, It is the policy of this facility to implement infection control measures to prevent the spread of communicable disease and conditions. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. Examples of high-contact resident care activities requiring gown and gloves use for EBP include: Dressing, bathing/showering, transferring, providing hygiene.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident`s dignity and respect in full recognition of their individualities for one of one sampled resident (Resident 26) when Certified Nursing Assistant 2 (CNA 2) was standing over the resident while assisting him during a meal. This deficient practice had the potential to negatively affect the resident`s psychosocial wellbeing and loss of dignity. Findings: During a review of Resident 26's Admission Record (face sheet), the Admission Record indicated that the facility originally admitted the resident on 3/28/2024, and readmitted on [DATE], with diagnoses including Parkinson`s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dysphagia (difficulty swallowing), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and need for assistance with personal care. During a review of Resident 26's Nutrition/Hydration Risk Evaluation form dated 3/18/2025, the evaluation indicated that the resident was slow to response and required verbal cues to feed himself. During a concurrent observation and interview on 3/29/2025 at 7:50 a.m., inside Resident 26`s room, Certified Nursing Assistant 2 (CNA 2) was standing over Resident 26 while feeding him. CNA 2 stated that she always stands over residents and feed them because it is easier for her. During a concurrent observation and interview on 3/29/2025 at 7:52 a.m. with MDS Coordinator 1 (MDSC 1), inside Resident 26`s room, MDSC 1 observed CNA2 standing over Resident 26 while assisting him with his breakfast. MDSC 1 stated staff are able to assist the residents with feeding in standing or sitting positions. During an interview on 3/29/2025 at 8:00 a.m., with the Director of Nursing (DON), the DON stated staff are required to assist residents with feeding in a sitting position so they can maintain their dignity. During a review of facility`s Policy and Procedure (P&P) titled Feeding the Dependent Resident, last reviewed 1/2025, the P&P indicated that some residents cannot feed themselves because of severe weakness, doctor`s order, or impaired ability so they cannot use their hands. Sit at eye level of the resident. This allows social interaction and better observation if any swallowing difficulty. During a review of facility`s Policy and Procedure (P&P) titled Dignity and Respect, last reviewed 1/2024, the P&P indicated that staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human being.

Based on observation, interview, and record review, the facility failed to maintain privacy of confidential information for one of three sampled residents (Resident 94), when Licensed Vocational Nurse 1 (LVN 1) left Resident 94's electronic health record (EHR- a digital version of a patient's paper chart) open and unattended. This deficient practice violated the resident's right to privacy and confidentiality of medical records. Findings: During a review of Resident 94's Admission Record, the Admission Record indicated that the facility admitted Resident 94 on 3/17/2025 with diagnoses including acute pulmonary edema (a condition where fluid accumulates in the lungs, making it difficult to breathe) and heart failure (occurs when the heart can't pump enough blood to meet the body's needs, leading to symptoms like shortness of breath, fatigue, and swelling). During a review of Resident 94's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/21/2025, the MDS indicated that the resident had the ability to sometimes understand others and the ability to sometimes makes self-understood. The MDS further indicated that Resident 94 is totally dependent on staff for toileting hygiene, shower, lower and upper body dressing. During a concurrent medication pass observation and interview on 3/29/2025 at 4:47 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed LVN 1 left the computer screen open, displaying Resident 94` medication list and photo, while stepping away from the medication cart to enter Resident 94's room. During an interview with LVN 1, LVN 1 stated that she should have ensured that Resident 94`s electronic chart was not accessible to anyone while she stepped away from the computer which was on top of the medication cart. LVN 1 stated that it is a violation of the Health Insurance Portability and Accountability Act (HIPAA) to have the resident's health information visible to unauthorized persons. During a review of The Health Insurance Portability and Accountability Act (HIPAA) of 1996, it indicated the HIPAA Security Rule protects specific information cover the Privacy Rule law applies fully to nursing homes, requiring them to protect the privacy of residents' health information (PHI) by implementing appropriate safeguards, including technical, administrative, and physical measures to prevent unauthorized access, use, or disclosure of this information, particularly electronic protected health information (ePHI). During a review of the facility's policy and procedure (P&P), titled, Pharmacy Services for Nursing Facilities, last reviewed on 1/15/2025, the policy indicated that during administration of medications, the medications cart is kept closed and locked when out of sight of the medication nurse or aide .in addition, privacy is maintained always for all resident information by closing the computer screen when not in use .

Based on interview and record review, the facility failed to ensure licensed nurses provided non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) to one of three sampled residents (Resident 15) prior to administering as needed (prn) opioid ([narcotic-treats moderate to severe pain) pain medication. This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from use of opioids. Findings: During a review of Resident 15's Admission Record, the Admission Record indicated the facility admitted the resident on 1/03/2025 with diagnoses including atrial fibrillation (a heart condition that causes an irregular heartbeat) and pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid). During a review of Resident 15's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/08/2025, the MDS indicated that the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 15 required substantial-to-maximal assistance for showering, toileting and personal hygiene, dressing and chair-to-bed transfer. During a review of Resident 15's physician's orders, the physician's orders indicated the following orders: - Percocet Oral Tablet ([Oxycodone with Acetaminophen] medication used to treat moderate to severe pain) 5-325 milligrams (mg - unit of measurement), give one tablet by mouth every eight (8) hours as needed for severe pain 7-10/10 (numerical scale used to measure pain with 0 being no pain and 10 being the worst pain), ordered on 1/06/2025. - Provide non-pharmacological intervention for pain, including repositioning, quiet environment, relaxation, distraction, music, and massage every shift. During a concurrent interview and record review on 3/29/2025 at 6:30 p.m., with the Director of Nursing (DON), reviewed Resident 15's Medication Administration Record (MAR - a report that serves as a legal record of the drugs administered to a resident at a facility by a health care professional) for the month of 03/2025. The DON verified the dates when Percocet were administered and also verified that there were no non-pharmacologic interventions provided to Resident 15 prior to administration of Percocet on the following dates: 3/20/2025 at 9:18 p.m. 3/21/2025 at 9:45 p.m. 3/26/2025 at 8:45 p.m. The DON stated that non-pharmacologic interventions should be attempted first because the pain might just be caused by Resident 15's position in bed, or other external factors that are causing the pain. The DON stated that when the non-pharmacologic interventions are not effective, then that is the time to administer Percocet. The DON stated that the use of narcotic pain medication such as Percocet can increase the risk of a resident experiencing adverse effects of the medication such as dizziness which can lead to fall and respiratory depression. During a review of Resident 15`s Care Plan (CP-are written tools that outline nursing diagnoses, interventions, and goals) for Acute or Chronic Pain dated 1/03/2025, the CP indicated a goal for the resident to have no interruption in normal activities due to pain through the review date. During a review of the facility's policy and procedure titled, Pain Recognition and Management, last reviewed and revised on 2/2025, the policy and procedure indicated The care plan will include preventative or care interventions (pharmacological and non-pharmacological) to manage and/or prevent pain and consider the resident needs, preferences, and goals .