Every finding on record at Laurel Convalescent Hospital

Based on interview and record review, the facility failed to protect residents from mental abuse (verbal or nonverbal conduct that causes or could cause humiliation, intimidation, fear, shame, or agitation) for one of three sampled residents (Resident 1) when the Administrator (Admin) stopped Resident 1 from sharing her feelings during a complaint discussion, dismissed her stated fears and past experiences, and told her that if she had an issue in the activities room, she should leave the activities. This failure had the potential for Resident 1 to feel intimidated and fearful, limit her participation, and withdrawal from activities.Findings: An unannounced visit was made to the facility on August 5, 2026, at 9:37 AM, to investigate a facility reported incident regarding an allegation of mental abuse. A review of Resident 1's face sheet (a document that gives a summary of resident's information), undated, indicated an admission date of April 6, 2026. Resident 1 had diagnoses that included depression (a long lasting feeling of sadness or loss of interest that makes it hard to function in daily life). Resident 1 was discharged on July 1, 2026 to home with home health services. During an interview on August 5, 2026, at 10:56 AM, with a Social Services Director (SSD), the SSD explained she was recounting what Resident 1 had told her. The SSD stated Resident 1 reported a situation in the activities room involving a group of residents who were intolerant of another resident's behavior during bingo. Resident 1 recalled this resident frequently getting up from her chair and moving around the area, supposedly disturbing the bingo activity. Resident 1 stated she felt the need to protect this resident and spoke up to the angry residents in her defense. Resident 1 then told the SSD she began experiencing retaliation from those residents and developed a distinct feeling they were against her, prompting her complaint to the facility. During a continued interview, the SSD explained she was recounting what she witnessed during a meeting with the Admin and Resident 1 on June 15, 2026, when they went to Resident 1's room to address her complaint. The SSD stated the Admin began reviewing the facility's resident rights policy, and Resident 1 attempted to explain her side of the complaint. The SSD recalled the Admin raising her hand toward Resident 1's face and telling her to stop and let the Admin finish before speaking. The SSD said she observed Resident 1 becoming agitated, trying to talk over the Admin in a loud voice in an effort to be heard. The Admin again raised her hand toward Resident 1's face and told her to stop speaking until the policy review was finished. The SSD stated Resident 1's agitation continued to escalate, and Resident 1 expressed that she had a lot going on with her and had suffered abuse at another facility, which made her feel anxious. The SSD recounted the Admin responding that this facility was not the other facility, implying Resident 1's feelings and fears were not relevant to the current situation. The SSD stated, I felt this was dismissive of [Resident 1's] trauma. The SSD further recalled the Admin telling Resident 1 that if she had a problem in activities, then she needed to leave the activities. The SSD stated the Admin completed the resident rights policy review and directed Resident 1 to sign it, which increased Resident 1's agitation even more. The SSD stated she felt the Admin went overboard with the policy review and seemed to escalate the situation instead of resolving it. During a continued interview, the SSD stated she visited Resident 1 on June 16, 2026, after Resident 1 had reported to the Director of Nursing (DON) and multiple staff members that she had been emotionally abused by the Admin. The SSD stated Resident 1 had been crying and said she could not attend activities because the Admin told her that if she complained, she could not attend activities. The SSD stated Resident 1 told her she was feeling emotional and scared and had been crying in her room. During an interview on August 5, 2026, at 11:19 AM, with the Regional Director of Operations (RDO), the RDO stated he had suspended the Admin on June 19, 2026, and had conducted the abuse investigation. The RDO stated he agreed with the SSD's witness account and felt the SSD's account was reasonable and honest. The RDO stated the facility placed the Admin on suspension and, after additional review, terminated the Admin's employment. The RDO stated the Admin's administrative approach to the complaint and Resident 1 brought about the investigation and that it should not have happened in this manner. The RDO stated the Admin was supposed to be an advocate for the residents, not the cause of distress. The RDO clarified the Admin's termination was not a direct result of the abuse allegation; however, it was a factor in the facility's decision to end her employment on June 24, 2026. A review of the facility's policy and procedure (P&P) titled, Resident Rights, dated February 2021, the P&P indicated, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; d. be free from corporal punishment or involuntary seclusion, . u. voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal; .

Based on observation, interview, and record review, the facility failed to ensure potentially hazardous foods were maintained at or above 140 degrees Fahrenheit (unit of measure) at the time of service to residents, when two of two test trays (test trays of food prepared by the facility for temperature and palatability testing) had hot food items which were served to the residents below 140 Degrees Fahrenheit. This failure had the potential to cause foodborne illness in a vulnerable population of 80 residents who reside in the facility.Findings: During a review of the facility's food menu titled, Good for Your Health Menus, dated March 9, 2026, through March 15, 2026, the menu indicated breakfast for Wednesday, March 11, 2026, was to include biscuits with gravy, scrambled eggs, oatmeal, and raisins, with orange juice.During a concurrent observation and interview on March 11, 2026, at 8:19 AM, with the Dietary Services Supervisor (DSS), and the Consultant Registered Dietician 1 (CRD 1) the last meal tray cart (a cart used by staff to transport multiple resident trays of food throughout the facility) was brought out of the kitchen. At the same time the last resident food tray was removed from the tray cart, the food temperatures were taken on the test tray with the DSS and CRD1. The test tray with foods that were of puree texture/consistency (foods that are blended to a smooth, uniform consistency with no lumps so they can be eaten safely without chewing) had eggs which were 108 degrees F, and biscuits which were 125 degrees F. The test tray with foods that were of regular texture/consistency had eggs which were 104 degrees F, and a biscuit which was 104 degrees F. All temperatures were verified by the DSS and CRD 1 using the facility's thermometer. When asked what temperatures the hot foods were supposed to be when served to residents, the CRD 1 stated hot food was required to be served at or above the danger zone. The CRD 1 further stated she knew what temperatures consisted of the danger zone was but was unable to recall the temperatures because she was nervous. The DSS stated hot foods should be served to residents at or above 140 degrees F.During a review of the facility's food menu titled, Good for Your Health Menus, dated March 9, 2026, through March 15, 2026, the menu indicated lunch for Wednesday, March 11, 2026, was to include sweet and sour chicken, sesame noodles, stir fry vegetables, mandarin Asian salad, and lemon snow bar.During a concurrent observation and interview on March 11, 2026, at 1:07 PM, with the DSS and CRD 1, the last meal tray cart was brought out of the kitchen. At the same time the last resident food tray was removed from the tray cart, the food temperatures were taken on the test tray with the DSS and CRD1. The test tray with foods that were of puree texture/consistency had sweet and sour chicken that was 130 degrees F, and puree pasta that was 135 degrees F. The test tray with foods that were of regular texture/consistency had sweet and sour chicken that was 130 degrees F. All temperatures were verified by the DSS and CRD 1 using the facilities thermometer. The DSS stated temperatures were better than they were at breakfast but still were not at 140 degrees F as was required by the facility's policy.During an interview on March 11, 2026, at 2:35 PM, with the DSS, the DSS stated the policy and procedure regarding what temperatures food was supposed to be served to the residents at was covered in the policy titled, Food Preparation Policy. The DSS further stated the facility considered the holding temperatures to be the same temperature the food should be provided to the resident when they are served their meal tray.During a review of the facility's policy and procedure (P&P) titled, Food Preparation Policy, (undated), the P&P indicated, All food will be prepared by methods that preserve nutritive value, flavor, and appearance, and will be attractively served at the proper temperature and in a form to meet the individual needs of the resident.Hold foods for the shortest time possible before service.Hot food must be >= [greater than or equal to] 140 F and cold food <= [less than or equal to] 40 F. Cover all food during holding.

Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when:1. Certified Nursing Assistant 3 (CNA 3) removed a set of gloves after providing care for a resident and did not perform hand hygiene prior to putting on a new set of gloves to assist another resident.2. CNA 4 (CNA 4) did not wear a gown when changing linens or providing patient care for Resident 3 who was on enhanced barrier precautions (EBP - an infection control strategy that requires healthcare staff to wear gowns and gloves during high-contact care activities for residents who are known or suspected to be colonized/infected with multidrug-resistant organisms or who have wounds or indwelling devices which place them at increased risk for infection). 3. Resident 41's oxygen humidifier (small bottle attached to an oxygen tank that adds moisture to the oxygen before you breathe it in) was not changed based on the physician's order.4. The facility failed to provide tracking compliance for hand hygiene surveillance (systematic process of watching, measuring, and reporting how often healthcare workers clean their hands) for the months of November 2025, December 2025, January 2026 and February 2026.5. CNA 6 (CNA 6) did not wear a gown while holding Resident 45, who was on EBP (enhanced barrier precautions are infection control measures requiring staff to wear gowns and gloves during high contact activities to prevent multi-drug resistance organism transmission) while walking in his room with a walker and assisting him to sit on the edge of the bed. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to 80 medically compromised residents and staff in the facility. Findings: 1. During a concurrent observation and interview on March 9, 2026, at 10:23 AM, with Certified Nursing Assistant 3 (CNA 3), CNA 3 removed a gown and gloves as she was exiting the room of a resident who was on enhanced barrier precautions. After removing her gown, and gloves, CNA 3 did not perform hand hygiene (handwashing or use hand sanitizer) and immediately went into another resident's room and put on a new set of gloves to assist another resident. CNA 3 stated she had just finished assisting a resident who was on enhanced barrier precautions because the resident needed assistance with changing her clothes. CNA 3 then stated she did not perform hand hygiene after removing her gloves and did not perform hand hygiene prior to putting on new gloves because she forgot and was in a rush. CNA 3 further stated she was supposed to perform hand washing or use alcohol-based hand sanitizer after removing her gloves but she did not. During an interview on March 12, 2026, at 1:39 PM, with the Director of Nursing (DON), the DON stated staff were supposed to perform hand hygiene immediately after removing gloves. During an interview on March 12, 2026, at 3:20 PM, with the Infection Preventionist (IP), the IP stated staff were supposed to remove gloves and then perform hand hygiene immediately after the gloves were removed. The IP further stated the importance of performing hand hygiene was to protect residents from harmful organisms or infections. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated April 2023, the P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.a. important facets of infection prevention include: .8. Following established general and disease-specific guidelines such as those of the Centers for Disease control (CDC) and California Department of Public Health (CDPH). During a review of the CDC's guidance titled, Clinical Safety: Hand Hygiene for Healthcare Workers, dated February 27, 2024, found at found at https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html the guidance indicated, .CDC provides the following recommendations for hand hygiene in healthcare settings.know when to clean your hands.immediately after glove removal. 2. During a review of Resident 3's Face Sheet (contains medical and demographic information), the Face sheet indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included dementia (an illness which causes a progressive decline in cognitive functions – such as memory, thinking, reasoning, and the ability to perform everyday activities), hemiplegia and hemiparesis (weakness and paralysis) of right dominant side, and encounter for attention to gastrostomy (G-tube- a medical device inserted through the abdominal wall directly into the stomach – used for delivering nutrition, hydration, or medications )healthcare involving the care of an existing gastrostomy). During a concurrent observation and interview on March 9, 2026, at 11:27 AM, with Certified Nursing Assistant 4 (CNA 4), CNA 4 was observed to be changing the dirty linens of Resident 3 who was on enhanced barrier precautions. CNA 4 was only wearing gloves and was not wearing a gown. When CNA 4 was finished, CNA 4 stated she had just finished changing Resident 3's diaper and dirty linens. CNA 4 stated she did not wear a gown while assisting Resident 3 or changing Resident 3's linens because she had forgotten. There was a sign posted above Resident 3's bed which indicated, Providers and staff must also.wear gloves and a gown for the following high contact resident care activities, dressing, bathing/showering, transferring, changing linens, changing briefs or assisting with toileting. During a review of Resident 3's Electronic Health Record (EHR – electronic medical record), the EHR indicated, Enhanced Barrier Precautions due to G-tube care, During an interview on March 12, 2026, at 1:39 PM, with the Director of Nursing (DON), the DON stated that staff were supposed to wear a gown and gloves when providing direct patient care or changing dirty linens for a resident on enhanced barrier precautions. During an interview on March 12, 2026, at 3:16 PM, with the Infection Preventionist (IP), the IP stated the importance of wearing appropriate Personal Protective Equipment (PPE – protective gear worn by staff to reduce exposure to hazards or prevent the spread of infection, such as gloves and gowns) was to protect residents from the spread of organisms and to prevent infections. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier (standard) Precautions, dated January 2024, the P&P indicated, Enhanced barrier precautions (EBPs or ESPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents.2. EBPs/ESPs employ targeted gown and glove use during high contact resident care activities.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs/ESPs include: .e. changing linens; f. changing briefs or assisting with toileting. 3. During a review of Resident 41's admission Record (contains medical and demographic information), the admission Record indicated Resident 41 was admitted to the facility on [DATE] with the diagnoses which included Chronic obstructive pulmonary disease (COPD- an ongoing lung condition caused by damage to the lungs), asthma (a long-term lung condition where the airways become inflamed, narrow, and produce extra mucus, making it difficult to breathe) and pleural effusion(a collection of fluid around the lungs). During a review of Resident 41's Physician Order dated February 20, 2026, the Physician Order indicated, Change humidifier q [every] night shift, every Sunday. During an observation on March 9, 2026, at 11:11 AM in Resident 41's room, the resident's oxygen humidifier was observed labeled with a date of March 2, 2026. During a concurrent observation and interview conducted on March 9, 2026, at 11:24 AM with the licensed vocational nurse 1 (LVN 1) in Resident 41's room, the resident's oxygen humidifier was observed labeled March 2, 2026. The LVN 1 stated oxygen humidifiers are changed every Sunday and acknowledged the humidifier should have been changed on March 8, 2026, in accordance with the Physician order. During a concurrent interview and record review conducted on March 9, 2026, at 11:45 AM with the Director of Nursing (DON), Resident 41's physician order was reviewed and indicated to change the oxygen humidifier every Sunday on night shift. The DON confirmed the physician order was not followed and stated the oxygen humidifier should have been changed as ordered to reduce the risk of potential infections. 4. During an interview on March 11, 2026, at 11:28 AM, with the Infection Preventionist (IP), the IP stated she conducts daily hand hygiene surveillance weekly; however, she confirmed the surveillance activities had not been documented. The IP stated she did not have documentation available to verify ongoing hand hygiene surveillance. The IP further stated she had access to the California Department of Public Health healthcare-associated infection program adherence monitoring hand hygiene form, but acknowledged the form had not been utilized during her two months in the Infection Preventionist role. The IP stated she understood hand hygiene surveillance is an essential component of infection control monitoring within the facility. When requested to provide surveillance records, the IP was only able to produce hand hygiene monitoring documentation dated October 15, 2025, October 25, 2025, and October 31, 2025. During a concurrent interview and record review on March 11, 2026, at 11:42 AM, with the DON, the facility policy and procedure (P&P) titled, Monitoring Compliance with Infection Control, dated April 2023 was reviewed. The P&P indicated, 2. Monitoring includes regular surveillance of adherence to hand hygiene practices and availability of hand hygiene supplies, and the availability of personal protective equipment and its appropriate use.3. The infection preventionist conducts compliance surveys at least quarterly.4.Compliance surveillance includes the use of standardized assessment and observation tools. The DON further stated the facility's policy was not followed, the facility failed to provide tracking compliance for hand hygiene surveillance and it's important because hand hygiene is the most important infection prevention practice. 5. During a review of Resident 45's Face Sheet, the Face Sheet indicated Resident 45 was admitted to the facility on [DATE], with diagnoses of acute cholecystitis (sudden inflammation[the body's natural response to injury, infection, or irritation and swelling of the gallbladder), urinary tract infection (an infection in any part of the kidneys, ureters, bladder, and urethra), and difficulty of walking. During an observation on March 9, 2026 at 9:04 AM in Resident 45's room, there was an EBP (Enhanced barrier Precautions- are infection control measures requiring staff to wear gowns and gloves during high contact activities to prevent multi-drug resistant organism transmission) sign posted above Resident 45's bed which indicated, Providers and staff must also.wear gloves and a gown for the following high contact resident care activities., transferring. During an observation on March 9, 2026, at 12:14 PM, Resident 45's foley catheter (flexible tube that is inserted into the bladder through the urethra to drain urine) bag and cholecystostomy tube (a tube inserted through the skin into the gallbladder to drain infected bile and fluids) bag were hanging from the resident's walker. CNA 6 was holding the resident and the walker while the resident was walking within the room. CNA 6 subsequently assisted by holding onto Resident 45 from a standing to a sitting position on the bed while wearing gloves with no gown. During an interview on March 9, 2026, at 12:20 PM, with CNA 6, CNA 6 stated that the facility's policy for caring for a resident on enhanced barrier precautions requires staff to wear both gloves and a gown. CNA 6 acknowledged and confirmed that she did not wear a gown when assisting Resident 45 and should have. During an interview on March 10, 2026, at 4:10 PM, with the infection preventionist (IP), the IP stated staff must wear both gloves and a gown when having direct contact with residents who are on enhanced barrier precautions to prevent the spread of infection. During a concurrent interview and record review on March 11, 2026, at 1:00 PM, with the DON, the facility's P&P titled, Enhanced Barrier (Standard) Precautions dated January 2024 was reviewed. The P&P indicated, . Policy Interpretation and Implementation . b. Gloves and gown are applied prior to performing the high contact resident care 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs/ESPs include: .c. transferring. The DON stated the P&P was not followed. The DON further stated it is important for staff to wear appropriate personal protective equipment (PPE) to ensure effective infection control and prevent the spread of infection.

Based on observation, interview, and record review, the facility failed to ensure that two of two residents (Residents 86 and 47) received food served at an appetizing and palatable temperature when Residents 86 and 47 reported their hot foods were often served cold. This failure had the potential to negatively affect Residents 86 and 47 comfort, appetite, and overall satisfaction with meals due to not receiving food at the preferred temperature.Findings: During a review of the facility's resident council meeting minutes (meeting notes from a group of residents who meet regularly to discuss their rights and quality of care in a facility as well as to make recommendations, raise grievances, and influence decisions related to their daily living in the facility), the meeting minutes from January 27, 2026, indicated residents were complaining that their hot food was served cold during mealtimes.During a concurrent observation and interview on March 12, 2026, at 3:35 PM, with Resident 86, Resident 86 was lying in bed and stated often times, her food which was supposed to be hot, would be served cold. Resident 86 further stated when her food was cold she doesn't like to eat as much because she doesn't like it that way.During a concurrent observation and interview on March 12, 2026, at 3:38 PM, with Resident 47, Resident 47 was lying in bed and stated her food which is supposed to be hot is also served cold oftentimes but she has to eat to survive so she just eats it cold even though she does not like it that way.During an interview on March 12, 2026, at 3:50 PM, with Resident 57, Resident 57 stated she was the president of the resident council. Resident 57 further stated the resident council has brought up to the facility many times that the food which was supposed to be hot, was served cold during mealtimes. Resident 57 stated multiple residents have been complaining about the issue for a while now.During a review of the facility's food menu titled, Good for Your Health Menus, dated March 9, 2026, through March 15, 2026, the menu indicated breakfast for Wednesday, March 11, 2026, was to include biscuits with gravy, scrambled eggs, oatmeal, and raisins, with orange juice.During a concurrent observation and interview on March 11, 2026, at 8:19 AM, with the Dietary Services Supervisor (DSS), and the Consultant Registered Dietician 1 (CRD 1) the last meal tray cart (a cart used by staff to transport multiple resident trays of food throughout the facility) was brought out of the kitchen. At the same time the last resident food tray was removed from the tray cart, the food temperatures were taken on the test tray with the DSS and CRD1. The test tray with foods that were of puree texture/consistency (foods that are blended to a smooth, uniform consistency with no lumps so they can be eaten safely without chewing) had eggs which were 108 degrees F, and biscuits which were 125 degrees F. The test tray with foods that were of regular texture/consistency had eggs which were 104 degrees F, and a biscuit which was 104 degrees F. All temperatures were verified by the DSS and CRD 1 using the facilities thermometer. When asked what temperatures the hot foods were supposed to be when served to residents, the CRD 1 stated hot food was required to be served at or above the danger zone. The CRD 1 further stated she knew what temperatures consisted of the danger zone was but was unable to recall the temperatures because she was nervous. The DSS stated hot foods should be served to residents at or above 140 degrees F.During an interview on March 11, 2026, at 2:35 PM, with the DSS, the DSS stated the policy and procedure regarding what temperatures food was supposed to be served to the residents at was covered in the policy titled, Food Preparation Policy. The DSS further stated the facility considered the holding temperatures to be the same temperature the food should be provided to the resident when they are served their meal tray.During a review of the facility's policy and procedure (P&P) titled, Food Preparation Policy, (undated), the P&P indicated, All food will be prepared by methods that preserve nutritive value, flavor, and appearance, and will be attractively served at the proper temperature and in a form to meet the individual needs of the resident.Hold foods for the shortest time possible before service.Hot food must be >= [greater than or equal to] 140 F and cold food <= [less than or equal to] 40 F. Cover all food during holding.

Based on interview, and record review, the facility did not ensure one of one resident (Resident 85) medication order for Ambien (a medication used to help treat insomnia [the inability to maintain or initiate sleep]) had a frequency in which the medication could be administered. This had the potential for Resident 85 to experience an overdose of Ambien medication which can cause severe sedation, cognitive impairment, respiratory arrest or coma.Findings: During a review of Resident 85's Face Sheet (contains medical and demographic information), the Face Sheet, indicated Resident 85 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain dysfunction which can appear as confusion, memory loss, or personality changes), depression, and history of traumatic brain injury.During a review of Resident 85's physician's orders, an order dated February 25, 2026, indicated Zolpidem Tartrate [Ambien - a sedative-hypnotic medication used to help adults fall asleep or stay asleep through the night] ER [extended release] oral tablet extended release 6.25 MG [milligrams - unit of measure] Give 1 tablet by mouth as needed for insomnia m/b [manifested by] inability to sleep. The order had no frequency indicated on to specify how frequently the medication could be administered to Resident 85. The order was discontinued on March 11, 2026 (it was an active order for 15 days).During a concurrent interview and record review on March 12, 2026, at 1:47 PM, with the Director of Nursing (DON), Resident 85's physician's orders were reviewed. The DON acknowledged the physician's order dated February 25, 2026, indicated, Zolpidem Tartrate [Ambien - a sedative-hypnotic medication used to help adults fall asleep or stay asleep through the night] ER [extended release] oral tablet extended release 6.25 MG [milligrams - unit of measure] Give 1 tablet by mouth as needed for insomnia m/b [manifested by] inability to sleep. The DON stated the order did not have a frequency to indicate how often the medication can be administered to the resident, but it should have one. The DON further stated all medication orders were supposed to have a frequency indicated in the order to ensure the resident is not overdosed by the medication. The DON stated Clinical Coordinator (CC) was the nurse who input the order into the Electronic Health Record (EHR - electronic medical record.)During a concurrent interview and record review on March 12, 2026, at 2:20 PM, with the CC, Resident 85's physician's orders were reviewed. The CC acknowledged the physician's order dated February 25, 2026, indicated, Zolpidem Tartrate [Ambien - a sedative-hypnotic medication used to help adults fall asleep or stay asleep through the night] ER [extended release] oral tablet extended release 6.25 MG [milligrams - unit of measure] Give 1 tablet by mouth as needed for insomnia m/b [manifested by] inability to sleep. The CC further stated she was the nurse who input the order into Resident 85's EHR and she must have forgot to enter in the frequency as part of the order.During an interview on March 12, 2026, at 4:37 PM, with the facility's Pharmacy Consultant (PC), the PC stated all medication orders were supposed to have a frequency indicated. The PC further stated it was important so staff know how often the medication could be administered to the resident.During a review of the facility's policy and procedure (P&P) titled, Medication and Treatment Orders, dated July 2016, the P&P indicated, Orders for medications and treatments will be consistent with principles of safe and effective order writing.9. Orders for medications must include: a. name and strength of the drug; b. number of doses, start and stop date, and or specific duration of therapy; c. dosage and frequency of administration.

Based on observation, interview, and record review, the facility failed to ensure resident's equipment was maintained in safe operating condition for 1 of 2 residents (Resident 86) when Resident 86 bed malfunctioned such that the foot section would not elevate, the head and foot controls were reversed, and normal bed positioning could not be performed as intended. This failure had the potential to affect Resident 86 safety, comfort, and positioning needs, and create risk for confusion, distress, and delayed staff response during care.Findings:During a review of Resident 86's clinical record, the Record of Admission (contains demographic and medical information), the Record of Admission indicated, Resident 86 was admitted to the facility on [DATE] with diagnoses which included, Spinal Stenosis Lumbar Region(A narrowing of the tunnel in the lower back that houses nerves, causing pressure on nerves), Fibromyalgia ( A chronic disorder characterized by widespread pain, fatigue, and tenderness throughout the body), Arthrodesis status(a surgical procedure that permanently connects two or more bones in a joint to stop them from moving).During observation on March 9, 2026, at 10:48 AM with Resident 86 in Resident 86's room, Resident 86 bed was tested and observed not to function properly. The foot section of the bed failed to elevate when activated. In addition, the hand control functions were reversed, such that activating the head control raised the foot section and activating the foot control raised the head section when operable. Resident 86 states the bed has not been functioning properly since I was admitted on [DATE] and staff have been notified. Resident 86 further states I was told the bed would be replaced. Resident 86 states I would really like to raise my feet for comfort.During a concurrent observation and interview on March 9, 2026 at 11:07 AM, with Certified Nurse Assistant 2 (CNA 2) in resident 86 room, CNA 2 confirmed the bed was not functioning as intended and acknowledged the controls were reversed. CNA stated the bed had not been removed from service or tagged for repair.During a concurrent observation and interview on March 11, 2026, at 8:05 AM with the Maintenance Director (MD), in Resident 86 room, the MD verified Resident 86's bed was not functioning in a safe operating condition. The MD further stated maintenance was not aware of resident 86 bed not functioning properly. During a concurrent interview and record review on March 11, 2026, at 8:11 AM with MD, March maintenance log for unit B was reviewed. The March maintenance log indicated Resident 86's bed repair was not documented as a work request. MD stated that the staff did not log a work request for Resident 86 bed repair.During a concurrent interview and record review on March 11, 2026, at 11:53 AM, with the MD, the facility's Policy and Procedure (P&P) titled Maintenance Service dated December 2009, was reviewed. The P&P indicated, .1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.8. The maintenance director is responsible for maintaining the following records and reports.l. work order request.10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. The MD acknowledged and stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure dietary staff prepared and served the large portion sizes, as specified in the resident's physician order, for one of one sampled resident (Resident 66) when Resident 66's breakfast tray was sent from the kitchen without the required large portions.This failure had the potential for Resident 66 to receive a meal inconsistent with the prescribed dietary order.Findings: During a review of Resident 66's Face Sheet (contains medical and demographic information), the Face Sheet, indicated Resident 66 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis), hypertension (high blood pressure), and malignant neoplasm of unspecified site of left breast (breast cancer).During a review of Resident 66's physician's orders, an order dated March 15, 2025, indicated Resident 66 was to receive, .Large portions TID [three times a day].During a review of Resident 66's Care Plan Report, (individualized plan for the medical care of a resident), a care plan titled, I, [name of Resident 66], have difficulty with my nutrition due to: aging process.missing teeth, muscle weakness. dated May 27, 2024, indicated, Goal.I will not have any unplanned weight changes through the next assessment.interventions.diet as ordered.During a review of the facility's food menu titled, Good for Your Health Menus, dated March 9, 2026, through March 15, 2026, the menu indicated breakfast for Wednesday March 11, 2026, was to include biscuits with gravy, scrambled eggs, oatmeal & raisins, and orange juice.During a review of the facility's food production worksheet titled, Cooks Spreadsheet - Spring Cycle Menus (document which indicates the amount of food residents were supposed to receive at each meal based upon their physician ordered portion sizes), undated, the document indicated residents with large portions ordered were supposed to receive two scoops of egg of the number 12 green scoop (1/3 cup serving) for a total of 2/3 a cup. Additionally, the document indicated residents were supposed to receive two biscuits.During a concurrent observation and interview on March 11, 2026, at 7:54 AM, with the Dietary Service Supervisor (DSS), during breakfast tray line (plating of food for residents), Resident 66's meal tray received only one green scoop (1/3 cup serving) of egg, and two biscuits. Resident 66's meal tray was not served a total of 2/3 cup of eggs for large portions as specified in the physician order. Resident 66's meal tray was then covered and placed on the meal cart (a cart used to transport multiple meal trays from the kitchen to the facility units) and pushed out of the kitchen and into the hallway for distribution to residents. Prior to Resident 66's meal tray being served to the resident, the DSS was asked to review Resident 66's meal tray. The DSS confirmed Resident 66's meal tray contained two biscuits and one scoop of eggs (size 1/3 cup portion). The DSS further stated residents who had large portions were supposed to get double of one item as part of the meal and for this meal, it was double the amount of biscuits but only one scoop of egg. The DSS was then asked to review the Cooks Spreadsheet - Spring Cycle Menus, undated. Upon Review of the Cooks Spreadsheet, the DSS stated that residents who were supposed to receive large portions were actually supposed to receive two scoops of egg (for a total of 2/3 cup) and not just one as she initially thought.During an interview on March 12, 2026, at 3:25 PM, with Resident 66, Resident 66 was lying on her right side while in bed. Resident 66 stated she was supposed to receive large portions of food but sometimes she felt as though she did not receive large portions like she was supposed to.During a review of the facility's policy and procedure (P&P) titled, Food Preparation Policy, (undated), the P&P indicated, .All meals must comply with the physician-ordered diet, approved menu, and portion control standards to ensure consistency, adequate nutrition, and regulatory compliance.a. Standardized portion sizes must be followed for all food items, including meats, in accordance with the approved menu and diet manual.c. portion utensils (e.g., scoops, serving utensils, ladles) must be labeled and used to ensure consistent portioning.D. dietary staff must refer to the production sheet or meal ticket to confirm proper portion for each resident diet.e. Dietary Supervisor or Lead [NAME] must monitor the meal service to ensure correct portion is being served.

Based on observation, interview, and record review, the facility failed to ensure medication error rate was less than five percent. There were three medication errors observed out of a total of 29 opportunities for errors, affecting three out of 13 observed residents (Residents 27, 45, and 82), resulting in an overall medication error rate of 10.34 percent when:1. Famotidine (a medication to treat acid reflux) was not administered to Resident 82 within 60 minutes of scheduled time (one hour before and one hour after) according to the facility's policy and procedure (P&P).2. Omeprazole (a medication to treat acid reflux) was not administered to Resident 45 before 30 minutes of meal according to a physician order.These failures had the potential to result in unmet health care needs and increased risk of complications related to acid reflux for Residents 45 and 82. 3. Hydralazine (a medication to treat high blood pressure) was not administered to Resident 27 according to the physician-order parameters.This failure had the potential to result in ineffective or unsafe blood pressure management and increased risk of harm to Resident 27's health.Findings: 1. During a review of Resident 82's admission Record (contains demographic and medical information), the admission Record indicated Resident 82 was admitted to the facility on [DATE], with diagnoses of heart failure (the muscle of the heart too weak or stiff to pump blood efficiently), dysphagia (difficulty of swallowing), and muscle weakness.During a review of Resident 82's physician's order, dated March 10, 2026, it indicated Resident 45 had an order for Famotidine 20 mg (milligram- unit of measurement) Give 1(one) tablet by mouth one time a day for GERD [gastroesophageal reflux disease- when stomach acid backs up into the throat].During a review of Residents 82's Medication Administration Record (MAR- record for what medication a resident has received), it indicated the scheduled administration time for Famotidine was 6:30 AM.During a medication administration observation on March 11, 2026, at 5:19 AM, in Resident 82's room, the Registered Nurse 2 (RN 2) administered Famotidine 20 mg Oral Tablet to Resident 82.During an interview on March 11, 2026, at 7:07 AM with the RN 2, the RN 2 stated Resident 82's Famotidine should have been administered within 60 minutes of the scheduled time (one hour before or one hour after). The RN 2 further stated Resident 82 received Famotidine, scheduled for 6:30 AM, at 5:19 AM (11 minutes early), which falls outside the acceptable medication administration time range.2. During a review of Resident 45's admission Record, the admission record indicated Resident 45 was admitted to the facility on [DATE], with diagnoses of acute cholecystitis (sudden inflammation[the body's natural response to injury, infection, or irritation] and swelling of the gallbladder), urinary tract infection (an infection in any part of the kidneys, ureters, bladder, and urethra), and difficulty of walking.During a review of Resident 45's physician's order, dated March 10, 2026, it indicated Resident 45 had an order for Omeprazole DR (delayed release) 20 MG CAP (capsule) Give 1 capsule by mouth two times a day for GERD GIVE 30 MINUTES BEFORE MEAL.During a review of Residents 45's MAR (medication Administration Record), it indicated the scheduled administration time for Omeprazole was 7:30 AM.During a medication administration observation on March 11, 2026, at 5:40 AM, in Resident 45's room, the RN 2 administered Omeprazole 20 MG Delayed Release Oral Capsule to Resident 45.During an interview on March 11, 2026, at 8:42 AM with the RN 2, the RN 2 stated Omeprazole should have been administered 30 minutes before meal according to the physician order. The RN 2 further stated Resident 45 received Omeprazole, scheduled for 7:30 AM, at 5:40 AM (50 minutes early), which falls outside the 30 minutes before meal order.During a concurrent interview and record review on March 11, 2026, at 1:02 PM with the Director Of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Medication Administration-General Guidelines dated October 2017 was reviewed. The P&P indicated, .B. Administration.10. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before and after meal orders, which are administered based on mealtimes. The DON stated the P&P was not followed.3. During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE], with diagnoses of metabolic encephalopathy (impaired brain function caused by organ failure, chemical imbalance or toxins), Urinary tract infection, and pseudomonas aeruginosa (bacteria found in the environment) cause of disease.During a review of Resident 27's physician's order, dated January 19, 2026, it indicated Resident 27 had an order for hydralazine HCL Oral tablet 10 MG (Hydralazine HCl) Give 1 tablet by mouth every 6 hours as needed for HTN [hypertension- high blood pressure] GIVE WHEN SBP [systolic blood pressure- the top number in a blood pressure reading]>160mmHg. During a medication administration observation on March 11, 2026, at 5:47 AM, in Resident 27's room, the RN 2 administered Hydralazine 10MG Oral Tablet for blood pressure 160/110 to Resident 45.During an interview on March 11, 2026, at 7:09 AM with the RN 2, the RN 2 stated the administration parameter for Hydralazine was to give the medication only if the SBP is greater than 160. The RN 2 further stated Resident 27 received Hydralazine when the SBP was exactly 160, which did not meet the physician ordered parameters. The RN 2 stated, based on the order, the Hydralazine should not have been administered.During a concurrent interview and record review on March 11, 2026, at 1:05 PM with the DON, the facility's P&P titled Medication Administration-General Guidelines dated October 2017 was reviewed. The P&P indicated, .B. Administration .2. Medications are administered in accordance with written orders of the attending physician. The DON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure administered medications were accurately documented according to the facility's policies and procedures (P&P) for two out of 13 residents (Residents 45 and 82) when:1.Registered Nurse 2 (RN 2) did not document Resident 45's administration of Omeprazole (a medication used to treat acid reflex) on the Medication Administration Record (MAR- record for what medication a resident has received). This failure had the potential to result in medication errors, including double dosing and may adversely affect Resident 45's health and safety. 2. RN 2 inaccurately documented the administration time of Resident 82's Famotidine (a medication used to treat acid reflex) as 6:53 AM when the medication was observed to be administered at 5:19 AM. This failure had the potential to result in medication errors, including improper dosing intervals and inaccurate assessment of Resident 82's response to therapy.Findings: 1.During a review of Resident 45's admission Record (contains demographic and medical information), the admission record indicated Resident 45 was admitted to the facility on [DATE], with diagnoses of acute cholecystitis (sudden inflammation[the body's natural response to injury, infection, or irritation] and swelling of the gallbladder), urinary tract infection (an infection in any part of the kidneys, ureters, bladder, and urethra), and difficulty of walking.During a review of Resident 45's physician's order, dated March 10, 2026, it indicated Resident 45 had an order for Omeprazole DR (delayed release) 20 MG (milligram- unit of measurement) CAP (capsule) Give 1 capsule by mouth two times a day for GERD [gastroesophageal reflux disease- when stomach acid backs up into the throat] GIVE 30 MINUTES BEFORE MEAL.During a medication administration observation on March 11, 2026, at 5:50 AM, in Resident 45's room, the RN 2 administered Omeprazole 20 MG Delayed Release Oral Capsule to Resident 45.During a concurrent interview and record review on March 11, 2026, at 8:42 AM with the RN 2, the RN 2 reviewed Resident 45's MAR. The RN 2 stated the administered Omeprazole was not documented because it was not scheduled for her shift. The RN 2 confirmed and acknowledged she did not document the Omeprazole she administered.2. During a review of Resident 82's admission Record, the admission Record indicated Resident 82 was admitted to the facility on [DATE], with diagnoses of heart failure (the muscle of the heart too weak or stiff to pump blood efficiently), dysphagia (difficulty of swallowing), and muscle weakness.During a review of Resident 82's physician's order, dated February 27, 2026, it indicated Resident 82 had an order for Famotidine Oral Tablet 20 mg Give 1 tablet by mouth one time a day for GERD(acid reflex).During a medication administration observation on March 11, 2026, at 5:19 AM, in Resident 82's room, the RN 2 administered Famotidine 20 mg Oral Tablet to Resident 82.During a concurrent interview and record review on March 11, 2026, at 7:07 AM with the RN 2, the RN 2 reviewed Resident 82's MAR and noted Famotidine was documented as administered at 6:53 AM. The RN 2 stated she forgot to sign the MAR at the time the medication was administered and later documented the administration at 6:53 AM, despite the medication been administered at 5:19 AM.During a concurrent interview and record review on March 11, 2026, at 1:07 PM with the director of nursing (DON), the facility's Policy and Procedure (P&P) titled, Medication Administration-General Guidelines, dated October 2017 was reviewed. The P&P indicated, .c. Documentation . 1) The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given . The DON stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure staff documented the location of a resident's pain as required by the physician's order for 1 of 2 residents ( Resident 18) reviewed for pain management.This failure had the potential to result in inaccurate pain assessment, inadequate monitoring, and unmet pain management needs for Resident 18.Findings: During a review of Resident 81's Face Sheet (contains medical and demographic information), the Face Sheet, indicated Resident 81 was admitted to the facility on [DATE], with diagnoses which included fracture of the left lower leg, age-related osteoporosis (disease which causes loss of bone density and strength), acute kidney failure (a sudden decrease in kidney function), and history of falling.During a review of Resident 81's Care Plan Report, (an individualized plan for the medical care of a resident), titled, Resident has potential for alteration in comfort/pain related to: dx [diagnosis] of.fracture left lower leg, osteoporosis.akf [acute kidney failure], hx [history] of falling.GERD [gastro-esophageal reflux disease - a digestive condition where stomach acids or contents flow back into the esophagus, causing symptoms like heartburn]. dated March 10, 2026, the care plan indicated, Interventions.Monitor s/s [signs and symptoms] of pain.Assess characteristics of pain: location, duration, quality.During a review of Resident 81's physician's orders, an order dated March 5, 2026, indicated, Hydrocodone-Acetaminophen [pain reliever medication] oral tablet 5-325 MG [milligrams - unit of measure] give 1 tablet by mouth every 6 hours as needed for pain.document pain site in the progress notes.During a review of Resident 81's Medication Administration Record (MAR), dated March 1, 2026, through March 31, 2026, the MAR indicated Resident 81 was administered the medication Hydrocodone-Acetaminophen a total of 16 times from March 6, 2026, through March 12, 2026. During a review of Resident 81's progress notes dated March 1, 2026, through March 12, 2026, the progress notes indicated the location of pain was not documented and was left blank for nine out of 16 (9 of 16) times the medication Hydrocodone-Acetaminophen was administered to the resident. Additionally, there was no other documentation in the clinical record regarding the location of pain for the times the medication was administered.During a concurrent interview and record review on March 12, 2026, at 9:47 AM, with the Director of Nursing (DON), Resident 81's MAR dated March 1, 2026, through March 12, 2026, was reviewed. The DON stated her expectation was that staff documents the pain location in the progress notes as indicated by the physician's order for Resident 81 every time the medication Hydrocodone was administered. The DON further stated the pain location should be in the progress notes section of the MAR or in the regular progress note for the resident in the Electronic Health Record (EHR). The DON reviewed both the MAR and also the progress notes of the EHR and stated staff did not document the location of pain for the administration of the hydrocodone medication as they were supposed to. The DON stated she was unable to find documentation regarding the location of pain for the administration of the hydrocodone on multiple days.During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2023, the P&P indicated, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.During a review of the facility's P&P titled, Charting and Documentation, dated July 2017, the P&P indicated, .The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.3. Documentation in the medical record will be objective.complete, and accurate.

Based on observation, interview, and record review, the facility failed to ensure implementation of their policy and procedure (P&P) for advance directive (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) was completed for one of 24 residents (Resident 87) reviewed for advance directives. This failure had the potential to result in delay of treatment for the Resident 87 as related to advance directives, or for life sustaining measures to be rendered against what the resident wanted.Findings: During a review of Resident 87's admission Record (contains demographic and medical information), the admission Record indicated Resident 87 was admitted to the facility on [DATE], with diagnoses of acute respiratory failure with hypoxia (life-threatening, sudden inability of lungs to oxygenate blood that result in low oxygen levels), sepsis (life-threatening reaction to an infection that causes immune system to harm healthy tissues and organs), and generalized muscle weakness.During an observation, on March 9, 2026, at 4:50 PM, Resident 87 was in her room, lying in bed with the head of the bed elevated.During a record review of Residents 87's chart, there was no advance directives form found.During a concurrent interview and record review on March 10, 2026, at 3:20 PM with the social service director (SSD), Resident 87's medical record was reviewed and the SSD stated there was no Advance directives form completed and it should have been done. The SSD further stated, it is important to address advance directives and ensure documentation is completed in the medical record so that staff know the residents' code status and, if an advance directive exists, can obtain a copy and follow the instructions contained in it.During concurrent interview and record review on March 11, 2026, at 12:58 PM with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Advance Directives, dated September 2022 was reviewed. The P&P indicated, .Determining Existence of Advance Directive, 1. Prior or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. The DON stated the P&P was not followed. The DON further stated the Advance directives form should have been completed upon admission or there should be a note in the resident's medical record indicating the Advance directives was addressed.

Based on observation, interview, and record review, the facility failed to ensure the resident and/or the representatives (RP) was informed of psychotropic medication (medications that affect the mind, emotions, and behaviors) treatment for one of one resident (Resident 63) when Resident 63's informed consent (document signed by resident or RP to give permission for a proposed psychotropic medication and possible risks and benefits expected) was not updated and signed by a provider and by the resident and/or the RP for Resident 63's order of Divalproex Sodium (Depakote-antiseizure and mood stabilizer) 125 milligram (MG-unit of measurement). This failure resulted in Resident 63 and/or their RP not being informed of the psychotropic medication risks, benefits, adverse reactions, and the right to refuse the administration of medications.Findings: During a review of Resident 63's admission Record (clinical record with demographic information), the admission Record indicated, Resident 63 was admitted to the facility on [DATE], with diagnoses of chronic kidney disease (progressively kidneys are damaged and cannot filter blood properly) , Hemiplegia (complete or partial loss of muscle function on one side of the body) and Hemiparesis (mild or moderate muscular weakness or reduced control on one side of the body) following cerebral infraction (brain tissue death due to lack of oxygen and nutrients).During observation on March 9, 2026, at 12:07 PM, Resident 63 was in her room, lying on her left side, asleep.A review of Resident 63's physician order, dated July 25, 2025, indicated Resident 63 had an order for Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 4 Capsule by mouth two times a day for POOR IMPLUSE CONTROL M/B [manifested by] GETTING AGITATION EASILY, LEADING TO VERBAL AND PHYSICAL AGRESSION.During a review of Resident 63's Informed Consent, dated October 10, 2025, the Informed Consent was incomplete and lacked the required signatures of the physician and the resident and/or RP.During Interview on March 10, 2026, at 3:47 PM with the Registered Nurse (RN), the RN verified and acknowledged Resident 63 did not have a complete informed consent for Divalproex Sodium/Depakote. The RN further stated it is important for the physician to discuss the risks and benefits of the medication with the resident and/or RP before the medication is given.During a concurrent interview and record review on March 12, 2026, at 8:47 AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Informed consent, dated January 2026 was reviewed. The P&P indicated, Purpose: to ensure that residents and their representatives are fully informed of the benefits, risks, frequency/duration, possible side effects and alternative approaches before initiating the administration of psychotherapeutic drugs. The DON stated the informed consent was not signed therefore P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure a dignified dining experience for three of twelve residents (Residents 19, 76 and 1) when a Restorative Nursing Assistant (RNA 1), and two Certified Nursing Assistants (CNA 1 and 5) were standing while assisting them to eat during lunch time. These failures had the potential to negatively impact Resident 19, 76 and 1's dignity and psychosocial well-being by failing to provide a respectful, person-centered approach to their dining experience.Findings: 1. During a review of Resident 19's clinical record, resident Face Sheet (a summary page in a medical chart that lists a resident's basic information), and History & Physical (a medical document completed by a healthcare provider that describes a resident's past medical history, current health problems, and findings from a physical examination) indicated, Resident 19 was admitted on [DATE], with a history of dementia (decline in brain function resulting in memory loss, confusion), epilepsy (a brain condition that causes repeated seizures due to abnormal electrical activity in and is bedbound (unable to get out of bed without full assistance). During a concurrent observation and interview on March 9, 2026, at 12:42 PM, with Restorative Nursing Assistant 1 (RNA 1), in the dining room, RNA 1 was feeding Resident 19 while standing. RNA 1 stated she stands because the chair is too high and it's uncomfortable. 2. During a review of Resident 76's clinical record, resident Face Sheet and History & Physical indicated, Resident 76 was admitted on [DATE], with a history of schizophrenia (a long term mental health condition that affects how a person thinks, feels, and understands reality, sometimes causing hallucinations, unusual beliefs, or trouble thinking clearly), chronic kidney disease (a slow, long term loss of kidney function that makes it hard for the body to filter waste and excess fluid), and general weakness (a feeling of reduced strength or energy throughout the body, making it harder to move around or perform daily tasks). During an observation on March 9, 2026, at 12:42 PM, in the dining room, Certified Nursing Assistant 1 (CNA 1) was feeding Resident 76 while standing. During an interview on March 11, 2026, at 12:45 PM, CNA 1, stated she tried to sit down but she couldn't because there was no room. 3. During a review of Resident 1's admission Record it indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of encephalopathy (condition that alters brain function resulting in confusion, memory loss or personality changes), lobar pneumonia (infection in the lungs), and dementia (decline in brain function resulting in memory loss, confusion and trouble performing daily living tasks). During an observation on March 9, 2026, at 1:19 PM, in Resident 1's Room, Resident 1 was lying in bed while CNA 5 (CNA 5) was standing next to her bed, feeding her lunch. During an interview on March 9, 2026, at 1:25 PM with CNA 5, CNA 5 stated she normally stands while feeding residents. CNA 5 further stated, She (Resident 1) is a slower eater, so I stand. During a concurrent interview and record review on March 11, 2026, at 11:51 PM, with the Director of Nursing (DON), the facility's Policy and Procedure (P&P), titled, Assistance with Meals, dated 2001 was reviewed. The P&P indicated, .Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals. The DON stated, that based on the observations of the facility, the P&P was not being followed. The DON further stated the importance of following the facility's P&P was to promote resident safety and dignity. During a review of the facility provided RNA job description, dated January 27, 2022, the job description states, A RNA .Preserves the . dignity . of all residents at all times. During a review of the facility provided CNA job description, dated January 27, 2022, the job description states, A CNA .Provides assistance with supervision, eating . appropriate seating arrangement .

Based on interview and record review, the facility failed to prevent one of three sampled residents (Resident 1), who was diabetic, obese, and immobile and at risk for skin breakdown develop pressure injuries (pressure on body prominence causes breakdown to tissue) as follows: a. Left heel, left great toe and 1st metatarsal developed a deep tissue injury (DTI). And right medial foot fluid blister. b. Acquired an open wound to left elbow and sacral (tailbone) c. No family notification of left elbow and sacral open wound and wound treatment. This failure had the potential to result in a clinically compromised resident, (Resident 1) to be placed at risk for unnecessary pain, infection and death due to wounds not being identified and treated to prevent progressing. Findings: During review of Residents 1's Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included: myocardial infarction type 2 (heart attack), diabetes type 2 (body does not produce enough insulin, or resist insulin), hemiplegia and hemiparesis (partial paralysis on one side of body), hypertension (high blood pressure). During a record review of Resident 1's medical records, reviewed and verified the following with Assistant Director of Nursing (ADON): a. Admission Reassessment dated [DATE], wound sites: Abdomen (gastrostomy (gastrostomy tube-a tube surgically inserted through abdominal wall to administer medications and liquid nourishment), right inner arm discoloration, sacrococcyx (tailbone)(scar tissue). No other skin breakdown. b. Change of Condition (COC) dated May 25, 2024, 10:54, Multiple skin Conditions: Treatment nurse noted that resident had multiple skin conditions. As follows: 1 Right medial foot fluid filled bister 2. Left heel Deep Tissue Injury (DTI) 3x3 Unstageable full thickness or tissue loss depth unknown (UTD). 3. Left Great Toe (DTI 0.5x0.5xUTD. 4. Left 1stMetatarsal DTI 1.5x1.5 UTD. c. COC dated July 03, 2024, at 1359, Noted with Left elbow trauma wound reopened and pressure injury to sacrum .treatment initiated as order .attempted to call daughter {name}, no answer and could not leave voicemail. Called son {name}, no answer and could not leave voice mail. (Family was not notified, no follow up notification noted in medical records). During an interview on December 12, 2024, with the Treatment Nurse (TXT Nurse), TXT nurse stated, When there is a new wound, we do a COC, we monitor for 3 days, update the careplan, call the doctor and family. I leave a voice message and call back number, if voice message full, I would continue to call the family. Resident 1 did develop the Sacrococcyx wound in facility, he was on the heavier side, and be pushed back when we tried to reposition him. He was not able to reposition himself. I can agree the family was not notified and we should have continued with follow up call to inform. During an interview on December 12, 2024, with the Assistant Director of Nursing (ADON), ADON states, Just based on the records reviewed, He did come in with no wounds and he did develop the wounds here. I can agree they should not have developed here. There is no note that the family was ever notified of wound on July 06, 2024, he was sent out July 10, 2024. He was getting wound care treatment on the new wounds. During an interview on December 12, 2024, with the Administrator (Admin), Admin states, Resident 1, I can agree he should not have developed any wounds, I am aware of the documentation. The family was called but there should have been follow through on the notification of new wounds and wound treatments we started. During a review of the facility's policy and procedure titled, Pressure Sore Management (no date), the policy and procedure indicated, All available measures shall be taken to reduce skin breakdown and pressure sores. During a review of the facility's policy and procedure titled, Prevention of Pressure Injuries revised March 2023, the policy and procedure indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific factors .Assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition .reposition all residents with or at risk for pressure injuries on an individualized schedule, as determined by the interdisciplinary team .evaluate, report and document potential changes in the skin, review the interventions and strategies for effective ness on an ongoing basis. During a review of the facility's policy and procedure titled, Change in a Resident's Condition or Status revised (February 2021), the policy and procedure indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and or status (e.g., changes in level of care .).

Based on observation, interview, and facility policy review, the facility failed to ensure the kitchen refrigerator temperature was maintained at 40 degrees Fahrenheit (F) or lower. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: An undated facility policy titled, Refrigerator/Freezer Storage revealed, 3. If temperatures are not within appropriate range, dietary staff will notify the dietary supervisor and / or Maintenance Supervisor and Administrator: Refrigerator Temperature 40 degrees F or lower. During an observation of the kitchen on 11/11/2024 at 8:35 AM, 8:43 AM, and 10:06 AM, the refrigerator temperature was noted as 45 degrees F. During a concurrent observation and interview on 11/11/2024 at 1:45 PM, the Dietary Supervisor (DS) checked the thermometer inside the refrigerator and stated the temperature was 45 degrees F. The DS stated a temperature reading of 45 degrees F could impact the food. The DS stated the temperature of the refrigerator should not be above 41 degrees F. During an observation on 11/11/2024 at 2:00 PM, the internal thermometer of the refrigerator temperature was listed as 49 degrees F. During an interview on 11/ 11/2024 at 2:45 PM, the Regional Dietician stated it was not okay for the refrigerator temperature to be 45 degrees F because dependent on how long it was 45 degrees F, it could cause a food-borne illness. During an interview on 11/14/2024 at 8:32 AM, the Director of Nursing (DON) stated she would not know the temperature, but expected staff to follow the food code regulations. The DON stated she believed that food should not be served if it was in the danger zone as bacteria loved heat. During an interview on 11/14/2024 at 9:31 AM, the Administrator stated the refrigerator temperature should be 41 degrees F or lower and acknowledged the facility policy indicated a temperature of 40 degrees of F or less. According to the Administrator, the refrigerator temperature should be maintained at 41 degrees F to ensure the prevention of food-borne illnesses.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' fingernails were clean and trimmed for 2 (Resident #2 and Resident #136) of 3 sampled residents reviewed for activities of daily living (ADLs). Findings included: A facility policy titled, Activities of Daily Living (ADLs), Supporting, revised 03/2023, revealed, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. The policy specified, 2. Appropriate care and services will be provided for resident's who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a hygiene (bathing, dressing, grooming, and oral care.) 1. An Admission Record revealed the facility admitted Resident #2 on 11/20/2007. According to the Admission Record, the resident had a medical history that included diagnoses of contracture of the right and left knee, personal history of transient ischemic attack, age-related osteoporosis, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/16/2024, revealed Resident #2 had a Staff Assessment for Mental Status (SAMS), which indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS indicated that Resident #2 was dependent on staff for all ADLs. Resident #2's care plan, included a focus area initiated 11/27/2018, that indicated the resident required assistance with ADLs because of a history of dementia and cognitive impairment. Interventions directed staff to assist with grooming and trimming of the resident's fingernails. During an observation on 11/12/2024 at 8:19 AM, Resident #2's fingernails were black and curled under. During an interview on 11/13/2024 at 9:32 AM, Certified Nurse Aide (CNA) #1 stated the trimming of a resident's fingernails was done by the restorative nurse aide (RNA). CNA #1 stated Resident #2's fingernails needed to be trimmed and that she noticed this a few weeks ago. According to CNA #1, she told a nurse, but she did not remember who, and the nurse stated she would direct the RNA to trim the resident's fingernails. During an interview on 11/13/2024 at 9:47 AM, Registered Nurse (RN) #3 stated the aides were allowed to trim the fingernails of residents who were not diabetic or at risk for infection of complications. During a concurrent follow-up interview and observation on 11/13/2024 at 10:22 AM, RN #3 stated she was not notified that Resident #2 needed their fingernails trimmed. RN #3 observed Resident #2's fingernails and stated eight of the resident's 10 fingernails needed to be trimmed. During an observation on 11/13/2024 at 10:24 AM, RN #3 stated Resident #2's fingernail in the middle of their left hand was black, long, and curled over. 2. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/28/2024, revealed the facility admitted Resident #136 on 10/23/2024. Per the MDS, the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #136 required partial/moderate assistance with personal hygiene. According to the MDS, the resident had active diagnoses to include other fracture, atrial fibrillation, hypertension, and abnormal posture, Resident #136's care plan, included a focus area initiated 10/26/2024, that indicated the resident required assistance with ADLs because of a history of displaced fracture of lateral malleolus of left fibula. Interventions directed staff to assist with grooming and trimming of the resident's fingernails. During an observation on 11/13/2024 at 10:06 AM, Resident #136's fingernails were long and black in color underneath. During an interview on 11/13/2024 at 10:07 AM, Resident #136 stated they would like to have their fingernails cut, but that has not happened for them. During an interview on 11/13/2024 at 9:47 AM, Registered Nurse (RN) #3 stated the aides were allowed to trim the fingernails of residents who were not diabetic or at risk for infection of complications. During a concurrent interview and observation on 11/13/2024 at 10:10 AM, Restorative Nurse Aide (RNA) #5 stated CNAs and RNAs could trim the fingernails of residents who were not diabetic. RNA #5 stated Resident #136's nails were long, dirty, and needed to be cut. During a concurrent follow-up interview and record review on 11/13/2024 at 10:15 AM, RNA #5 stated Resident #136 was a newly admitted resident and that was why their nails had not been cleaned or trimmed. RNA #5 reviewed Resident #136's medical record and stated the resident admitted to the facility on [DATE]. During a concurrent follow-up interview and observation on 11/13/2024 at 10:22 AM, RN #3 stated Resident #136 had been in the facility for three weeks and the resident should have had their fingernails trimmed. RN #3 stated Resident #136's fingernails were dirty and needed to be trimmed. Per RN #3, seven of the resident's 10 fingernails need to be trimmed and had black/brown stains underneath the fingernails. During an interview on 11/14/2024 at 8:39 AM, the Director of Nursing stated she expected the residents' fingernails to be clean and trimmed. During an interview on 11/14/2024 at 9:26 AM, the Administrator stated the residents' fingernails should be checked daily and their fingernails should be trimmed and cleaned regularly.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's catheter was secured using a securement device for 1 (Resident #52) of 2 sampled residents reviewed for urinary catheters. Findings included: A facility policy titled, Catheter Care, Urinary, revised 08/2022, indicated 4. Ensure that the catheters remains secured with a securement device to reduce friction and movement at the insertion site. An Admission Record indicated the facility admitted Resident #52 on 07/22/2022. According to the Admission Record, the resident had a medical history that included diagnoses of chronic kidney disease, benign prostate hypertrophy with lower urinary symptoms, obstructive and reflex uropathy, and urinary tract infection. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/2024, revealed Resident #52 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS revealed Resident #52 had an indwelling catheter. Resident #52's Order Summary Report, which contained active orders as of 11/13/2024, revealed an order dated 09/07/2024, that directed staff to secure the resident's indwelling catheter tubing with anchor, every shift to minimize dislodgement of the catheter. During catheter care observation on 11/12/2024 at 11:07 AM, Resident #52's indwelling care was not secured with a securement device. During an interview on 11/12/2024 at 11:13 AM, Licensed Vocational Nurse (LVN) #6 stated a resident's securement device for an indwelling catheter should be checked daily. LVN #6 stated she did not know why Resident #52 did not have a securement device, but there should be one. During an interview on 11/12/2024 at 11:49 AM, the Director of Nursing (DON) stated a leg band or anchor device should be in place for all residents with a catheter to ensure the catheter was kept in place. According to the DON, nurses were to ensure the device was in place at all times. During an interview on 11/14/2024 at 9:48 AM, the Administrator stated he expected the nurse aides to verify a resident's securement device was in place every shift and notify the nurse if it was not, so that it could be replaced.

Based on observation, interview, and record review the facility failed to follow their Policy when the nursing staff failed to provide care for 2 of 3 sampled Residents (Resident 1 and 2). This failure had the potential to place two clinically compromised Residents (Resident 1 and 2) psychosocial health and safety at risk. When facility staff failed to provide Resident ' s 1 and 2 with requested care and services. Findings: During an interview on October 2, 2024, at 4:37 PM, with Resident 1, Resident 1 in bed, is alert and oriented. Resident 1 stated it will take hours for the nursing staff to change her diaper no matter what time of day she activates the call light. During review of Resident 1 ' s admission Record (General demographics) on October 2, 2024, indicates admitted to facility on September 18, 2024, with diagnosis (DX) include Enterocolitis (inflammation of both the small intestine and the colon) muscle weakness, abnormalities of gait (the way a person walks) and mobility, hypertension (high blood pressure), Gastro-esophageal reflux (heartburn). During an interview on October 2, 2024, at 4:45 PM, with Resident 2. Resident 2 in bed, is alert and oriented Resident 2 stated three hours was the longest he had to wait before his call light was answered. He further added, sometimes they answer the light, leave without giving him the assistance he needs, and never return. During review of Resident 1 ' s admission Record (General demographics) on October 2, 2024, indicates admitted to facility on March 1, 2024, with diagnosis (DX) include Myocardial infraction (heart attack), abnormal posture, muscle weakness, pleural effusion (a condition where too much fluid builds up in the space between the lungs and the chest wall), type 2 Diabetes Mellitus (a chronic disease that occurs when the body can ' t properly use glucose, or blood sugar), Hypertension (High blood pressure). During concurrent observation and interview on October 2, 2024, at 5:20 PM with the Certified Nursing Assistant (CNA 1). From 4:43 PM to 5:20 PM, the call light was heard, but nobody answered. CNA 1 claimed that since she had not heard the call light, the sound must have come from the DSD office; however, when examining the call light panel, it was discovered that the sound was coming from a resident ' s room. During an interview on October 2, 2024, at 5:43 PM, with the Director of Staff Development (DSD 1), When asked why staff was not alerted by the call light sound, DSD 1 stated staff may have look at the hallway and don ' t see light on and didn ' t do anything. Stated they should have look at the panel to check where the sound came from. Stated in this case her staff is not following the guideline and policy. A review of the facility Policy and Procedure titled, Answering the Call light, Version 1.3 (H5MAPR0016), indicated, . 1. Answer the resident call system in timely manner .

Based on interview and record review the facility failed to prevent for one of three sampled residents Resident 1, two pressure injuries from reopening and an physician order placed a Computed tomography (CT) to right foot, instead of left foot. This failure placed a clinically compromised Residents (Resident 1) health and safety at risk and could have delayed treatment. Findings: During review of Residents 1 ' s Admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: contracture right knee (stiffness), vascular dementia (brain damage by multiple strokes, causing memory loss), flaccid neuropathic bladder (bladder doesn ' t contract, lead to urine retention). During a review concurrent interview and record review of Resident 1 ' s Medical Record with the Assistant Director of Nursing (ADON), reviewed are as follows: 1. SKIN PROGRESS REPORT: July 12, 2024, Coccyx Stage 4, measuring 3.5cmx4.6cmx0.1cm . Reopened sacrococcyx wound. 2. Skilled Nursing Facility (SNF) Wound Care Note dated July 12, 2024, Left hip reopened stage 3 measuring, 0.7x0.7x0.1, post debridement measurements 0.7x0.7x0.2. 3. Interdisciplinary Team (IDT) Note dated August 02, 2024, ' Meeting with daughter to discuss plan of care. Notified doctor family has concerns of foul smell and we are referring to osteomyelitis . 4. Order dated August 02, 2024, at 1457: May have Computed tomography (CT) (computerized X-ray imaging to Right heel to rule out osteomyelitis. (ORDER FOR THE WRONG FOOT, Right heel resolved June 03, 2024, per notes). During an interview on September 05, 2024, with the Treatment Nurse (TXT), the TXT nurse states, Resident 1 had right and left heel wounds, the right one was resolved. We were just treating his Left heel, I ' m not sure who put in the order for the Right Foot CT scan, that nurse is no longer here anymore. The wound specialist did not see signs of infection, we did notice a slight smell .she wound debride every time she came, there was slough to it. The daughter told me around the time he was sent out, it does not look well. During a concurrent interview and record review on September 05, 2024, with the Assistant Director of Nursing (ADON), the ADON states, On August 02, 2024, we had meeting with family, the concerns were the foot infection. We called the doctor and got an order for (CT) right heel for osteomyelitis. The family wanted to send him out, so we did not get a chance to do the CT on the foot. Acknowledge after record review, order was written for the wrong foot. During an interview with the Director of Nursing (DON), DON states, Resident 1 wounds did reopen here, he does have medical history that can attribute. Acknowledge after record review, order was written for the wrong foot. During a review of the facility ' s policy and procedure titled, Prevention of Pressure Injuries revised March 2023, the policy and procedure indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific factors .Assess the resident on admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition .reposition all residents with or at risk for pressure injuries on an individualized schedule, as determined by the interdisciplinary team .evaluate, report and document potential changes in the skin, review the interventions and strategies for effective ness on an ongoing basis. During a review of the facility ' s policy and procedure titled, Wound Care 2021, the policy and procedure indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.

ased on interview and record review, the facility failed to protect against physical and verbal abuse for one of three sampled residents (Resident 1) when Resident 1 fell out of bed and a Certified Nursing Assistant (CNA 1) pulled Resident 1 by one arm back onto the bed and Resident 1 ' s hip rubbed against the footrest. The CNA 1 stated to Resident 1 Stop that! you ' re being annoying! This failure caused Resident 1 to suffer physical and verbal abuse. Findings: An unannounced visit was made to the facility on [DATE], at 9:48 AM, to investigate a facility reported incident regarding an allegation of physical and verbal abuse. A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an initial admitted [DATE]. Resident 1 had diagnoses that included partial paralysis of the left side of the body following a stroke and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of a Registered Nurse Supervisor ' s (RNS) witness statement, undated, indicated, RN [RNS]: I walked into the room and noticed that resident [Resident 1] had rolled off her bed unto the other mattress, so I said to CNA [CNA 1], ' hold on, let me put on my gloves. ' Unfortunately, she didn't wait, and CNA [CNA 1] pulled resident by one arm onto the bed and the resident rubbed hip against the footrest. The RNS was unavailable for interview. During an interview with Resident 1 on May 21, 2024, at 11:14 AM, Resident 1 stated, I'm sorry I don't feel like talking. During an interview with a Minimum Data Set/Licensed Vocational Nurse (MDS/LVN 1) on May 21, 2024, at 2:14 PM, The MDS/LVN 1 stated she was walking out of her office and overheard CNA 1 say, Stop that! you're being annoying! from Resident 1 ' s room. The MDS/LVN 1 stated she knew CNA 1 well enough to know it had been her voice. During an interview with a Licensed Vocational Nurse/Infection Preventionist (LVN/IP) on May 21, 2024, at 2:21 PM, The LVN/IP stated she saw CNA 1 walk into Resident 1's room and heard her state Stop that! you're being annoying! A review of CNA 1 ' s statement, undated, indicated, CNA [CNA 1] Statement: At around 12:00 pm we asked CNA [CNA 1] if she had been a little rough with resident [Resident 1] and she answer ' No. ' The CNA 1 was unavailable for interview. During an interview with the Administrator (Admin) on May 21, 2024, at 12 PM, the Admin stated he was the facility ' s abuse coordinator. The Admin stated he was not working as the Administrator at the time of the incident, however, after reviewing the interviews and records from the prior Administrator he determined the facility had failed to protect Resident 1 from verbal and physical abuse. The Admin stated the facility ' s policy and procedure titled, Abuse and Mistreatment of Residents, dated May 3, 2023, had not been followed. A review of the facility ' s policy and procedure titled, Abuse and Mistreatment of Residents, dated May 3, 2023, indicated, Purpose: To uphold a resident ' s right to be free from verbal, sexual, and mental abuse, corporal punishment, neglect, and involuntary seclusion. Prevention Guidelines: Facility shall institute procedures to provide residents, families, and staff information on how and to whom they may report concerns, incidents, and grievance without the fear of retribution. The facility shall also provide feedback regarding the concerns that have been expressed. Facility shall also institute procedures that allow for identification, correction, and intervention in situations in which abuse, neglect, and/or misappropriation of resident property is more likely to occur. Areas of identification, correction, and intervention may include, but are not limited to facility environment, staffing and supervision of staff, identification of residents with potential for behavioral symptoms and manifestations that may lead to conflict or anger through comprehensive assessment, care planning, and monitoring.

Based on observation, interview, and record review, the facility failed to ensure the highest quality of care when licensed nursing staff did not accurately assess the injuries sustained by one of three residents (Resident 1), who they failed to protect from serious injury. Resident 1 required set up and supervision with meals and was not assisted by the certified nursing assistant (CNA 3) who placed a cup of hot coffee on Resident 1's overbed table but did not ensure the coffee was within Resident 1's reach. This failure resulted in the cup of hot coffee to slide off the overbed table, which was slightly slanted, when Resident 1 tried to pull the overbed table closer to reach his coffee, causing scalding [CONDITION(S)] on Resident 1's left hand, wrist and the left side of his abdomen. In addition, the facility's failure to identify the injury as a first-degree scalding burn (top layer of skin is reddened), instead of listing it as scattered redness, and not reporting to the physician when swelling, blisters and peeling skin were observed on the burn sites, resulted in a delay of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: During an interview on June 27,2022, at 4:05 PM with the Director of Nurses (DON) regarding a self-reported incident of Resident 1 spilling hot coffee on himself, the DON stated facility failed to report the incident in a timely manner because she thought it was only scattered redness. During a concurrent observation and interview on June 27, 2022, at 4:13 PM, with Resident 1, while in his room sitting in his wheelchair, Resident 1 was observed to have a bandaged left hand. Observed Resident 1 to be unable to raise or move his left arm and hand, due to a previous stroke leaving him with a contracted left hand and left side weakness. Resident 1 stated he spilled hot coffee on his left hand and abdomen as he tried to reach for the coffee that was slowly sliding from the edge of his bedside table. Observed table surface was not straight but slightly slanting. During an observation on June 27,2022, at 4:23 PM in Resident 1's room, the Director for Staff Development (DSD) was going to remove the dressing from Resident 1's left hand and explained what she was going to do before removing the dressing to observe the site of injury. The skin of the left hand was observed to be peeled off from the base of the thumb to the wrist, showing a beefy red wound bed, with some areas having white to greenish patches. The wound bed measured 7 x 3 centimeters (cm= 0.39 inches). During observation on June 27,2022, at 4:23 PM of Resident 1's abdomen where the hot coffee had spilled, there were multiple scald [CONDITION(S)] the size of a dime some with eschar (dead tissue) that were located from below the left nipple line through the left lower abdominal area. During a review of Resident 1's face sheet (a record that provides the demographic data of the resident) indicated, an elderly resident who was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 1's Minimum Data Set (MDS) Section G, Functional Status, indicated Resident 1 requires supervision and set up during meals. Resident 1 also had limited range of motion on one side (left) of his upper extremity (shoulder, elbow, wrist, hand). During a review of Nursing Care - Change of Condition (NC -COC)/ Assessment Form (SBAR) (Situation, Background, Assessment, Recommendation) (communication tool that helps provide essential and concise information) v1.3: nursing notes dated June 24, 2022, written by a Licensed Vocational Nurse (LVN 1) (11:00 PM- 7:00 AM shift), indicated, At around 7:00 AM resident called that he spilled his coffee on self. Half of the cup was spilled on him and his bed. No blisters noted to abdomen or left hand. Per resident he only feels some stinging. Cleaned area and provided towels. Resident comfortably at this time. Inform the physician and endorses continuation of care to incoming nurse. During a review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of a second physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the Treatment Administration Record (TAR), dated June 2022, it indicated that [MEDICATION(S)] Cream was started June 25, 2022, instead of on June 24, 2022, when medication was initially ordered. During a review of NC -COC/ Assessment Form (SBAR) v1.3: nursing notes dated June 24,2022 written by LVN 2 (7:00 AM - 3:00 PM shift), indicated, with new order to apply cold compress to left hand and abdomen Q2hrs (every two hours) for 15 minutes for 24 hours. Wife was informed. Some redness on abdomen and redness and some peeling noted on the left hand. During a review of NC (Nursing Care) Licensed Nurse Record Change of Condition v1.1: nursing notes dated June 24, 2022, written by LVN 3 (3:00 PM - 11:00 PM shift), indicated, Some redness noted on abdomen and redness and some peeling noted on left hand. During a review of NC (Nursing Care) Licensed Nurse Record Change of Condition v1.1nursing notes dated June 24, 2022, written by LVN 1 (11:00 PM- 7:00 AM shift), indicated, Resident continues with treatment order [MEDICATION(S)] cream 1% and cold compress x 24hrs to abdomen and left hand. No open skin noted. Some redness still noted. During a review of NC (Nursing Care) Licensed Nurse Record Change of Condition v1.1nursing notes dated June 25,2022, written by LVN 4 (7:00 AM - 3:00 PM shift), indicated, Abdominal area is slight pink in color with no swollen areas noted. Left hand burn is swollen and red. During a review of NC (Nursing Care) Licensed Nurse Record Change of Condition v1.1nursing notes dated June 25, 2022, written by LVN 5 (3:00 PM- 11:00 PM shift), indicated, Resident is on monitoring for burn to abdomen and left-hand wrists area. Abdomen area noted to pink and left hand noted with swelling. During a review of NC (Nursing Care) Licensed Nurse Record Change of Condition v1.1: nursing notes dated June 25,2022, written by LVN 1 (11:00 PM- 7:00 AM shift), indicated, Redness still noted left hand with some peeling. During a review of NC (Nursing Care) Licensed Nurse Record Change of Condition v1.1: nursing notes dated June 26,2022, written by LVN 4 (7:00AM- 3:00 PM shift), indicated, Abdominal area is slight pink in color with no swollen or open areas noted. Left hand burn swollen and red. During a review of NC (Nursing Care) Licensed Nurse Record Change of Condition v1.1: nursing notes dated June 26,2022, written by LVN 3 (3:00 PM- 11:00 PM shift), indicated, Continues monitoring for redness to abdominal area and left hand due to spilling coffee on self. Redness still noted to left hand with some peeling. During a review of NC (Nursing Care) Licensed Nurse Record Change of Condition v1.1: nursing notes dated June 26,2022 written by LVN 6 (11:00 PM - 7:00 AM shift), indicated, Redness to his abdominal area and his left hand with some peeling. Continue with [MEDICATION(S)] cream 1% (is a topical antimicrobial drug indicated as an adjunct for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of NC (Nursing Care) Licensed Nurse Record Change of Condition v1.1: nursing notes dated June 27,2022, written by LVN 2 (7:00 AM - 3:00 PM shift), indicated, On monitoring for redness to left arm and abdominal area. Redness with peeling noted on left arm and some redness throughout abdomen s/p spilling coffee on self. During an interview on June 27,2022, at 4:45 PM, with a Certified Nurse Assistant (CNA 1), CNA1 stated on Friday, June 24,2022 she worked her regular shift (3:00 PM-11:00 PM shift) and learned about the incident from the report given by her co-worker. She didn't see what happened to the left hand as it was bandaged but saw Resident 1 had redness on his abdomen while changing his diaper. She notified the charge nurse but was informed that they are aware, and it was being treated. When asked how coffee was provided to residents, CNA 1 coffee was obtained for residents two ways, first was from the kitchen, a cup with a lid was used, because of the long walk from the kitchen to the resident's room. The second way was from the coffee cart that was being used to deliver coffee to resident's rooms before meals. The coffee delivered from the coffee cart did not have a lid. During a concurrent observation and interview on June 27,2022, at 5:08 PM, with the Registered Nurse Supervisor (RN Sup), in the hallway, observed CNA 2 pushing the coffee cart and offering coffee to residents. On this coffee cart was a large multi-cup coffee pot, colored plastic mugs and condiments. CNA 2 stated cup lids were not used, because there was only a short distance from the cart to the resident's room. The RN Sup stated, when the coffee comes directly from the kitchen then the cup would have a lid, because of the long walk from the kitchen to the resident's room. Upon request CNA 2 poured a sample of the coffee into a colored plastic mug, the mug was cool to touch, however, when coffee temperature was measured using a thermometer it read 166.6 degrees Fahrenheit. The RN Sup stated, That is hot. During an interview on June 27,2022, at 5:53 PM, with the Wound Care Nurse (WCN), the WCN stated she assessed Resident 1 at 10:00 AM on Friday June 24, 2022, and initially no skin discoloration or redness was seen on the left hand and abdomen, but when she reassessed Resident 1 between 3:00 -4:00 PM she saw blistering on the left hand, but nothing on the abdomen however, she admitted she didn't document her findings. She also stated, she was aware of the [MEDICATION(S)] cream order and assumed it was acquired from the pharmacy. She also stated, the physician ordered the [MEDICATION(S)] cream to probably granulate and prevent burn. During an interview on June 27,2022, at 6:15 PM with the Director of Nursing (DON), the DON stated, she didn't report the incident right away because there was only redness and no blister on the left hand and left abdomen where the coffee spilled. The DON stated, Yes, agree it's a burn. When asked when she saw the redness from spilled coffee and the physician ordered [MEDICATION(S)] Cream wouldn't a scalding burn from a hot liquid be considered an unusual occurrence and reportable? The DON repeated, It was only redness. During an interview on June 28, 2022, at 2:10 PM with CNA3, CNA 3 stated, Resident 1 will request coffee at 7:00 AM and watches TV. She stated, on June 24, 2022, she got Resident 1 a cup of coffee from the kitchen and placed it at his bedside table and left. She also stated she left because Resident 1 was alert and only needs set-up. During an interview on July 6, 2022, at 2:35 PM with LVN3, LVN3 was asked about her assessment on Resident 1's injuries, she stated, Yes, I knew it was a burn. LVN 3 stated she didn't document her assessment as [CONDITION(S)] because didn't seem like it was at that time, however, she stated she had seen small blister like areas forming on Resident 1's left lower abdomen when she re-assessed the resident. During a concurrent interview and record review on July 6, 2022, at 2:10 PM with the DON, NC- Licensed Nurse Record (Change of Condition) v1.1 dated June 25, 2022, was reviewed. The NC- Licensed Nurse Record (Change of Condition) v1.1 indicated, LVN4 observed Resident 1's left hand burn was swollen, and red. The DON stated, She took it upon herself to document it was a burn and no, there was no documentation that she called the physician. During a concurrent interview and record review on July 6, 2022, at 2:10 PM with the DON, NC- Licensed Nurse Record (Change of Condition) v1.1 dated June 25, 2022, was reviewed. The NC- Licensed Nurse Record (Change of Condition) v1.1 indicated, LVN5 (registry nurse) observed Resident 1's burn to the abdomen and left-hand wrist was swollen. DON stated, No, there was no documentation that she called the physician. During a concurrent interview and record review on July 6, 2022, at 2:10 PM, with the DON, Policy: Change of Condition (undated) was reviewed. The policy indicated, Definition: A change of condition is a sudden or marked difference in resident's: .12. Bruises, lacerations, blister, rashes, or skin tears. 13. Skin condition (e.g., swelling or discoloration) .Content: C. Upon Change in Condition for any reason, nursing staff members are to take the following actions .b. Physician shall be called promptly. DON stated her staff did not follow the policy.

Based on observation, interview, and record review, the facility failed to ensure the glucometer (a device used to perform the finger stick blood test (pricking with a tiny needle and then using a little strip and a glucometer to test blood sugar levels) was disinfected according to the manufacturer's guidelines and adhere to use specified Environmental Protection Agency (EPA) approved disinfectant (a chemical agent that destroy bacteria, virus, and fungi) and to the facility's policy and procedure to use the appropriate disinfectant before and after residents' use for four of 35 sampled residents (Residents 63, 56, 30, and 9) in the universe of 95 residents. 1. For Resident 63, the Licensed Vocational Nurse (LVN 2) did not disinfect the glucometer before resident use. 2. For resident 56, 30 and 9 the LVN 5 did not disinfect the glucometer before, after and between the finger stick blood test. These failures created an overall danger of transmission of a blood borne infection (disease that can be spread through contaminated blood and other body fluids) to 35 residents who shared a potentially contaminated glucometer. Findings: 1. During a review of the clinical record for Resident 63, the Admission Record (a document containing demographic and medical information) indicated, Resident 63 was admitted on (MONTH) 4, 2019, with a [DIAGNOSES REDACTED]. During a review of Resident 63's Order summary report dated (MONTH) 26, 2019, indicated, Finger stick blood sugar monitoring: AC meals (before meals) During a review of the clinical record for Resident 63, the Medication Administration Record [REDACTED]. During an observation on (MONTH) 18, 2019, at 12:19 PM, LVN 2 took the glucometer out of the medication cart then put on gloves. LVN 2 then placed the glucometer on Resident 63's bed and performed a finger stick blood test. LVN 2 removed the gloves along with the blood test strip and placed the glucometer on the medication cart. LVN 2 disinfected the glucometer with the disinfectant wipes. LVN 2 did not disinfect the glucometer prior to use and he failed to perform hand hygiene after the finger stick blood sugar was checked on Resident 63. During an interview with LVN 2 on (MONTH) 18, 2019, at 12:28 PM, LVN 2 acknowledged he did not wash his hands after Resident 63's finger stick blood test and instead he wore the gloves in order to prevent infection. LVN 2 further stated he would not disinfect the glucometer prior to use and only disinfect after the use. 2. A review of the clinical record for Resident 56, the Admission Record (a document containing demographic and medical information) indicated, Resident 56 was admitted on (MONTH) 4, (YEAR) with [DIAGNOSES REDACTED]. During a review of Resident 56's History and Physical (H&P) dated (MONTH) 10, (YEAR) indicated, Resident 56 had a medical [DIAGNOSES REDACTED]. During a review of Resident 56's Order summary report dated (MONTH) 26, 2019, indicated, blood sugar monitoring: BID (twice a day) AC meals (before meals) During an observation on (MONTH) 20, 2019, at 5:35 AM, LVN 5 placed the glucometer on the Medication Cart B and inserted the strip, put on gloves and placed the glucometer on Resident 56's bed and performed the finger stick blood test on Resident 56. LVN 5 removed gloves and the discarded the lancet (tiny needle) in to the sharp container and placed the glucometer on the medication cart B. LVN 5 did not disinfect the glucometer before and after the finger stick blood test on Resident 56. A review of the clinical record for Resident 30, the Admission Record (a document containing demographic and medical information) indicated, Resident 30 was admitted on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. During a review of Resident 30's Order summary report dated (MONTH) 26, 2019, indicated, Finger stick blood sugar monitoring BID (twice a day) AC meals (before meals) @6:30 AM and 4:30 PM During an observation on (MONTH) 20, 2019, at 5:51 AM, LVN 5 took the strip out of the container and attached to the glucometer, put on gloves and placed the glucometer on Resident 30's bed. LVN 5 pricked the right index finger of the resident (Resident 30) and obtained the blood sample and placed the glucometer with the blood sampled strip on the medication cart B and removed the blood strip after the meter read the blood sugar. LVN 5 did not disinfect the glucometer before and after the finger stick blood test on Resident 30. A review of the clinical record for Resident 9, the Admission Record (a document containing demographic and medical information) indicated, Resident 9 was admitted on (MONTH) 17, (YEAR), with [DIAGNOSES REDACTED]. During a review of Resident 9's Order summary report dated (MONTH) 26, 2019, indicated, Finger stick blood sugar monitoring daily . During an observation on (MONTH) 20, 2019, at 5:58 AM, LVN 5 attached the blood sugar strip on the glucometer then put on gloves and placed the glucometer on Resident 9's bedside table and obtained the blood sample to the strip after pricking the finger of the resident with a lancet. LVN placed the glucometer on the Medication Cart B after removing the blood sampled strip. LVN 5 did not disinfect the glucometer before and after the finger stick blood test on Resident 30. During an interview with LVN 5 on (MONTH) 20, 2019, at 6:05 AM, LVN 5 stated he did not clean the glucometer with disinfectant wipes before and after these three residents (Residents 56, 30 and 9). LVN 5 further stated he usually cleans the glucometer with alcohol swabs or if the disinfectant wipes available. LVN 5 was unable to find a disinfectant wipe on his medication cart. During an interview with the Director of Staff Development/Infection Preventionist (DSD/IP) on (MONTH) 20, 2019, at 8:48 AM, the DSD/IP, stated staff are expected to clean the glucometer with the facility approved disinfectant wipes (BRAND NAME) before, after and between the resident's use. The DSD/IP further stated the facility used red lid (BRAND NAME) disinfectant wipes to disinfect the glucometer, in order to prevent the cross contamination and blood borne infection. During a review of the facility's undated policy and procedure titled Cleaning Glucometers indicated .3. Wipe glucometer thoroughly with appropriate disinfectant, such as Sani-cloth HB, Cavi Wipe, or Sani- cloth plus, and leave for recommended time .6. Wipe the outside of the meter .after each resident use During a concurrent interview and record review with the Director of Nursing (DON) on (MONTH) 20, 2019, at 9:02 AM, the DON, stated staffs are expected to disinfect the glucometer with the facility's approved disinfectant wipes (red lid BRAND NAME), before after and between resident's finger stick blood test and wait for air dry. The DON further reviewed the facility's approved disinfectant wipes canister and stated the kill time was 2 minutes and staff are expected to wait for two minutes after disinfection of the glucometer. The DON further reviewed the facility's undated policy and procedure titled Cleaning Glucometers and acknowledged the facility did not follow the policy and procedure. During a review of the (BRAND NAME) undated glucometer's reference manual, indicated, the EPA registered wipes with the name (BRAND NAME). The failure to follow and implement infection control prevention policy and procedure and manufacturer's guideline resulted in an Immediate Jeopardy (IJ- immediate danger of harm). An IJ was identified and called on (MONTH) 20, 2019, at 1:15 PM, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). The ADMIN and DON was informed of the observations, interviews, and record reviews with the facility staff. The facility provided a corrective action plan, which included employee asked to come in for a 1:1 in serviced/ re- education about, Infection control guidelines that includes but is not limited to handwashing, disinfection of equipment particularly glucometers. Proper use of glucometer, strips, and control solution. Including performance and documentation of glucose monitoring system record. Employee received performance corrective notice. Deficient practice immediately rectified, and employee will be monitored for performance during the next 30 days. Initiated in service/ re- education amongst Licensed Nurses(LN) about Infection control guidelines that includes but is not limited to handwashing, disinfection of equipment particularly glucometers. Proper use of glucometer, strips, and control solution. Including performance and documentation of glucometer quality control (QC) monitoring system record. Ordered new glucometers: once available old glucometers to be replaced and initial QC check performed prior to use. Update policy and procedures for glucometer to include steps how to clean the equipment. All residents who uses the glucometer for blood sugar monitoring are being assessed by a Registered Nurse(RN) for any signs and symptoms of infection. Glucometers will continuously be monitored fro QC by checking daily. All staff were informed electronically via On- shift regarding proper handwashing. All LNs were reminded electronically via On- shift regarding proper disinfection of glucometers. The Staff Developer (DSD) or Designee will continue to provide ongoing in services or re- education about handwashing and proper disinfection of glucometers. The DSD or designee will review glucometer QC monitoring weekly for completeness for four weeks. The corrective plan will be used as a part of our QAPI and will be reviewed at the monthly utilization review meeting for evaluation and recommendations. Facility's policy and procedure titled Disinfecting Glucometers dated (MONTH) 20, 2019 updated with .3. Wipe glucometer thoroughly with disinfectant wipes (Red BRAND NAME). Keep glucometer wet for two minutes and allow to dry . The IJ was lifted on (MONTH) 21, 2019, at 2:30 PM, in the presence of the ADMIN and DON after submission of an acceptable corrective action plan. Observation, staff interviews, and record reviews were conducted to ensure corrective action plan was implemented.

Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free of hazards when one resident (Resident 342) was observed with an electrical space heater in his room with the doors closed for one of 95 sampled residents. This failure had the potential to develop electrical hazards to the residents through the improper use or maintenance of the space heater, which can potentially jeopardize the resident's safety with fire risks,[MEDICAL CONDITION] death. Findings: During an observation on (MONTH) 18, 2019, at 11:10 AM, a space heater was found on the bedside table and it was used by the resident (Resident 342) in the room with the doors closed. During a concurrent interview with Resident 342 he stated he always felt the room was cold and would like to keep the space heater nearby him turned on. Resident further stated he told the facility staff about the room temperature and they did not do anything. A review of Resident 342's Admission Record (basic information containing demographic and medical information) indicated, Resident 342 was admitted on (MONTH) 5, 2019, with a [DIAGNOSES REDACTED]. During a review of Resident 342's admission Minimum Data Set (MDS, an assessment tool) dated (MONTH) 12, 2019, indicated a Brief Interview for Mental Status (BIMS, an assessment tool) with a score of 15 (a BIMS score of above 13 show little to no impairment on a person's cognition). During an interview with the Maintenance Supervisor (MS) on (MONTH) 18, 2019, at 2:37 PM, the MS acknowledged that Resident 342 was using a space heater and the resident did not want to remove it. The MS further stated as long as the space heater cord was good and there were no frayed wires, it was safe to use. During an interview with the administrator (ADMIN) on (MONTH) 18, 2019, at 2:40 PM, the ADMIN acknowledged Resident 342 was using a space heater in his room. During a concurrent interview and observation with the Director of Nursing (DON) in Resident 342's room, on (MONTH) 18, 2019, at 2:43 PM, the DON stated it was not okay to have a space heater being used with doors closed. The DON further acknowledged the room (Resident 342's) doors were closed and the space heater being used by Resident 342. The DON further stated the family brought in the space heater couple of days after his admission. During a review of Resident 342's Interdisciplinary Team Conference record (IDT- group of health care professionals from diverse fields), dated (MONTH) 17, 2019, the IDT meeting conducted for the refusal to leave the door open and prefers to use portable heater. During a review of Resident 342's clinical record reflects, a Care plan: Noncompliance (an individualized plan for the medical care of a resident) dated (MONTH) 17,2019, which indicated, Patient prefers to use his personal heater, patient refused to leave door open with a goal of turn on heater for a few hours and recheck During a concurrent interview and record review with the Licensed Vocational Nurse (LVN 6) on (MONTH) 18, 2019, at 2:55 PM, LVN 6 stated the resident (Resident 342) preferred to close his room doors always and complains the room was cold. LVN 6 further reviewed Resident 342's inventory list dated (MONTH) 5, 2019, and acknowledged there was no space heater listed. LVN 6 stated CNAs and any other staff would usually update the inventory list any time the family brings any other personal belongings with a plastic tab for additional belongings and acknowledged there were no additional belongings updated in the inventory list of Resident 342. During a follow up interview with the MS on (MONTH) 18, 2019, at 3:15 PM, the MS stated when a resident or family brings in any portable electric equipment, the MS or his assistant will do a continuity test of the equipment initially and then monthly. The MS was unable to provide the initial continuity test document on (MONTH) 18, 2019. During a follow up interview and record review with the DON on (MONTH) 19, 2019, at 10:05 AM, the DON reviewed and acknowledged the facility's record titled Maintenance Request Log for the month of March, 2019. The Maintenance Request Log did not indicate Resident 342 had a complaint of the room temperature. This failure to follow the regulation resulted in an Immediate Jeopardy (IJ- immediate danger of harm). An IJ situation was identified and called on (MONTH) 18, 2019, at 4:15 PM, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). The ADMIN and DON was informed of the observations, interviews, and record reviews with the facility staff concerning the space heater for Resident 342. The facility provided a corrective action plan, which included the space heater was immediately removed from Resident 342's room, blankets were offered to the resident to keep him warm. The MS adjusted room temperature to 75 degrees Fahrenheit (F-a unit of measurement). All residents room were checked by the MS/assistant to ensure no other rooms have space heater. No other rooms were identified to have deficient practice. ADMIN provided one on one in service education to the MS and maintenance assistant that no space heater is to be in resident's room. All employees present were provided with in-service education by the DSD after the deficient practice was identified to ensure resident's safety. Will continue to provide on-going in-services for all employees. Certified Nursing Assistants (CNA) while doing the inventory upon admission and readmission, they are to remove any space heater, maintenance supervisor/assistant are to do the daily rounds on all new residents to the facility to ensure no space heater. During the admission process the admission coordinator will notify residents and family that no space heaters are allowed in the facility. The staff developer will continue to provide ongoing in service education on space heater. Department heads are to do visual checks on their assigned room rounds and ensure that no space heater are in the resident's rooms. All staffs were also informed via On-shift regarding space heater. MS/Assistant will do a daily monitoring for 4 weeks, then monthly for three months, then quarterly for a year and onwards. MS/Assistant will report to the ADMIN of his findings. The ADMIN will report the findings and monitoring as part of our QAPI during the monthly Utilization review meeting for evaluation and recommendations. The IJ was lifted on (MONTH) 19, 2019, at 3:35 PM, in the presence of the ADMIN and DON after submission of an acceptable corrective action plan. Observation, staff interviews, and record reviews were conducted to ensure corrective action plan was implemented.

Based on observation, interview, and record review, the facility failed to ensure for two of 23 residents (Resident 47 and 80) who receive insulin (an injectable medication which helps keep blood sugar level from getting too high or too low) that the insulin is administered according to the physician's orders [REDACTED].>1. For Resident 47, review of the Medication Administration Record (MAR), revealed Licensed Vocational Nurse (LVN 5) failed to administer insulin in accordance with the physician's orders [REDACTED]. This placed Resident 47 at risk for [MEDICAL CONDITION] (high blood sugar) or [DIAGNOSES REDACTED] (low blood sugar). 2. For Resident 80, Licensed Vocational Nurse (LVN 7) did not perform the blood sugar testing and administer the insulin as per the physician's orders [REDACTED]. These failures had the potential to cause harm and even death to Resident 47 and Resident 80 due to the effects of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Findings: 1. A review of Resident 47's clinical record, indicated Resident 47 was admitted to the facility on (MONTH) 4, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident 47's physician's orders [REDACTED]. A review of the Resident 47's medication administration record (MAR) for the month of (MONTH) 2019 indicated the following: On (MONTH) 2, 2019, (MONTH) 3, 2019, (MONTH) 5, 2019, (MONTH) 9, 2019, (MONTH) 10, 2019, (MONTH) 14, 2019 and (MONTH) 19, 2019, there was no documented evidence in Resident 47's clinical record the blood sugar testing had been performed and documented. A further review of the MAR for the month of (MONTH) 2019, indicated the following: On (MONTH) 1, 2019, the long acting insulin was held with a documented blood sugar of 100. On (MONTH) 17, 2019, the long acting insulin was held with a blood sugar documented as 100. On (MONTH) 18, 2019, the long acting insulin was held with a blood sugar documented as 108. A further review of the MAR for the month of (MONTH) 2019, indicated the following: On (MONTH) 3, 2019, insulin was administered with no blood sugar results documented. On (MONTH) 5, 2019, there was no long acting insulin given and no blood sugar results documented. On (MONTH) 2, 2019, The long acting insulin was held and there was no blood sugar reading. On (MONTH) 3, 2019, the long acting insulin was administered with no blood sugar results. On (MONTH) 5, 2019, there was no blood sugar reading. There was no long acting insulin given. On (MONTH) 7, 2019, the long acting insulin was held with no blood sugar reading. On (MONTH) 9, 2019, the long acting insulin was held with no documented blood sugar reading. On (MONTH) 10, 2019, the long acting insulin was held with no documented blood sugar reading. On (MONTH) 14, 2019, the long acting insulin was held with no documented blood sugar reading. During an interview with LVN 3, on (MONTH) 19, 2019 at 2:00 PM, she stated, I would check the blood sugar and record it on the MAR and hold for the parameter. LVN 3 stated It was not being consistently documented on the MAR. During an interview with medical records (MR), on (MONTH) 19, 2019 at 3:32 PM she confirmed and stated the insulin is being held at times when the orders show it should have been given. During an interview and concurrent record review with the Director of Nurses (DON) on (MONTH) 19, 2019 at 3:36 PM, the DON confirmed there was no documented evidence the blood sugars were checked on (MONTH) 2, 2019, (MONTH) 3, 2019, (MONTH) 5, 2019, (MONTH) 9, 2019, (MONTH) 10, 2019, (MONTH) 14, 2019, and (MONTH) 19, 2019. The DON stated, Doctor's orders were not followed. The DON further stated, Insulin should have been given (MONTH) 1, 2019, (MONTH) 17, 2019, and (MONTH) 18, 2019. The DON confirmed there was no documented evidence in the nurses notes to show a change of condition for holding the long acting insulin. There was no documented evidence of notification to the physician for the held insulin. This had the potential to cause harm or death to Resident 47. During an interview on (MONTH) 20, 2019 at 7:30 AM, with LVN 5, regarding the blood sugar check on (MONTH) 1, 2019, when [MEDICATION NAME] (long acting) insulin was held for blood sugar of 100, he stated that it was what he did, held it in error. On Mach 2, 2019, LVN 5, held [MEDICATION NAME] but did not document it anywhere. On (MONTH) 3, 2019 [MEDICATION NAME] was given per LVN 5, with no documented blood sugar check. LVN 5 stated, I cannot prove that I did check the blood sugar. LVN 5 stated he held the [MEDICATION NAME] on (MONTH) 18, 2019, for a blood sugar result of 108. LVN 5 stated he did not document the blood sugar result and gave the [MEDICATION NAME] on (MONTH) 19, 2019. LVN 5 verified the MAR documentation. During a record review of the Licensed Nurse Competency Check List for LVN 5 it revealed LVN 5 as being signed off as competent for Demonstrates ability to perform blood sugar checks using glucometer . on (MONTH) 12, (YEAR) and for Demonstrates ability to administer medications efficiently and correctly on (MONTH) 12, (YEAR). During a telephone interview on (MONTH) 20, 2019 at 2:25 PM, with the facility pharmacist (PHARM), she stated she reviews the Medication Administration Record (MAR) of which she audits once a month and if she found a discrepancy she would talk to the charge nurse and give her a report and also report it to the Director of Nurses. The PHARM states her last two reviews were done on (MONTH) 17, 2019 and chart review only on (MONTH) 17, 2019. The PHARM was informed for the date of (MONTH) 28, 2019 there was no blood sugar documented and the [MEDICATION NAME] was held, and on (MONTH) 1, 2019 blood sugar documented as 100 and [MEDICATION NAME] was held, and on (MONTH) 2, 2019 no blood sugar documented and [MEDICATION NAME] was held for Resident 47. The PHARM stated, I don't have anything on that, I haven't reviewed all the MAR's for the month of March. The PHARM stated, I did not inform anyone of the discrepancy on the MAR for Resident 47. The PHARM stated, Insulin is considered a high alert medication. A review of the facility's policy and procedure titled, Blood Sugar Monitoring with Insulin Administration, undated, indicated, This facility will administer insulin according to the physician's orders [REDACTED]. The blood sugar value will be documented and, if ordered, insulin coverage given will be administered and documented. A review of the facility's policy and procedure titled, Medication Administration-General Guidelines, dated (MONTH) (YEAR), indicated, Medications are administered in accordance with written orders of the attending physician. 2. During a review of the clinical record for Resident 80, the Admission Record (a document containing demographic and medical information) indicated, Resident 80 was admitted on (MONTH) 13, (YEAR), with a [DIAGNOSES REDACTED]. During a review of Resident 80's History and Physical (H&P) dated (MONTH) 17, (YEAR), the H&P indicated resident has a [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 80, the Order Summary Report dated (MONTH) 26, 2019, indicated, Finger stick blood sugar(BS) Monitoring :BID (twice a day) AC meals (before meals)with regular insulin sliding scale coverage sub Q (Subcutaneous-route to administer insulin under the skin with a needle) as follows: 150-200 = 2U (Unit is a measurement), 201-250 = 4U, 251-300 = 6U, 301-350 = 8U, 351-400 = 10U. Notify MD if blood sugar is above 400 and below 60 MG/DL(Milligrams -MG/Desi liter-DL- unit of measurement) two times a day for DM. Insulin NPH (Human) ([MEDICATION NAME]) suspension (type of medicine to control the blood sugar level) 100U/ML inject 4 unit sub Q two times a day for DM hold if BS below 100 MG/DL. During a review of the clinical record for Resident 80, the Medication Administration Record (MAR- record of drugs administered to the resident) for the month of (MONTH) 2019, indicated, on (MONTH) 17, 2019, at 4:30 PM, neither the BS was performed nor the sliding scale insulin was administered. During further review of the MAR indicated on (MONTH) 17,2019, at 6:00 PM, for insulin NPH BS level and the site of insulin administration were left blank. During a concurrent interview and record review with Licensed Vocational Nurse (LVN 6) on (MONTH) 20, 2019, at 12:20 PM, LVN 6 reviewed Resident 80's MAR for the Month of (MONTH) 2019 and verified (MONTH) 17, 2019, at 4:30 PM, neither the BS was performed nor the sliding scale insulin administered. During further review of the MAR indicated on (MONTH) 17, 2019, at 6:00 PM, for insulin NPH BS level and the site were left blank. LVN 6 further stated if they withhold or did not perform the BS the LVN will document behind the MAR for the rationale to withhold the medication. LVN 6 further reviewed the back side of the MAR and acknowledged there was no documentation on (MONTH) 17, 2019, indicated with the reason for withholding the medication. During a concurrent interview and record review with the Director of Nursing (DON) on (MONTH) 20, 2019, at 12:25 PM, the DON reviewed Resident 80's MAR for the Month of (MONTH) 2019 and verified (MONTH) 17, 2019, at 4:30 PM and 6:00 PM, the BS and the insulin administration were left blank. The DON further reviewed resident 80's care plan (an individualized plan for the medical care of a resident) for Accucheck (finger stick BS monitoring) revised on (MONTH) 27, 2019, indicated administer my medications as ordered. The DON further stated, If it was not documented, it was not happened. The DON further reviewed Resident 80's Multidisciplinary Progress Record and acknowledged there no documentation by the Licensed Nurses (LNs) for the rationale for not having performed the BS and the medication was not administered. During a telephone interview with Licensed Vocational Nurse (LVN 7), on (MONTH) 20, 2019, at 4:25 PM, LVN 7 acknowledged she was assigned to Resident 80 on (MONTH) 17, 2019. LVN 7 further stated she was expected to document on the resident's MAR immediately after the BS check and the medication administration with the site and amount of insulin given. The facility's undated policy and procedure titled, Blood Sugar Monitoring with Insulin Administration, indicated, .1. If ordered, blood sugar will be monitored using a glucometer. 2. The blood sugar value will be documented and if ordered, insulin coverage will be administered and documented . During a follow up interview and record review with the DON on (MONTH) 21, 2019, at 9:45 AM, the DON reviewed the facility's undated policy and procedure titled, Blood Sugar Monitoring with Insulin Administration, and acknowledged the facility did not follow the policy and procedure for blood sugar monitoring and insulin administration. The facility's undated policies and procedure (NAME) titled Appendix . indicated, insulin .use of antidiabetic medications should include monitoring for example, periodic blood sugar) for effectiveness based on desired goals . An IJ situation was identified and called on (MONTH) 20, 2019, at 4:00 PM, in the presence of the Administrator (ADMIN) and the Director of Nursing (DON). The DON and the ADMIN were informed of the observations, interviews, and record reviews concerning insulin administration and blood sugar monitoring being performed. A Corrective Action Plan (CAP) was requested. Observation, staff interviews, and record review were conducted on (MONTH) 21, 2019 at 10 AM to ensure the corrective action plan provided by the facility was implemented. The facility's corrective action plan included Resident assessed with [REDACTED]. DON have in-serviced the identified nurse assigned for that particular patient immediately. All licensed nurses were given an On-Shift memo and notification in regards to insulin parameters and blood sugar readings documentation. Director of Nursing Services or designee will identify other residents with insulin and parameter order. Physician orders [REDACTED]. During admission process, admission nurse will review orders for insulin and make sure that Parameters are properly indicated and written in the telephone orders and MAR. RN (Registered Nurse) Supervisor will review all residents identified with insulin and parameter orders and will ensure that the MAR will indicate area to record blood sugar reading, Medical Record or designee will review recapped MAR monthly times two months before giving to licensed nurse for use. Will ensure there is a specific area to record blood sugar readings. An acceptable Corrective Action Plan was verified with the facility to be implemented through observation, interview, and record review. The IJ was lifted on (MONTH) 21, 2019 at 2:30 PM, in the presence of the ADMIN., and DON.

Based on observation, interview, and record review, the facility failed to: 1) provide a therapeutic diet as ordered by the physician, and 2) comprehensively assess the nutritional status of a resident with a significant weight gain and abnormal lab values for one of 19 sampled residents (Resident 5). This failure resulted in Resident 5 having increased blood glucose (sugar) levels, which resulted in a need to increase the amount of diabetic (disease which causes high blood sugar) medication, including injections of insulin (an injectable medication used to keep blood sugar levels within normal limits). Findings: A review of the medical record for Resident 5 indicated the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Monthly Record of Vital Signs and Weights document indicated, Resident 5's weight on admission was 166 pounds. The physician's orders [REDACTED]. A review of the Physician order [REDACTED]. A review of the Laboratory Reports for Resident 5, dated July 20, 2015, indicated the resident's HEMOGLOBIN A1c (a blood test that shows the average blood sugar control over the previous three months) was 5.9 %. The desirable range for this test is 4.1-5.6 %. Results ranging between 5.7-6.4 % indicate impaired glucose tolerance (pre-diabetic-higher that normal blood sugar without the criteria for having diabetes). Results ranging above 6.5 % indicate Provisional diabetes (temporary [DIAGNOSES REDACTED]. A review of the document titled, Diabetic Testing, dated July, 2015, indicated Resident 5 required the quick acting insulin 25 of 90 times his blood sugar was checked. During August 2015, the resident required the insulin 7 of 76 blood sugar checks. During September 2015, insulin was given 18 of 60 checks. During October 2015, insulin was given 26 of 62 checks. The Monthly Record of Vital Signs and Weights document indicated Resident 5's weight on October 10, 2015 was 176 pounds. This was a 10 pound increase since admission three months earlier and a 9 pound increase in one month. A review of the Resident 5's tray card (instruction to facility staff regarding the resident's diet, indicated he was to be served Regular, CCHO (consistent carbohydrate or diabetic) No Added Salt, Low Fat/ Low Chol. (cholesterol), Large Portions diet. Further instructions on the resident's tray card indicated for breakfast he was to receive 2 over medium eggs, sausage, 4 slices of toast, ice cream, SF (sugar free) every morning. A review of the resident's record revealed a document titled, Interdisciplinary Weight Management Care Plan, dated October 12, 2015, indicated Resident 5 had a 9 pound weight increase in one month. The document indicated the weight gain was expected. The document further indicated Resident 5's [DIAGNOSES REDACTED]. The resident's diet order was listed as Regular, No Added Salt, Consistent Carbohydrate. The short term goal indicated was for the resident to maintain weight with his ideal body weight of 144 to 176 pounds every month for 3 months. The approaches listed for achieving this goal were: 1) Provide diet as ordered, 2) Assess for food preferences and provide within reason There was no indication on this document that the resident was receiving large portions and this may have contributed to his significant weight gain in one month. There was no Registered Dietitian (RD) signature on the document to indicate that the RD contributed to the care plan. A review of Resident 5's medical record indicated that there was no RD assessment of the 9 pound weight gain, the amount of food the resident was eating or his elevated blood sugars. Review of Resident 5's Diabetic Testing dated November 2015, showed insulin was given 56 of 60 checks, his blood sugar ranged from 180 to 403 mg/dl. For the month of December 2015, insulin was given 62 of 62 blood sugar checks, his blood sugar ranged from 251 to 407 mg/dl with only four checks under 300 mg/dl. For the month of January 2016, insulin was given 45 out of 48 blood sugar checks, his blood sugar ranged from 190 to 399 mg/dl. Normal blood sugar level is between 70 and 125 mg/dl. The Laboratory Reports for Resident 5 indicated that on December 29, 2015 the result for the HEMOGLOBIN A1c was 10.3 %. A review of the Doctor's Verbal Order showed there was a new order dated December 29, 2015, for [MEDICATION NAME] (a long-acting insulin) 15 units every day to be given subcutaneously (under the skin). There was also an order [REDACTED]. During a review of the Resident 5's medical record, a document titled, Nutrition Assessment, dated January 11, 2016, indicated the resident had a weight trend of 14 pound increase in 6 months. His current weight was 180 pounds. The assessment indicated that the resident was eating 100% of his Regular NAS CCHO diet (low salt and diabetic). There was no mention that large portions were being provided to the resident. The assessment noted the HEMOGLOBIN A1c was 10.3 % on December 29, 2015 and the resident's Triglycerides (a fat in the blood) were 403 mg/dl (normal range was 35 - 150) on October 27, 2015. The RD assessment indicated a recommendation to change his diet to Regular NAS, CCHO, Low Cholesterol. During a review of the Physician's Telephone Orders, dated January 13, 2016, there was an order to discontinue the previous diet order and start Resident 5 on a Regular No Added Salt, Consistent Carbohydrate diet. A review of the diet order communication slip sent to the dietary department with the same date indicated a diet change to Regular, No Added Salt, Consistent Carbohydrate, Low Cholesterol, Low Fat. A Multidisciplinary Progress Report note dated the same day showed, DC (discontinue) previous order diet, start Reg (regular) NAS (no added salt), CCHO (consistent carbohydrate or diabetic), low chol (cholesterol), low fat .notified Dr. (MD 1) made aware. There was no order for large portions. During an observation of lunch on January 25, 2016, at 12:35 PM, Resident 5 was eating in the dining room. His meal consisted of meatballs, pasta, mixed vegetables, spinach salad, pineapple chunks and milk; the portions were large. He ate 83% of this large portion meal. During a concurrent interview with Resident 5, when asked if he liked the food at the facility he shrugged and said, Its ok, but it's not the food I ate at home. I eat what they bring me. During a breakfast observation on January 27, 2016 at 8:20 AM, Resident 5 was eating in a chair in his room. His meal consisted of two eggs, two slices of French toast with syrup, four slices of toast with jelly, one bowl of hot cereal, milk, and orange juice. He ate 100% of the meal and asked for the sausage that was reflected on his tray card as a daily request. The Dietary Services Supervisor (DSS) brought the sausage to him, but she dropped it on the floor and Resident 5 told her he didn't want it anymore. Also observed were two sandwiches at the resident's bedside: one with two slices of bread and ham, and the other with one slice of bread with peanut butter and jelly. During a concurrent interview with the DSS, she stated the sandwiches were given to Resident 5 as a bedtime snack the previous night around 8:00 PM. During an interview with the DSS on January 27, 2016, at 1:40 PM, she stated that Resident 5 was getting large portions including 2 eggs, sausage and 4 slices of toast in addition to the breakfast served every morning because he requested it. She stated that Resident 5 did not have a physician order [REDACTED]. She stated that 2 eggs and sausage every morning was not consistent with a low fat, low cholesterol diet. She verified that 2 slices of French toast, 4 slices of toast, a bowl of hot cereal and orange juice for a breakfast meal was more carbohydrates than what should be on a consistent carbohydrate diet. During an interview with the Director of Nursing (DON) on January 27, 2015, at 1:50 PM, she stated that Resident 5's weight gain was determined to be unavoidable because he was allowed to eat what he wanted to eat. She verified that Resident 5 was not told about the risks of increasing his blood sugars and his triglycerides when he ate the requested foods. She stated that the DSS attended the Interdisciplinary (IDT) weight review meetings. The DON stated that the DSS did not tell the IDT that dietary service sent large portions at meals which included 2 eggs, sausage and 4 pieces of toast every morning for breakfast. The DON also stated that the physician was notified when Resident 5's HEMOGLOBIN A1c was 10.3 % in December and the physician ordered more insulin. She reviewed the record and noted that Resident 5's HEMOGLOBIN A1c was 5.9 % when he was admitted to the facility in July 2015. She verified that this was a significant increase and the only intervention the facility implemented was to increase the insulin. During a telephone interview with the RD on January 27, 2016, at 2:20 PM, she stated that when a resident had a physician's orders [REDACTED]. She stated that she did not speak to Resident 5 about his weight gain, increased blood sugars, or increased triglycerides. She was not aware that Resident 5 was receiving the food listed on his tray card. During a record review of the Doctor's Verbal Order dated January 28, 2016, the [MEDICATION NAME] 15 units daily was increased for Resident 5 to [MEDICATION NAME] 30 units daily. During a telephone interview with Resident 5's physician (MD 1) on January 29, 2016, at 10:30 AM, he stated the facility informed him of Resident 5's increasing blood sugars and he ordered an increase in the resident's insulin to 15 units, then 30 units. He stated that he was not told that Resident 5's diet included large portions, extra bread with eggs and sausage every day. A review of the facility's Diet Manual, undated, reflected, The Consistent Carbohydrate Diet is designed to provide a sufficient amount of calories in a consistent distribution of carbohydrates, protein and fat to maintain the individual at a desirable weight and/or control the blood glucose (sugar) level. The description of the Low Cholesterol Diet in the Diet Manual reflected, The purpose of the low cholesterol diet is to reduce the amount of saturated animal fats and cholesterol. This diet is designed to lower elevated levels of serum (blood) cholesterol and other lipids (fats), in an effort to reduce the risk of [MEDICAL CONDITION]. The guidelines indicate, Limit (eggs) to 2 whole eggs per week .