Every finding on record at Lodi Nursing & Rehabilitation

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for one of one sampled resident (Resident 1), when staff did not perform hand hygiene and change their gloves during a nephrostomy tube (a tube that drains urine directly from the kidney) dressing change for Resident 1 who was on Enhanced Barrier Precautions (EBP, an infection control strategy used in nursing homes that requires use of gowns and gloves during high-contact care activities to reduce the transmission of germs and bacteria).This failure increased the risk for infection to Resident 1 and had the potential to spread infection and cause health problems for the residents in the facility.Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnoses including artificial openings of urinary tract status (surgically created route to divert urine out of the body when the normal pathway is blocked, diseased, or bypass).A review of Resident 1's TREATMENT ADMINISTRATION RECORD, dated for the months of June and July 2026, indicated, .Nephrostomy Tube Right Flank - Cleanse site with NS [normal saline- a mix of salt and sterile water], pat dry, apply split gauze dressing daily and PRN [as needed] if soiled or dislodged.A review of Resident 1's undated Care Plan, indicated that Resident 1 was at high risk for developing complications including UTI (urinary tract infection) due to the presence of a nephrostomy tube. The care plan interventions included to implement EBP and to observe good hand-washing technique.During a concurrent observation and interview on 7/2/26, at 11:54 AM, with Licensed Nurse (LN) 1, LN 1 entered Resident 1's room to change Resident 1's nephrostomy tube dressing. LN 1 was observed donning gloves without performing hand hygiene and then proceeded to touch the light fixture and curtains inside Resident's room. LN 1 wiped the edges of the dressing with adhesive remover and then removed Resident 1's soiled nephrostomy dressing. LN 1 proceeded with cleaning the nephrostomy tube site. LN 1 then placed a new dressing on the nephrostomy tube site without doing hand hygiene and changing gloves. LN 1 confirmed that she did not change her gloves during the dressing change and used only one set of gloves during the entire wound treatment.During an interview on 7/2/26, at 2 PM, with the Infection Preventionist (IP), the IP stated when providing treatments, the staff needed to follow infection control practices. The IP further stated that if a resident was on EBP with high contact activities, the staff need to perform hand hygiene, then don (put on) gown and gloves. The IP stated the nurse have changed their gloves after the soiled dressing was removed. The IP further stated that after cleansing the wound, nurses need to change their gloves again, before placing the new dressing. The IP explained that if nurses did not perform hand hygiene and changed their gloves, then the resident would be at risk for infection, and it would take the wound longer to heal.During an interview, on 7/2/26, at 2:51 PM, with the Director of Nursing (DON), the DON stated that when providing treatments, the nurses needed to follow the doctor's order regarding the frequency for changing the dressings and cleansing the site, follow up with an assessment, and documenting the treatment provided. The DON further stated that the nurse should have changed their gloves when providing a new dressing change to Resident 1' nephrostomy tube.A review of the facility's policy and procedure titled, Wound Care, revised 2010, indicated, .Steps in the Procedure.4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptable. Wash and dry your hands thoroughly. 6. Put on gloves.

Based on observation, interview, and record review, the facility failed to ensure safe medication storage in the medication refrigerator located at Nurse Station 1 for a census of 69 residents when:1. The medication refrigerator was observed with extensive frost buildup and temperature outside the facility's required range per policy; and,2. The facility had not implemented a log or tracking system for routine cleaning and defrosting of the medication refrigerator.These failures had the potential to contribute to unsafe medication storage and use, which could affect the health and well-being of vulnerable elderly residents.Findings: 1.During a concurrent observation and interview on 3/3/26, at 8:35 a.m., in the facility's medication room at Nurse Station 1, accompanied by Licensed Nurse (LN) 2, the medication refrigerator used to store insulins, tuberculin tests, eye drops, and the emergency kit was observed with heavy frost buildup on the top section. Further observation indicated the refrigerator temperature was 24 degrees Fahrenheit, which was outside the facility's required temperature range. During the interview, LN 2 acknowledged the findings and stated she was unsure who was responsible for defrosting the refrigerator. LN 2 further stated that the refrigerator temperature should be maintained between 36 and 46 degrees Fahrenheit. LN 2 stated that medications stored in the refrigerator must be kept within a specific temperature range, as improper temperatures could damage the medications and affect their effectiveness. During an interview on 3/4/26, at 1:08 p.m., LN 7 stated that nursing staff were required to check the medication refrigerator located in the medication rooms twice daily, during the morning shift and night shift, to ensure the temperature remains within the acceptable range and to monitor refrigerator cleanliness and the absence of frost buildup. LN 7 further stated that medications stored in the refrigerator include insulins and eye drops, which must be maintained within a specific temperature range. LN 7 stated that temperatures outside of the required range could affect the mechanism of action of the medication and their effectiveness. During a phone interview on 3/05/2026, at 11:09 a.m., the Pharmacy Consultant (PC) stated that his expectation for the facility was that nursing staff check the medication refrigerator temperatures as required by facility policy and ensure the temperature remained within the acceptable range. The PC stated that when temperature was outside of the acceptable range, staff should take corrective action and notify the responsible personnel so the issue can be addressed. The PC further stated that temperature excursions could occur; however, they should be promptly addressed. The PC also stated that nursing staff should monitor the refrigerator for excessive frost buildup and defrost the refrigerator when needed. During an interview on 3/5/26, at 3:45 p.m., the Infection Prevention (IP) Nurse stated that nursing staff were required to check the medication refrigerator temperature during the morning shift and night shift, clean the refrigerator weekly, and visually monitor the refrigerator for frost buildup that might require defrosting. The IP Nurse further stated that tuberculin tests and other medications requiring refrigeration were stored in the medication refrigerator at Nurse Station 1 and might be negatively affected if exposed to temperature below the required range. During an interview on 3/6/26, at 10:23 a.m., the Director of Nursing (DON) stated that medication refrigerator temperature should be maintained within the proper range, and if it was found to be outside of the required temperature range, it should be addressed immediately. The DON stated there was a risk involved when certain medications that require storage at specific temperatures were not maintained within the required range, as improper storage temperature could affect the effectiveness of the medications. The DON further stated that his expectation was that the medication refrigerator should be always maintained in a clean condition and should be routinely monitored for the frost buildup. The DON explained that excessive frost buildup could affect the internal refrigerator temperature by lowering it, which could potentially impact the medications stored in the refrigerator. 2.During a concurrent observation and interview on 3/3/26, at 8:35 a.m., LN 2 explained that when the temperature was found to be out of range, staff should notify the Director of Maintenance (DOM) immediately, remove the medications from the refrigerator, place them in another refrigerator, defrost and clean the unit, and then return the medications once the appropriate temperature was restored. During an interview on 3/4/26, at 1:08 p.m., LN 7 stated that medication refrigerator should be cleaned and defrosted as needed. LN 7 further stated that she was unaware of any cleaning log that was developed for cleaning/defrosting the medication rooms refrigerators. During an interview on 3/5/26, at 3:45 p.m., the IP Nurse stated that nursing staff were required to check the medication refrigerator temperature during the morning shift and night shift, clean the refrigerator weekly, and visually monitor the refrigerator for frost buildup that might require defrosting. The IP Nurse added that she was not aware of any scheduled log or system in place for routine cleaning or defrosting of the medication refrigerator. During an interview on 3/6/26, at 10:23 a.m., the DON stated that the medication refrigerator should be maintained clean and free of frost buildup, and any frost accumulation should be addressed promptly. The DON further stated that the medication refrigerator was expected to be defrosted on a monthly basis; however, the DON acknowledged that the facility had not implemented a log or tracking system for routine cleaning and defrosting of the medication refrigerator to ensure ongoing monitoring and prevention of frost buildup that could lead to out-of-range temperatures. Review of the facility's policy and procedure (P&P) titled MEDICATION STORAGE IN THE FACILITY, revised in January 2025, indicated, Medications and biological are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Procedures. K. Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 F) are kept in the refrigerator with a thermometer to allow temperature monitoring. The P&P did not address storage of the vaccine which were sensitive to extreme temperature. The P&P did not address who in the facility was responsible for maintaining and defrosting the refrigerator.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when:1. Two water pitchers, multiple spoons, spatulas, a blender, two metal baking sheets, and plates were stored wet, 2. A bag of uncooked pasta did not have a use by date; and, 3. A lunch cart did not have a cover, and two lunch plates in the food delivery cart were not fully covered. These failures had the potential of leading to a food-borne illness (an illness that comes from eating contaminated food) for all 69 residents receiving facility prepared meals.Findings:1a. During a concurrent observation and interview on 3/3/26, at 8:28 AM, with the Assistant Dietary Manager (DM), in the kitchen, two water pitchers were observed placed wet on the kitchen shelf next to the hot water dispenser machine. The DM confirmed the two water pitchers were stored wet. The DM stated the two water pitchers should have been dried completely before placing them on the kitchen shelf. The DM further stated bacteria could grow when water pitchers were stored wet.1b. During a concurrent observation and interview on 3/3/26, at 8:32 AM, with the DM, in the kitchen, multiple spoons and spatulas were stored wet in the dry utensil storage drawer, a blender was stored wet in the food preparation counter, two metal baking sheets were stacked wet on top of each other on the dry cooking pan storage area, and plates were stacked wet on the food preparation counter. The DM confirmed the multiple spoons, spatulas, the blender, two metal baking sheets, and plates were stored wet in the kitchen. The DM stated the utensils, blender, baking sheets and plates should have been dried completely before storing them in the food preparation area in the kitchen. The DM further stated bacteria could grow when utensils were stored wet.2.During a concurrent observation and interview on 3/3/26, at 8:49 AM, with the DM, in the kitchen dry food storage area, a bag of uncooked pasta had been removed from its original package and was stored in a clear plastic bag with no used by date. The DM confirmed the bag of uncooked pasta did not indicate a used by date. The DM stated the bag of uncooked pasta should have had a used by date labeled once removed from its original package. The DM further stated the uncooked pasta could have been expired and residents could have gotten sick by eating expired pasta. The DM stated food without expiration dates should not be used.3. During an observation on 3/3/26, at 12:12 PM, with Certified Nursing Assistant (CNA) 4, CNA 4 was observed taking an uncovered lunch food cart from the dining room and left it outside in the hallway outside a resident's room. Two lunch meal plates were further observed to not be fully covered with a plate cover.During a concurrent observation and interview on 3/3/26, at 12:14 PM, with CNA 4, CNA 4 was observed taking plates from the uncovered food cart and was delivering meal trays to residents' rooms. CNA 4 confirmed the food cart did not have a cover and the two lunch meal plates were not fully covered with a plate cover. CNA 4 stated the food carts and meal plates usually were covered when brought outside from the kitchen.During a concurrent observation and interview on 3/3/26, at 12:18 PM, with CNA 5, CNA 5 was observed delivering lunch meal trays from the uncovered food cart to residents' rooms. CNA 5 confirmed the food cart was not covered. CNA 5 stated the food could have cooled off faster and could cause bacteria when food was served from an uncovered food cart.During an interview on 3/3/26, at 12:21 PM, with the Registered Dietitian (RD), the RD stated the food carts and food plates should have been completely covered before they left the dining room. The RD further stated the temperature of the food could drop and go into a danger zone which could lead to bacteria buildup in the food when food was not covered completely. The RD stated bacteria from food could cause residents to get sick from a food borne illness. The RD further stated food temperatures in the danger zone could decrease the freshness of the food.During an interview on 3/3/26, at 12:25 PM, with the Director of Staff Development (DSD), the DSD the stated the food cart should have been be fully covered and insulated to maintain the required food temperature. The DSD further stated to prevent potential food contamination and the food from getting cold; the meal plates and the food cart should have been fully covered.During an interview on 3/6/26, at 11:17 AM, with the Administrator (ADM), the ADM stated the dishes in the kitchen should have been dried completely before being stored in the dry dish storage area. The ADM further stated storing dishes when wet could potentially cause infection. The ADM stated food that was stored without an expiration date could be potentially expired food. The ADM further stated using food that was potentially expired could cause food borne illness. The ADM stated to maintain food temperature, the food cart should be insulated and the food plates should have been fully covered before serving food to the residents. The ADM further stated to avoid potential food contamination, the food plates that were not fully covered should have been discarded and the food with fully covered plate covers should have been served to residents.During a review of the facility's (policy and procedure) P&P titled, DISHWASHING, dated 2023, the P&P indicated, .Dishes are to be racked loosely without overlapping.Dishes are to be air dried in racks before stacking and storing.During a review of the facility's P&P titled, STORAGE OF FOOD AND SUPPLIES, dated 2023, the P&P indicated, .All food will be dated-month, day, year.No food will be kept longer than the expiration date on the product. Dry food items which have been opened, such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles , etc will be tightly closed, labeled and date.During a review of the facility's P&P titled, LABELING AND DATING OF FOODS, dated 2023, the P&P indicated, .All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.Newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines.During a review of the facility's P&P titled, COVERING FOOD DURING TRANSPORT, dated 2023, the P&P indicated, .Food will be delivered from the kitchen to residents in a safe and sanitary manner that does not cause contamination.If tray leaves the dining room and is being delivered to patient rooms, all food on the tray needs to be covered.All hot food will be covered to maintain the proper temperature.The cart should be kept closed to protect the remaining trays.

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 69, when:Resident 86 had perishable food at the bedside that was not consumed or discarded two days after the date,An opened and half-filled single-use skin ointment packet was left on Resident 85's overbed table after being used during incontinent care,Certified Nursing Assistant (CNA) 6 did not wear personal protective equipment (PPE- equipment such as protective clothing, gloves, masks or other garments used to prevent or minimize exposure to hazards) when assisting Resident 93 who was on contact precautions (infection control steps used in a healthcare setting to prevent the spread of germs that are passed by direct contact with a patient or their environment),Resident 1's linens were not changed in a timely manner after blood was left exposed on the bed sheets and blankets,Resident 6's vital signs (measurements of the body's basic functions such as body temperature, blood pressure, hear rate and breathing rate) were obtained with ungloved hands while on enhanced barrier precautions (EBP- an infection control strategy in nursing homes requiring staff to wear gowns and gloves during high-contact resident care, such as bathing, dressing, or device care); and,Resident 76's puncture site (specific spot on the body where a needle or other sharp instrument has entered the skin for medical reasons) was cleaned using the resident's personal tissue after a blood glucose finger stick (a fast method used to check current blood sugar levels by pricking the fingertip with a tiny needle). These failures had the potential to spread infection to staff and other residents in the facility. Findings: 1. During a concurrent observation and interview on 3/3/26, at 11:24 AM, with the Director of Staff Development (DSD) in Resident 86's room, perishable food packed in a foam food container was noted on Resident 86's bedside table with the date 3/1/26 written on it. The DSD stated that per facility policy, perishable food needed to be discarded if it was not consumed by the resident within two hours after the resident received the food from an outside source. The DSD further stated the food had been in Resident 86's room since 3/1/26 for two days and if the resident ingested the food, Resident 86 was at risk for food contamination which could cause nausea, vomiting, and stomach pain. During an interview on 3/5/26, at 3:12 PM, with the Infection Prevention Nurse (IP), the IP stated residents' perishable food that was not stored in the refrigerator needed to be discarded within two hours after it was received. The IP stated food that remained at room temperature for more than two hours could allow bacterial growth that could cause foodborne illness and gastrointestinal (stomach and intestinal) upset due to food spoilage. During an interview on 3/6/26, at 9:45 AM, with the Director of Nursing (DON), the DON stated perishable foods needed be discarded within two hours after the resident received the food from an outside source. The DON further stated if perishable food remained in the room for more than two hours, any resident who could access and ingest the food was at risk for infection from bacterial overgrowth in the food. Review of the facility's policy and procedure (P&P) titled, Use and Storage of Food Brought in by Family or Visitors, revised in 10/2025, indicated, .Perishable foods left at bedside for extended periods .shall be discarded to reduce risk of spoilage. 2. During a concurrent observation and interview on 3/3/25, at 10:55 AM, with Resident 85, in Resident 85's room, Resident 85 was observed lying in her bed with an open, half-filled packet of single-use skin guard ointment (a protective ointment used to protect skin from moisture and irritation) on Resident 85's overbed table. Resident 85 stated staff left the skin guard ointment on her overbed table after staff used it during Resident 85s incontinent care (care provided when a resident cannot control bladder or bowel movements). During a concurrent observation and interview on 3/3/25, at 11:12 AM, with Licensed Nurse (LN) 8, in Resident 85's room, Resident 85 was observed lying in her bed with an open, half-filled packet of single-use skin guard ointment on Resident 85's overbed table. LN 8 stated the open half filled skin guard ointment should have been discarded after it was used due to safety concerns. During an interview on 3/5/26, at 3:12 PM, with the IP, the IP stated the skin guard ointment packet was intended for single use and needed to be discarded immediately after use. The IP further stated if staff used the ointment during incontinent care and then placed the packet on the resident's overbed table, which the resident used for eating, it created a risk for food contamination and potential infection for the resident. During an interview on 3/6/26, at 9:45 AM, with the DON, the DON stated the skin guard ointment was used to protect the residents' skin during incontinent care. The DON further stated the ointment packet was intended for single use and staff were expected to discard it immediately after use and not to leave it on surfaces such as the overbed table. The DON stated leaving the used packet on the overbed table was an infection control concern because it could serve as a source of contamination and spread infection. Review of the facility's P&P titled, Infection Prevention & Control Program Policy, revised in 10/2025, 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.Important facets of infection prevention include.Educating staff and ensuring that they adhere to proper techniques and procedures. 3. Review of Resident 93's admission RECORD, indicated Resident 93 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, extended-spectrum beta-lactamase (ESBL) resistance (a type of bacteria resistant to many antibiotics), muscle weakness, sepsis (a serious bloodstream infection), pneumonia (lung infection), and anxiety disorder. Review of Resident 93's Order Summary, indicated the physician ordered .Contact Isolation Precautions – Single/Private room every shift for UTI [urinary tract infection] ESBL Provide in-room services until infection resolves .Perform hand hygiene and don [put on] gloves and gown upon room entry. Review of Resident 93's care plan initiated on 3/4/36, in the section titled, Focus, indicated, .[Resident 93] Require isolation precaution due to: ESBL in urine. In the section titled, Interventions, indicated, .Contact Precautions maintained every shift.Observed contact isolation precaution.Inform.staff on indication for isolation. During a concurrent observation and interview on 3/5/26, at 12:13 PM, with CNA 6, in Resident 93's room, a contact precaution sign was posted on Resident 93's room door. CNA 6 was noted inside the room preparing Resident 93 for lunch and positioned the overbed table across Resident 93 while Resident 93 was lying in bed. CNA 6 was observed not wearing the required PPE while inside Resident 93's room, which was under contact precautions. CNA 6 exited Resident 93's room and stated he did not wear PPE and should have worn it before entering the room because Resident 93 was on contact precautions. CNA 6 further stated that without wearing the required PPE in a room under contact precautions, he was at risk of acquiring the infection and transmitting it to others. During an interview on 3/5/26, at 3:12 PM, with the IP, the IP stated Resident 93 was placed on contact precautions due to an active urinary tract infection caused by ESBL producing bacteria, which was highly transmissible (easily spread) and difficult to treat. The IP further stated staff were expected to wear the required PPE every time they entered Resident 93's room to prevent the spread of infection in the facility. During an interview on 3/6/26, at 9:45 AM, with DON, the DON stated staff were expected to wear appropriate PPE when entering the rooms of residents on contact precautions because of the higher risk of transmission of infection. Review of the facility's P&P titled, Isolation – Categories of Transmission-Based Precautions [special infection control measures to prevent the spread of germs], revised in 10/2018, indicated, .Contact Precautions.for residents known or suspected to be infected with microorganisms [germs such as bacteria that can cause infection] that can be transmitted by direct contact with resident or indirect contact with environmental surfaces or resident-care items in the resident's environment.Staff and visitors will wear gloves (clean, non-sterile) when entering the room.Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room. 4. A review of Resident 1's Order Summary Report, dated 3/4/26, the Order Summary Report, indicated, .Change Foley catheter [a flexible, sterile tube inserted through the urethra into the bladder to continuously drain urine into a collection bag] 16Fr [16 French- size of catheter]/10ml [milliliter- unit of measurement] balloon for increased sedimentation [buildup of solid particles]/dislodged/pulled out/leakage as needed.Order Date 2/6/26 . During a concurrent observation and interview on 3/3/26, at 11:26 AM, with Resident 1, Resident 1's bed sheets and linens were observed. Resident 1 confirmed that there was blood on the linens and sheets. Resident 1 stated that he had blood in his foley catheter and a nurse changed his catheter earlier in the morning, but no one changed his sheets or bed linens. Resident 1 further stated that he did not want to be sitting on bloody or dirty linens in his bed. During a concurrent observation and interview on 3/3/26, at 11:30 AM, with CNA 6, CNA 6 confirmed that there was blood on the linens and sheets and that it needed to be cleaned right away. CNA 6 stated that residents should not have blood on their bed sheets and linens. During an interview on 3/3/26, at 11:35 AM, with the IP, the IP stated the bed sheets and linens for Resident 1 should not have been dirty with blood and needed to be cleaned right away. The IP further stated that this situation presented an infection control issue. During an interview on 3/4/26, at 11:31 AM, with the DON, the DON stated that his expectation was for dirty sheets and linens to be cleaned and bagged properly as soon as possible. The DON further stated that there would be a cross-contamination risk and a possible spread of infection when bloody linens were still in use. During a review of the facility's P&P titled, Catheter Care, Urinary, revised 9/14, the P&P indicated, .Place soiled linen into designated container. During a review of the facility's P&P titled, Laundry and Bedding, Soiled, revised 10/18, the P&P indicated, .Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control.Laundry that is contaminated with blood or body substances is placed in leak-proof bags or containers. 5. Review of Resident 6's MEDICATION ADMINISTRATION RECORD, (MAR- where nurses document what and when administered ordered medications), indicated an active order for, .ENHANCED BARRIER PRECAUTIONS-Apply enhanced barrier to prevent the spread of infections.every shift-Start Date-11/19/2025 . During an interview on 3/3/26, at 2:51 PM, CNA 2 stated that residents placed on EBP might carry certain bacteria. CNA 2 further stated that staff should take additional precautions and follow the instructions on the EBP signage when providing direct care to those residents. CNA 2 stated PPE should be applied before entering the resident's room when performing direct care to prevent the spread of infection to other residents and protect staff members as well. During a concurrent observation and interview on 3/4/26, at 10:28 AM, with LN 5 during a med pass observation, Resident 6 was noted to be on EBP, with PPE available in the hallway next to the entrance door. LN 5 stated that Resident 6 was on EBP due to a history of methicillin-resistant staphylococcus aureus (MRSA- a type of bacteria responsible for difficult-to-treat infections due to its resistance to many common antibiotics which could spread through direct contact with contaminated surface, or skin-to-skin contact). LN 5 further stated that Resident 6 had scheduled blood pressure medications and that vital signs (VS) were required prior to medication administration. LN 5 performed hand hygiene, gathered equipment including a blood pressure cuff (used to measure blood pressure), stethoscope (used to listen to heart and lung sounds), pulse oximeter (used to measure heart rate and oxygen level), and a thermometer (used to measure body temp). LN 5 then knocked on Resident 6's door and entered the room, introduced herself, identified Resident 6 using name and date of birth and placed the equipment directly on the bed linen on the left side of Resident 6. LN 5 then placed the blood pressure cuff on Resident 6's left arm and adjusted the position of the cuff with ungloved hands. LN 5 obtained the stethoscope from the bed linen, placed it in her ears, checked the blood pressure, and then placed the stethoscope back on Resident 6's bed linen. LN 5 then picked up the pulse oximeter from the bed and placed it on Resident 6's left ring finger to check the oxygen level. Lastly, LN 5 obtained the thermometer from the bed linen and checked Resident 6's temperature. After completing the vital signs, LN 5 reported the results to Resident 6, thanked the resident, gathered the equipment from the bed, and exited the room. Outside the room, after cleaning and sanitizing the equipment LN 5 stated that she should have worn PPE before entering the room and confirmed that she had direct contact with Resident 6's skin with ungloved hands while obtaining vital signs. LN 5 confirmed that she placed all equipment on Resident 6's bed linen without any barrier before using the equipment. LN 5 stated that there was a risk for cross-contamination because PPE was not used and Resident 6's skin was touched with ungloved hands while obtaining vital signs. LN 5 acknowledged that the stethoscope had been placed on Resident 6's bed prior obtaining vital signs. LN 5 stated that this practice could lead to cross-contamination and could potentially affect other residents under her care. Review of Resident 6's care plan for history of infection, MRSA, dated 12/4/24, indicated, .Interventions. Implement ENHANCE BARRIER PRECAUTION. During an interview on 3/5/26, at 3:45 PM, with the IP, the IP stated that staff were expected to follow the instructions posted on the signage for residents on EBP and to wear appropriate PPE prior to entering the room when performing direct contact or providing care to residents. The IP further stated that proper use of PPE was required to minimize the risk and prevent the spread of infection, and that without proper PPE there was a high risk for transmission of infection to other residents. The IP explained that staff should follow the instructions on the signage posted outside the room for residents on EBP. During an interview on 3/6/26, at 10:23 AM, with the DON, the DON stated that the expectation for nursing staff was to know the type of isolation required for each resident's infection and to adhere to the proper precaution instructions. The DON further stated that when staff did not wear appropriate PPE, there was a possibility of spreading infection. 6. Review of Resident 76's admission RECORD, indicated Resident 76 was admitted to the facility with diagnoses including type 2 diabetes mellitus (a chronic condition where the body cannot effectively use insulin or produce enough of it, leading to high blood sugar levels), and long-term use of insulin (medicine used to control blood sugar levels). During a concurrent observation and interview on 3/3/26, at 11:36 AM, LN 6 stated that Resident 76 was on blood glucose monitoring due to receiving insulin injections. LN 6 further stated that Resident 76's blood glucose levels needed to be checked prior to mealtime in order to administer insulin as ordered by physician. LN 6 reviewed the MAR, performed hand hygiene, and identified Resident 76 using the resident's name and date of birth . LN 6 explained the procedure to Resident 76, gathered the supplies including a glucometer (device used blood sugar levels), 2 alcohol prep pads, a lancet (small needle), and gloves. After putting on gloves, LN 6 inserted the test strip (a small, disposable plastic strip used with a glucometer to measure blood sugar levels) into the glucometer and entered Resident 76's room. LN 6 cleansed Resident 76's left pointer finger, as preferred by the resident, with an alcohol prep pad and performed the fingerstick using the lancet. LN 6 wiped the initial blood with an alcohol prep pad, obtained a blood drop, placed it on the test strip, and read the blood glucose level. After obtaining the reading, LN 6 grabbed a tissue from Resident 76's bedside tissue box and used it to wipe the blood from the puncture site. LN 6 then wrapped the same tissue around Resident 76's finger and applied pressure for approximately five seconds before removing the tissue. After exiting the room, LN 6 confirmed the observation and stated that wiping and holding pressure on the puncture site with the resident's tissue was not the correct way of performing the procedure. LN 6 stated that alcohol prep pads should be used to cleanse the puncture site and sterile gauze should be used to apply pressure to stop the bleeding. LN 6 further stated that using the resident's tissue on an open puncture site could allow bacteria to enter Resident 76's body through the broken skin. During an interview on 3/5/26, at 3:45 PM, the IP stated that nurses were expected to clean and sanitize the resident's bedside table prior to taking supplies to the resident's room and to use a tray or barrier to place the supplies on. The IP further stated that nurses should perform hand hygiene and put on gloves before performing the procedure. The IP stated the puncture site should be cleansed with an alcohol prep pad prior to using the lancet to perform the fingerstick and the remaining blood at the puncture site should be wiped with another alcohol prep pad or sterile gauze after completing the procedure. The IP further stated that the open puncture site could serve as a point of entry for bacteria. During an interview on 3/6/26, at 10:23 AM, the DON stated that the expectation for nurses was to follow infection control and prevention measures, including cleaning and sanitizing equipment before and after procedure, using barriers to prevent the spread of infection, and using sterile gauze or alcohol prep pads to remove blood from the puncture site during performing blood glucose monitoring. The DON further stated that there was a risk for infection when remaining blood on Resident 76's skin puncture site was removed using a tissue taken from the tissue box located at Resident 76's bedside. Review of the facility's P&P titled, Infection Prevention & Control Program Policy, revised on October 2025, indicated, .An infection prevention and control program.is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

Based on interview and record review, the facility failed to ensure safe pharmaceutical services were provided with the accountability of delivered medications based on standards of practice for a resident census of 69 when medication delivery slips and manifests from the pharmacy provider were not consistently signed and dated by licensed staff upon receipt from delivery courier for accuracy and accountability of prescription medication received. This failure had the potential to result in drug diversion (illegal use of drugs), medication error, misuse, unaccounted-for and missing resident medications. Findings: Review of the facility documents titled CONSOLIDATED DELIVERY SHEETS, located in the pharmacy delivery receipt binder at Nurse Station 1, for the period of 2/3/26 to 3/3/26, indicated, . AUTHORIZED SIGNATURES ONLY (stamped signatures & dates are not acceptable). The review further revealed that the documents were incomplete, as they were not consistently signed and dated by licensed nursing staff as required. During a concurrent interview and record review on 3/3/26, at 8:15 a.m., the facility's pharmacy delivery receipt binder located at Nurse Station 1 was reviewed with Licensed Nurse (LN) 3. LN 3 confirmed that pharmacy delivery manifests were not consistently signed and dated as required, and multiple pharmacy delivery manifests dated 2/24/26, multiple manifests dated 2/25/26, and one manifest dated 3/1/26 were found missing the required signatures and dates. LN 3 stated pharmacy deliveries occurred at various times and may be delivered during any shift. LN 3 confirmed that the deliveries included medications such as psychotropic medications (prescription drugs that manage mental health conditions by altering brain chemicals to affect mood, thoughts, and behavior) and antibiotics (medications used to treat infection). LN 3 explained that the pharmacy delivers medications to Nurse Station 1, and upon delivery, the receiving nurse was responsible for verifying that the residents listed on the delivery manifest currently reside in the facility. LN 3 added the nurse who received the medications was required to sign and date each delivery manifest, and a copy of the signed manifest should be maintained in the pharmacy delivery receipt binder located at Nurse Station 1. Nurse 3 stated that the nurse who received and signed for the medications was responsible for distributing the medications to the nurses assigned to the other medication carts. LN 3 further stated that signing and dating the pharmacy delivery manifests served as proof that medications were received. LN 3 stated when the delivery manifests were not signed and dated as required, and the blank copies were placed in the pharmacy delivery receipt binder, the facility could not verify whether the medications were received, misplaced, or not delivered. During an interview on 3/4/26, at 1:08 a.m., LN 7 stated that the pharmacy was delivering medications to the facility during all shifts. LN 7 explained the process for receiving medications upon delivery. LN 7 stated that the nurse stationed at Nurse Station 1 typically received medications. LN 7 added that receiving nurse was responsible for signing and dating the delivery manifest and printing their name on the manifest to acknowledge receipt of the medications. LN 7 further stated that a copy of the signed delivery manifest should be placed in the pharmacy delivery receipt binder located at Nurse Station 1 prior to distributing the medications to other nurses. LN 7 stated when delivery manifests were not signed and dated consistently, there was a possibility that medication could be diverted or lost. During a phone interview on 3/5/26, at 11:09 a.m., the Pharmacy Consultant (PC) stated that upon medication delivery, the receiving nurse should verify the medications listed on the delivery manifest. The PC added that the nurse should also verify whether the residents listed on the manifest were currently residing in the facility, and if a resident was no longer in the facility, the medications should be returned to the delivery driver at the time of delivery. The PC stated that the nurse receiving the medication was responsible for verifying the delivery and signing the delivery manifest to acknowledge receipt. The PC stated that when pharmacy delivery manifests were not consistently signed and dated, there was a potential that medications could be missed. During an interview on 3/6/25, at 10:23 a.m., the Director of Nursing (DON) stated that medications from the pharmacy provider were primarily received by the night shift nurses. The DON explained that licensed nursing staff were expected to reconcile medications with the medication delivery manifests and sign and date the receipts at the time of delivery. The DON further stated that when pharmacy delivery manifests were not consistently signed and dated, there was a risk that the medications received might not be appropriately reviewed. The DON further added that bubble-packed medications could potentially be broken upon delivery and the damage might not be identified if the delivery manifests were not properly reviewed, signed, and dated at the time of receipt. Review of the facility provided policy and procedure (P&P) titled Pharmacy Services Overview, revised in April 2007 indicated, . The facility shall accurately and safely provide or obtain pharmacy services .Policy Interpretation and Implementation. 3. The facility shall contract with a licensed Pharmacist to help it obtain and maintain . appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to. a. Develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services (including ordering, delivery and acceptance, storage, distribution. documentation, and reconciliation of all medications. Review of the facility provided P&P titled MEDICATION ORDERING AND RECEIVING FROM PHARMACY, dated April 2008 indicated, . The dispensing pharmacy will transport medication to the facility in a manner that prevents contamination, degradation, and diversion of medications. Procedures. D. Upon arrival at the facility, the courier delivers the medication directly to a licensed nurse. E. The pharmacy provides a method for both parties to confirm delivery.

Based on interview, and record review, the facility failed to ensure one of the nursing interventions to prevent the development or worsening of pressure injuries (pressure ulcers) for one of 23 residents (Resident 48) was care planned and communicated to staff when a physician ordered repositioning every two hours for Resident 48 for pressure injury prevention on 2/12/26, and the intervention was not included in the care plan or the Kardex (a quick reference care sheet used by Certified Nursing Assistants [CNAs] to guide daily care).This failure created the potential for unmet pressure injury prevention needs for Resident 48. Findings:Review of Resident 48's admission RECORD indicated Resident 48 was admitted to the facility with diagnoses including primary osteoarthritis of the left shoulder (joint damage that causes pain and stiffness), difficulty walking, muscle weakness generalized, primary osteoarthritis of the right shoulder, contracture of the right ankle (stiffness that limits movement of the joint), pressure ulcer of the left buttock stage II (a skin sore with partial skin loss), major depressive disorder, dizziness and giddiness (feeling lightheaded or unsteady). Review of Resident 48's Weekly Pressure Ulcer Observation Tool dated 2/11/26, indicated that Resident 48 had left buttock pressure injury stage II present on admission.During a concurrent interview and record review on 3/6/26 at 8:40 AM, with Licensed Nurse (LN) 9, Resident 48's physician order was reviewed. Physician order for Resident 48 dated 2/12/26 indicated .Turn and reposition every 2 hours. Utilize wedges and pillows every day shift. LN 9 stated to ensure staff implemented the order for Resident 48 repositioning every 2 hours, it had to be in the care plan. LN 9 stated that nursing utilized the care plan as a reference to provide consistent care and once it was care planned, it would trigger the Kardex for CNAs quick reference guide on what care to provide residents. Resident 48's care plan was reviewed with LN 9, LN 9 stated that repositioning every 2 hours was not in the care plan. LN 9 further stated that if a pressure injury prevention intervention was not in the care plan, the resident was at risk of not receiving repositioning every two hours and the resident's pressure injury had the potential to worsen, or the resident had the potential to develop a new pressure injury.During a concurrent interview and record review on 3/6/26 at 10:32 AM with Certified Nursing Assistant (CNA) 8, CNA 8 stated that if Resident 48 required repositioning every two hours, it was expected for the nurse assigned to Resident 48 to share the information with the CNA providing care to Resident 48. CNA 8 stated that a CNA used the Kardex as a quick reference for resident care. Resident 48's Kardex was reviewed with CNA 8. CNA 8 stated that repositioning every two hours was not in the Kardex, so it was possible Resident 48 was not repositioned every two hours if it was not included in the Kardex.During an interview on 3/6/26 at 10:35 AM with LN 10, LN 10 stated that Resident 48 was bed bound, confused and was at high risk for pressure injury. Review of Resident 48's Documentation Survey Report v2 dated 2/2026 in the section titled MOBILITY: Chair/Bed-to-Chair Transfer indicated that Resident 48 was transferred from bed to chair two times in morning shift and three times in evening shift from 2/11/26 through 2/28/26, which required maximal assistance to dependent assistance. In the section titled MOBILITY: Roll Left and Right indicated Resident 48 required dependent to moderate assistance to perform bed mobility from 2/11/26 through 2/28/26.Review of Resident 48's Minimum Data Set Assessment (MDS - a standardized assessment used to evaluate a resident's health, function, and care needs) dated 2/17/26 in the section titled Section C-Cognitive Patterns indicated Resident 48's BIMS Summary Score (a score used to measure memory and thinking ability) was 7 (indicates severely impaired cognition).Review of Resident 48's N Adv - Braden Scale - for Predicting Pressure Ulcer Risk Evaluation [a tool used to predict a resident's risk of developing pressure injuries] dated 3/5/26 indicated a Braden Score of 16 (indicates Resident 48 was at risk to develop pressure injuries).Review of Resident 48's Weekly Pressure Ulcer Observation Tool dated 2/21/26, indicated that Resident 48 developed a facility acquired pressure injury on 2/21/26 while in the facility on right heel as a suspected deep tissue injury (damage to skin and tissue under the skin caused by pressure).Review of Resident 48's wound provider notes dated 3/2/26, indicated Resident 48 had a right heel deep tissue pressure injury.During an interview on 3/6/26 at 10:40 AM with the Director of Nursing (DON), the DON stated if an ordered intervention to reposition a resident every two hours was not provided then the resident was at risk for further skin breakdown. Review of facility's policy and procedure (P&P) titled Pressure Ulcer/Injury Risk Assessment revised in 7/2017, the P&P indicated .Risk factors that increase a resident's susceptibility to develop or not heal PU/PI [pressure ulcer/pressure injury] include.Impaired/decreased mobility and decreased functional ability.Cognitive impairment.Develop the resident-centered care plan and interventions based on the risk factors identified.The interventions must be based on current, recognized standards of care.The effects of the interventions must be evaluated.The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate .

Based on observation, interview, and record review, the facility failed to ensure a functioning call light system (system/device used by residents to call staff for assistance) was in place for 2 of 23 sampled residents (Resident 61 and Resident 62) when Resident 61 and Resident 62's call light was not working.This failure had the potential to result in Resident 61 and Resident 62 being unable to call staff for help when needed and their needs not being met.Findings:1a. A review of Resident 61's admission RECORD, indicated Resident 61 was admitted to the facility in the spring of 2025 with diagnoses including difficulty in walking, muscle weakness, and acute respiratory failure with hypoxia (a condition where there is not enough oxygen or too much carbon dioxide in the body).A review of Resident 61's clinical record titled, Care Plan Report, dated [DATE], indicated .Focus: Altered bladder elimination due to incontinence related to: Mobility deficit .The interventions include: Answer light promptly.Focus: High risk for falls and injury related to Attempting to get out of bed unassisted, Bladder Incontinence, Limitation of mobility.The interventions include: Have things needed by the resident within reach including call light and other common personal items.During a concurrent observation and interview on [DATE], at 2:18 PM, with Resident 61, Resident 61 pressed his call light and the light turned on for approximately two seconds before turning off automatically. Resident 61 stated the call light system had been functioning this way for a long time and that it was annoying having to use the call bell that was provided as the Certified Nursing Assistants (CNA) could not hear it or would state they were helping someone else. Resident 61 further stated that he wanted a proper call light system to use as opposed to a call bell. Resident 61 stated he used the call bell, and it was heard faintly in the next room. Resident 61's room was located at the very end of the hall away from the nurse's station.During an interview on [DATE], at 2:28 PM, with CNA 7, CNA 7 stated the call light system for Resident 61's room had not been functioning properly for quite a while.During an interview on [DATE], at 2:37 PM, with the Director of Staff Development (DSD), the DSD stated the call light system should function properly so that staff could notice if a resident needed assistance. The DSD further stated his expectation was for the call light system to function as normally as possible. The DSD stated that alternative methods like the call bell should work properly and not be faint in sound. The DSD explained that alternative methods offered to residents should be effective as well.During an interview on [DATE], at 2:47 PM, with the Director of Nursing (DON), the DON stated the call light system should be audible to raise the awareness of the staff to assist the residents in need. The DON further stated that if the call light system was down, an alternative means provided to residents should have been effective and working properly.1b. A review of Resident 62's admission RECORD, indicated Resident 62 was admitted to the facility in the summer of 2025 with diagnoses including difficulty in walking, muscle weakness, chronic pulmonary embolism (occurs when blood clots in the lungs do not dissolve, causing persistent blockage, and scarring), and thrombosis of unspecified deep veins of the right lower extremity (a serious medical condition involving a blood clot in the deep veins of the right leg, excluding specific named veins like the femoral or popliteal. It often presents with pain, swelling, redness, or warmth in the calf or thigh).A review of Resident 62's clinical record titled, Care Plan Report, dated [DATE], indicated .Focus: Mobility deficit.The interventions include: Keep call light within reach.Answer light promptly.Focus: Altered bladder elimination due to incontinence related to: Mobility deficit.The interventions include: Keep call light within reach.Answer light promptly.During a concurrent observation and interview on [DATE], at 3:03 PM, with Resident 62, Resident 62 pressed the call light and it did not turn on. No call bell or whistle was noted to be in the room as an alternative method of staff notification. Resident 62 stated she had to yell out and scream for staff to come and assist her.During an interview on [DATE], at 4:02 PM, with CNA 2, CNA 2 stated Resident 62 would get mad if the call light was not answered in a timely manner, especially when she needed to go to the restroom. CNA 2 further stated that if the call light system was not working, the residents' mood would be affected as their needs were not met on time.During an interview on [DATE], at 8:51, with the Director of Maintenance (DOM), the DOM stated that there was a visual screening system, but not an auditory alert system at each nurses' station. The DOM further stated that if the call light system was not operating as intended, there could be a delay in the care for the residents.During a review of the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response, revised 10/25, the P&P indicated, .Call lights will directly relay to a staff member or centralized location to facilitate appropriate response.Call system should be accessible to Residents while in bed or other sleeping accommodations in room.Staff should report problems with a call light or call system immediately to their supervisor and/or maintenance director and provide alternative solutions until problem can be remedied.

Based on interview, and record review, the facility's Quality Assurance Committee (a mandatory, internal group within a nursing home or skilled nursing facility. Its purpose is to identify, monitor, and improve the quality of care and life for residents, as required by federal law for facilities receiving Medicare or Medicaid funding) failed to meet quarterly with all required members, when the Administrator (ADM) and the Medical Director (MD) did not attend the scheduled quarterly meetings as required.This failure decreased the facility's potential to identify, monitor, implement and enhance the quality of care for residents for a census of 69.Findings:During a concurrent interview and record review on 3/6/26, at 11:17 AM, with the Director of Nursing (DON) and the ADM, the Quality Assurance and Performance Improvement (QAPI- a data-driven, proactive approach mandated by the Centers for Medicare & Medicaid Services [CMS] for healthcare facilities to continuously monitor, analyze, and improve the quality of care and services) binder was reviewed. The ADM confirmed that the previous ADM did not attend the quarter 3 meeting on 11/7/25. The ADM further confirmed that the MD did not attend any of the scheduled quarterly meetings conducted on 4/10/25 (Quarter 1), 7/28/25 (Quarter 2), or 11/7/25 (Quarter 3).During an interview on 3/6/26, at 11:52 AM, with the DON, the DON stated that it was important for the MD to attend the quarterly QAPI meetings so that the MD would be able to give his medical input for the safety and quality of care for the residents residing in the facility. The DON further stated that the MD would be able to discuss the trends that were occurring in the facility to improve resident outcomes. The DON stated the QAPI committee would not be able to work collaboratively and develop plans for improvement if the MD did not attend. The DON explained that the ADM played a vital role in conducting the quarterly QAPI meetings and following through to make sure the meetings occurred. The DON stated the ADM and the MD should have attended all the regularly scheduled QAPI meetings.During an interview on 3/6/26, at 11:58 AM, with the ADM, the ADM stated that it was important for the MD to attend the scheduled QAPI meetings so he could share his perspective on potential issues that may be occurring so the staff would be able to improve and correct themselves. The ADM further stated that the MD needed to be aware of and understand the current quality of care that was being provided at the facility. The ADM explained that the ADM needed to attend the QAPI meetings to ensure team collaboration was occurring and to discuss resident outcomes. The ADM stated that it was his expectation for all required committee members including the MD and the ADM to attend the QAPI meetings.During a review of the facility's policy and procedure (P&P) titled, Quality Assurance and Performance Improvement (QAPI) Committee, dated 7/16, the P&P indicated, .This facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program.The following individuals will serve on the committee.Administrator.Medical Director.The committee will meet at Minimum Quarterly at an appointed time.

Based on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents (Resident 19) was treated with dignity and respect when a clothing protector (adult bib) was applied during mealtime against the resident's wishes. This failure violated Resident 19's right to dignity with the potential to negatively impact Resident 19's psychosocial well-being. Findings:During a review of Resident 19's admission record, the record indicated Resident 19's diagnosis included major depressive disorder (a common, serious mental health condition characterized by persistent, intense feelings of sadness, and a loss of interest in activities that severely impacts daily functioning and social isolation) and anxiety disorder (a group of mental health conditions characterized by persistence, excessive, or dread that interferes with daily life).During a concurrent observation and interview on 3/4/26 at 8:15 a.m. with Resident 19 in Resident 19's room, Resident 19 was observed in bed in a sitting position with the meal tray placed on the overbed table. During the interview, Resident 19 stated that she did not want to wear a clothing protector.During a concurrent observation and interview on 3/4/26 at 8:19 a.m. with the Certified Nursing Assistant (CNA) 1, CNA 1 confirmed Resident 19 was wearing a clothing protector during each mealtime to prevent her clothing from getting dirty. CNA 1 stated that if a clothing protector was not available; she would obtain a towel or a cloth napkin from the dining room to place on Resident 19 to protect her clothing from getting dirty. CNA 1 further acknowledged that there was a potential risk that Resident 19 could feel left out or singled out when she was the only resident wearing a clothing protector during meals in the room. During an interview on 3/4/26 at 1:13 p.m. with the Direct of Staff Development (DSD), the DSD stated that residents had the right to make their own decisions. The DSD stated that staff should have provided Resident 19 with the opportunity to maintain dignity and independence. The DSD further stated that staff should not have applied a clothing protector without the resident being asked first, or without the family being consulted first, if appropriate. The DSD stated that applying a clothing protector without the resident's consent does not maintain the resident's dignity.During an interview on 3/4/26 at 2:47 p.m. with the Director of Nursing (DON), the DON stated that residents should have been asked for their preference regarding wearing a clothing protector prior to mealtime. The DON stated that if a resident does not wish to wear a clothing protector, staff should honor the resident's choice. The DON further stated that it should not be standard practice for staff to automatically apply a clothing protector to residents during mealtimes.Review of the facility provided policy and procedure (P&P) titled, Assistance with Meals, revised in 7/17, indicated, . Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 3. Residents. comfort and dignity, for example. d. Avoiding the use of bibs or clothing protectors instead of napkins, unless requested by the resident.

Based on observation, interview, and record review, the facility failed to accommodate the needs of two of 23 sampled residents (Resident 10 and Resident 83) when,1. Resident 10'a call lights (devices used to contact staff for assistance) was not within their reach. 2. Resident 83's call light was not within reach.This failure placed Resident 10 and Resident 83 at increased risk for unmet care needs, delayed staff response, falls, and potential for accidents or injury.Findings:1.A review of Resident 10's admission RECORD, indicated Resident 10's diagnoses included malignant neoplasm of unspecified site of left female breast (breast cancer), palliative care (care focused on comfort and quality of life), secondary malignant neoplasm of unspecified lung (cancer that spread to the lung, dementia (a condition that affects memory and thinking), metabolic encephalopathy (a condition causing confusion due to a body imbalance or illness), anxiety disorder, and pain.During a concurrent observation and interview on 3/3/26 at 11:41 AM with Resident 10 in Resident 10's room, Resident 10 was sitting in her wheelchair next to her bed and stated she did not know where the call light was and could not use it if she needed to call for help.During a concurrent observation and interview on 3/3/26 at 11:45 AM with the Activity Director (AD) in Resident 10's room, Resident 10 was seated in her wheelchair on the left side of Resident 10's bed while the call light cord was wrapped around the right bed rail. The AD stated Resident 10's call light was not within Resident 10's reach because it was placed on the opposite side of the bed, placing Resident 10 at risk of falls and accidents.A review of Resident 10's fall care plan, initiated on 12/8/25, in the section titled, Focus, indicated, [Resident 10] High risk for falls and injury., in the section titled, Interventions, indicated, .Have things needed by the resident within reach including call light.2.A review of Resident 83's admission RECORD, indicated Resident 83's diagnoses included difficulty in walking, muscle weakness, pain, and other malignant neoplasm of kidney (kidney cancer).During a concurrent observation and interview on 3/4/26 at 8:14 AM with Resident 83 in Resident 83's room, Resident 83 was sitting upright in her bed and attempted to pull out the call light from being stuck between the left bed rail and the bed frame but was unable to remove it. Resident 83 stated the call light had also been stuck during the previous shift and staff had to pull the call light out to free it. Resident 83 further stated she would ask her roommate to press the roommate's call light so she could receive assistance from staff, which could delay staff response.During a concurrent observation and interview on 3/4/26 at 8:28 AM with Certified Nursing Assistant (CNA) 3 in Resident 83's room, Resident 83 was in bed with the call light stuck to the left bedrail. CNA 3 stated that Resident 83's call light was not within Resident 83's reach and this was a safety concern. CNA 3 further stated that if Resident 83 had an emergency, she would not be able to access her call light.A review of Resident 10's fall care plan, in the section titled, Focus, initiated on 1/20/26, indicated, [Resident 83] High risk for falls and injury., in the section titled, Interventions, indicated, .Have things needed by the resident within reach including call light.During an interview on 3/6/26 at 9:45 AM with the Director of Nursing (DON), the DON stated call lights must be within residents' reach and answered promptly by staff. The DON further stated if a resident does not have access to a call light, the resident was at risk for falls and care needs could be delayed. Review of facility's policy and procedure (P&P), titled Call Lights: Accessibility and Timely Response, revised on 10/25, the P&P indicated, .Staff should facilitate call light placement within reach of resident and secure it as needed.Call system should be accessible to Residents while in bed or other sleeping accommodations in room .

Based on interview and record review, the facility failed to ensure the right to be fully informed of the Bed-Hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) process for 1of 23 sampled residents (Residents 10) when the facility failed to provide a written Bed-Hold Notice to Resident 10 and her RP when transferred to the hospital on [DATE].This failure placed Residents 10 and her RP at risk for emotional distress (mental or emotional harm) and deprived Resident 10 and her RP of the option and information to keep the resident's bed during hospitalization (bed-hold).Findings:A review of Resident 10's admission RECORD, indicated Resident 10 was admitted to the facility with diagnoses which included breast cancer, lung cancer, and palliative care (care focused on comfort and quality of life), and had a resident representative (RP) listed in the admission record. A review of Resident 10's progress notes, dated 12/1/25, the progress notes indicated .Resident [Resident 10] transferred to [hospital] from PCP [Primary Care Provider] appointment.A review of Resident 10's progress notes, dated 12/8/25, the progress notes indicated, .Resident [Resident 10] arrived to facility via gurney [a wheeled stretcher used to transport patients] .During a concurrent interview and record review on 3/5/26 at 9:40 AM with Licensed Nurse (LN) 8, Resident 10's admission record was reviewed for admission, transfer, and discharge date s; and Resident 10's EHR was reviewed for a written Bed-Hold Notice. LN 8 stated Resident 10's RP had not receive a written Bed-Hold Notice when transferred to the hospital on [DATE].During an interview on 3/6/26 at 9:22 AM with LN 9, LN 9 stated a bed hold must be offered to the resident or RP when a resident was transferred to the hospital and a return to the facility was anticipated. LN 9 further stated failure to explain the bed hold process to the RP could have caused emotional distress if the resident returned to the facility and the expected return bed was not available.During an interview on 3/6/26 at 9:45 AM with the DON, the DON stated when a resident was transferred to the hospital, a written Bed-Hold Notice must be offered to the resident or RP to allow the option to hold the bed for up to seven days during hospitalization and to prevent emotional distress if the resident's bed was no longer available and a different bed was offered upon return to the facility.A review of facility's policy and procedure (P&P) titled, Bed-Holds and Returns revised in 03/17, the P&P indicated .Prior to transfers.residents or resident representative will be informed in writing of the bed-hold and return policy.

Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to maintain and prevent decline in functional ability (the resident's ability to move and perform daily activities) for one of 23 sampled residents (Resident 31) when Resident 31's physical therapy (PT: a healthcare specialty service focused on improving movement, reducing pain, and restoring physical function through tailored exercises, manual techniques, and education) was discontinued despite a physician's order to extend physical therapy and without a plan to maintain or prevent decline in functional abilities through restorative nursing assistant (RNA - a program where trained staff help residents practice exercises and daily activities to maintain strength and mobility) services.This failure placed Resident 31 at risk for functional decline and complications related to decreased mobility such as muscle atrophy (muscle becomes smaller and weaker from lack of use), pressure injuries, contractures (permanent tightening of muscles or joints), and range of motion (ROM) limitations.Findings:Review of Resident 31's admission RECORD indicated Resident 31 was admitted to the facility in 12/2025 with diagnoses including fracture of lower end of left femur (broken lower part of the left thigh bone), periprosthetic fracture around internal prosthetic left hip joint (break in the bone around an artificial hip joint), difficulty in walking, muscle weakness, acute kidney failure, major depressive disorder, disorders of bone density and structure, neuralgia and neuritis (nerve pain and nerve inflammation), pain, personal history of transient ischemic attack and cerebral infarction without residual deficits (previous mini-stroke and stroke without lasting effects), history of falling.Review of Resident 31's Physical Therapy PT Evaluation & Plan of Treatment dated 12/4/25, in the section titled Assessment Summary indicated, .Patient [Resident 31] present to P.T.[Physical Therapy] during evaluation with decline in overall mobility requiring assistance due to recent acute hospitalization with deconditioning, pain, gen [generalized] weakness and decreased activity tolerance.Patient requires skilled PT services to minimize falls, increase LE ROM [lower extremities range of motion] and strength.increase functional activity tolerance.Patient goals .[Resident 31] I want to get better, stronger and return home safely.Potential for Achieving Goals .Patient demonstrates good rehab potential as evidenced by recent onset, good cognition.active participation.Review of Resident 31's Physical Therapy Discharge Summary dated 2/19/26, in the section titled, STG [Short-Term Goals] #5.0 - Discontinue on 2/19/26 indicated, .[Resident 31] Not medically safe, will need significant help at home.In the section titled Discharge Status and Recommendations indicated, .Patient [Resident 31] discharged to live with family/friends .Discharge Recommendation: HHPT [Home Health Physical Therapist], w/c [wheelchair] . During a concurrent observation and interview on 3/3/25 at 3:43 PM, with Resident 31 in Resident 31's room, Resident 31 was sitting in her wheelchair next to her bed. Resident 31 stated she had a fracture of her left leg, was unable to walk, and was admitted to the facility for physical therapy. Resident 31 stated physical therapy services were discontinued a couple of weeks ago and she was not doing any exercises because no one was assisting her and she was just sitting in her wheelchair and hoping to walk again.During a concurrent interview and record review on 3/4/26 at 4:54 PM, with the Director of Rehabilitation (DOR), review of Resident 31's physician order dated 1/30/26, indicated, Skilled PT services to be extended qd [every day] 5x/wk [five times per week] for 8 wks [eight weeks] for difficulty in walking, tx [treatment] may include therapeutic exercise, therapeutic activity, neuro re-education [training to improve movement and balance], gait training , w/c mgt [wheelchair management], group therapy, patient education, and caregiver training. The DOR stated the physician's order to extend the PT services for 8 weeks for Resident 31 was not followed. The DOR verified Resident 31 did not receive PT services for 8 weeks as physician ordered to extend on 1/30/26. The DOR stated the Discharge summary dated [DATE], indicated Resident 31 was discharged home, which was incorrect because Resident 31 remained in the facility and could have been transitioned to the RNA program. The DOR stated Resident 31 was at risk for functional decline and complications related to decreased mobility such as muscle atrophy, pressure injuries, contractures, and ROM limitations when did not receive PT services as ordered or was not enrolled in RNA program.During an interview on 3/5/26 at 10:57 AM, with the Restorative Nursing Assistant (RNA) 1, RNA 1 stated Resident 31 was not enrolled in the RNA program and was not receiving restorative nursing services.

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices were followed when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with the census of 69 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 6 errors out of 26 opportunities which resulted in a facility wide medication error rate of 23.08 % in 1 out of 9 residents (Resident 6) during medication administration observation. These failures had the potential to result in unsafe medication use, medication errors, and noncompliance with the physician's orders.Findings: Review of Resident 6's electronic medical record, titled admission RECORD, dated 3/2026, indicated Resident 6 was admitted to the facility with diagnoses including hypertension (high blood pressure), convulsions or seizure disorder (refers to a temporary, sudden, involuntary muscle contractions), schizophrenia (mental disorder), anxiety disorder, and depression among others.During a concurrent medication administration observation and interview, with Licensed Nurse (LN) 5, at station 2 hallway, on 3/4/26, at 11:09 a.m., LN 5 prepared 12 medications to administer to Resident 6. LN 5 stated she was administering the morning medications as she was running late. The medications included pain medication, seizure medication, mental health drugs in addition to blood pressure and heart medications among others with administration time of 8 AM was being administered at 11AM. Review of Resident 6's electronic medical record, titled MEDICATION ADMINISTRATION RECORD (or MAR, where nurses document what and when administered ordered medications), dated 3/2026, the MAR record indicated six of the 12 medications were time sensitive for administration (medications to be used in a timely manner for safety and effectiveness) as follows: Furosemide Tablet 40 MG; (water pill for heart failure; MG is milligram, a unit of measure); Give 1 tablet by mouth one time a day at 8:00 a.m., order date 2/20/26. Gabapentin Oral Capsule 100 MG (pain medication for nerve pain) . Give1 capsule by mouth three times a day. at 8:00 a.m., 1200, and 4:00 p.m., order date 3/1/25. AmLODIPine Besylate (blood pressure medication) Tablet 5 MG Give 1 tablet by mouth one time a day. at 8:00 a.m., order date 3/2/25. ZyPREXA Oral Tablet 10 MG (or olanzapine, mood and mental health drug) Give 1 tablet by mouth every 12 hours. at 8:00 a.m., and 8:00 p.m., order date12/31/25. Keppra Solution . (or Levetiracetam, drug used to prevent seizure) Give 5 ml ('ml is milliliter, a measure of volume) by mouth two times a day. at 8:00 a.m., and 4:00 p.m., order date 3/1/25; and, QUEtiapine Fumarate Oral Tablet 50 MG (Quetiapine; mental health and mood control drug) Give 2 tablet by mouth every morning and at bedtime. at 8:00 a.m., and 8:00 p.m., order date 12/28/25.These ordered medications were not administered to Resident 6 at the prescribed time of 8 AM. The morning medications were due at 8 AM but were administered more than three hours past the scheduled time after 11 AM. During an interview on 3/4/26, at 1:00 p.m., Licensed Nurse (LN) 5 confirmed that medications for Resident 6 were prescribed to be given at 8:00 a.m. LN 5 further confirmed that Resident 6's medications were administered more than three hours after the scheduled time. LN 5 stated an acceptable administration window for medications was one hour before and up to one hour after the scheduled time. LN 5 stated medications scheduled for 8:00 am should have been administered between 7:00 a.m. and 9:00 a.m. LN 5 further stated that failure to administer medications within the designated time window could negatively affect Resident 6's health condition such as Resident 6's blood pressure could spike if the medication was not given within the appropriate timeframe. During an interview on 3/4/26, at 1:08 p.m., LN 7 stated medications should be administered at the prescribed time to prevent adverse reactions and maintain the residents' health condition. LN 7 further stated that when a resident was prescribed blood pressure medication and it was administered later than the acceptable timeframe, the resident might experience elevated blood pressure. LN 7 stated if anti-seizure medications were administered late, it might lead to seizure activity that could negatively affect the residents' health condition. During a phone interview on 3/5/26, at 11:09 a.m., the Pharmacy Consultant (PC) stated that his expectation for nurses was to administer medications within the established time window, which was 30 minutes before up to 30 minutes after the scheduled administration time as directed and documented in the electronic health record system. During an interview on 3/6/26, at 10:23 a.m., the Director of Nursing (DON) stated that his expectation for nurses during medication administration was to follow the five rights, which include the right patient, right medication, right dose, right route, and right time. The DON stated that if a medication administration delayed or administered outside the acceptable timeframe, he expected the nurse to notify the physician. The DON further explained that the physician was responsible for adjusting or changing the medication administration time if necessary. The DON further stated that there was a potential risk for adverse effects when medications were not administered as scheduled. Review of the facility's policy, titled PREPARATION AND GENERAL GUIDELINES. MEDICATION ADMINISTRATION-GENERALGUIDELINES, dated October 2017, indicated, . B. Administration. 2) Medications are administered in accordance with written orders of the attending physician. 10) Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after) .

Based on interview, and record review, the facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN: a notice that informs residents of changes to their Medicare Part A coverage for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay) to one of one sampled resident (Resident 2) reviewed for Medicare benefit notification after skilled services ended.This failure had the potential for Resident 2 not to be able to make informed decisions about his care and finances, being unaware of his right to appeal and placed him at risk for unexpected medical bills.During a concurrent interview and record review on 8/6/25, at 2:48 PM, the Admissions Coordinator (AC) stated Resident 2's Medicare Part A skilled services coverage ended on 7/23/25. The AC stated Resident 2 continued to stay in the facility after his skilled care ended. The AC confirmed that Resident 2's Medicare eligibility benefits document indicated that Resident 2 had 46 Medicare days remaining. The AC stated the SNF ABN notice should have been issued to Resident 2 when his skilled services coverage ended on 7/23/25 and he continued to remain at the facility. The AC further stated that without the SNF ABN, the resident might not know his rights.During a concurrent interview and record review on 8/6/25, at 12:40 PM, the Social Services Director (SSD) confirmed that Resident 2 was discharged from Medicare Part A services on 7/23/25, but Resident 2 remained in the facility as a long term care resident. The SSD further confirmed there was no indication in Resident 2's medical record that the SNF ABN was provided to Resident 2.During a concurrent interview and record review on 8/6/25, at 1:13 PM, the Director of Nursing (DON) stated Resident 2 was scheduled for discharge on [DATE], but remained in the facility and transitioned to long term care. The DON stated further Resident 2's last Medicare-covered day was 7/23/25. The DON stated the SNF ABN notice should be given to residents three days before the last covered day, so the residents knew their rights and had a chance to appeal. The DON confirmed that the SNF ABN notice was not provided to Resident 2. The DON stated that not providing the SNF ABN could lead to unexpected billing for the residents.Review of an undated facility policy titled, Advance Beneficiary Notices, indicated, .The facility shall inform Medicare beneficiaries of his or her potential liability for payment. A liability notice shall be issued to Medicare beneficiaries upon admission or during a resident's stay, before the facility provides: (a.) An item or service that is usually paid for by Medicare .or (b.) Custodial Care .For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055.

Based on interview, and record review, the facility failed to ensure an accident-free environment when necessary rehabilitation care instructions for nursing staff were not updated in the care plan for one of three sampled residents (Resident 1) when Resident 1 was placed in a regular wheelchair instead of a recliner wheelchair with a non-slip mat.This failure resulted in Resident 1 falling out of the wheelchair and hitting his head on the floor on 7/27/25. Findings:A review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility in 2025 with diagnoses including hemiplegia (paralysis or weakness to one side of the body) and hemiparesis (one- sided muscle weakness) following cerebral infarction (also known as stroke, when blood flow to the brain is interrupted, leading to brain tissue damage) affecting right dominant side, difficulty in walking, and paraplegia (inability to voluntarily move the lower parts of the body).A review of Resident 1's Brief Interview for Mental Status (BIMS - a standardized assessment to quickly evaluate a resident's cognitive function by asking a series of questions related to attention, orientation, and memory recall, resulting in a total score ranging from 0-15) dated 6/16/25, indicated Resident 1 had a BIMS Score of 10 which indicated moderate impairment.A review of Resident 1's medical record titled, Morse Fall Risk Screen, (is a rapid and simple method of assessing a patient's likelihood of falling, score of 0-24 low risk, 25-44 moderate risk, and 45 and higher as high risk) dated 6/16/25, indicated Resident 1 had a score of 56 which categorized Resident 1 as a high risk for falling.A review of Resident 1's Minimum Data Set (MDS - an assessment tool) Section GG (a standardized assessment in long-term care that measures a patient's ability to perform self-care and mobility activities, such as eating, bathing, and walking.) dated 6/19/25, indicated Resident 1 was, .Dependent- Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).A review of Resident 1's Nurses Notes, dated 7/27/25, at 6:49 PM, indicated, .Resident under Palliative Care Services [provides symptom relief, comfort and support to people living with serious or chronic illnesses.] under [name of hospice provider].Resident have [sic] a baseline of refusing ADLs [activities of daily living] care, but despite refusals, nursing staff still continues to offer resident to get up in wheelchair as tolerated. Resident has AROM [active range of motion] of right and left upper extremities and is contracted of right and left lower extremities.Due to patient's multiple attempts to get out of wheelchair unassisted, 2 CNAs [certified nursing assistants] assisted patient back to room [Resident 1's room] to prepare for transfer back to bed.Resident repeatedly attempted to push himself onto the floor still while being assisted to room.Resident had 1 CNA supervising him while the other CNA got the Hoyer lift [a mechanical, portable hoist used to safely transfer people with limited mobility].patient forcefully pushed himself forward past the CNA and projected forward onto the floor. [Resident 1] was in doorway of room.[Resident 1's forehead hit the floor which resulted in a minor lac [laceration or cut], scant bleeding was noted.During a phone interview on 8/5/25, at 2:03 PM, with Resident 1's responsibly party (RP), the RP stated she received a call from the facility on 7/27/25 and was informed that Resident 1 fell out of his wheelchair. The RP explained Resident 1 could not walk, was not able to move himself and he would fall forward. The RP stated Resident 1 required max assistance.During a joint interview on 8/6/25, at 1:52 PM, with the MDS Coordinator (MDSC) 1 and MDSC 2, both MDSC 1 and MDSC 2 stated Resident 1 needed a Hoyer lift to be transferred from bed to wheelchair and was dependent. MDSC 1 and MDSC 2 explained dependent meant that staff had to perform 100% of the activity. MDSC 1 and MDSC 2 stated Resident 1's sitting balance in therapy was poor and he required maximum assistance to maintain balance.During an interview on 8/7/25, at 3:03 PM, with the Medical Doctor (MD), the MD stated it was difficult to judge a resident's physical mobility because physical therapy recommended the ambulation status of the resident. The MD further stated he agreed with physical therapy if they recommended max assistance was needed for Resident 1's ability to be seated in a wheelchair.During a joint concurrent interview and record review on 9/8/25, at 9:28 AM, with the DOR and the Physical Therapist (PT), Resident 1's medical record was reviewed and indicated he was totally dependent with a 2 person assist for transfers. The PT stated she communicated with the nursing staff that Resident 1 could be transferred to a wheelchair and could tolerate sitting in a reclined position with a Dycem (a flexible, reusable, non-adhesive polymer material that can be cut to size and used on surfaces to secure people in chairs or wheelchairs, providing grip and stability by preventing sliding an slipping) on top of the wheelchair. The PT further stated Resident 1 had poor trunk control and it was not safe for him to be positioned in a 90-degree (a unit of measurement of angles) upright position. The PT stated after Resident 1's therapy sessions, he occasionally would stay in a wheelchair accompanied by a nurse or the activity staff to ensure that there was always someone supervising Resident 1. The PT further stated Resident 1 did not have a behavior of trying to move forward and he usually communicated when he was uncomfortable and would ask her to move him backward on the chair. Resident 1's care plan was reviewed with the DOR and PT, the DOR confirmed that interventions in the care plan did not include what was verbally communicated with the nursing staff which included the use of a recliner wheelchair and the placement of a Dycem for Resident 1. The DOR stated the purpose of the care plan was for staff to know the interventions and the goals for the residents. The PT stated Resident 1 was provided his own reclining wheelchair with a Dycem.During an interview on 9/8/25, at 10:04 AM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated on the day of the incident, the nurse told her and CNA 1 to get Resident 1 up because Resident 1 requested to be in a wheelchair and they just followed the instructions. CNA 2 further stated Resident 1 was sitting in a wheelchair in a 90-degree position in the hallway, yelling for approximately 2-5 minutes and Resident 1 requested to be back in bed. CNA 2 stated she was helping CNA 1 to put Resident 1 back in bed and CNA 1 was making the bed at the time. CNA 2 further stated Resident 1 was in a 90-degree position in the wheelchair, and she was standing in front of Resident 1 when she saw Resident 1 fall and hit his head on the floor and she tried to catch him, but it was too late. CNA 2 stated Resident 1 never had the behavior of leaning but he had a behavior of randomly screaming all the time. CNA 2 further stated that for all residents, the CNAs usually talked to the nurses to check if a resident could be up on a chair, how many people needed to assist the resident for transfer or if a Hoyer lift was needed. CNA 2 stated the CNAs relied on verbal communication with the nurses, nursing supervisors and therapists because they did not have access to the therapy notes and it was not in the plan of care. During an interview on 9/8/25, at 10:25 AM, with CNA 1, CNA 1 stated Resident 1 was asking to be in the wheelchair. CNA 1 further stated she used a Hoyer lift with the assistance of CNA 2 to transfer Resident 1 in a wheelchair. CNA 1 stated Resident 1 was in an upright position in a wheelchair for an hour in front of the nurses' station. CNA 1 further stated Resident 1 used his own regular wheelchair and not a recliner wheelchair. CNA 1 stated Resident 1 was not in a reclining wheelchair at that moment (7/27/25) and had never seen him in a reclining wheelchair. CNA 1 further stated the wheelchair was in Resident 1's room and he had 2 roommates and none of them had a reclining wheelchair. CNA 1 stated that after almost an hour up in the wheelchair, she took Resident 1 back to his room because it was almost an hour and she was preparing Resident 1's bed. CNA 1 further stated nobody asked her to put Resident 1 back to bed but Resident 1 looked uncomfortable, so she decided to wheel him back to the room. CNA 1 stated she was fixing the bed and Resident 1 was by the door sitting in the same position. CNA 1 further stated when she turned her back around, Resident 1 was already on the floor. CNA 1 stated CNA 2 was not in the room, and she was by herself. CNA 1 further stated she did not put any resident on a chair until the PT evaluated the resident. CNA 1 stated by talking to the PT she would know how she would care for the resident. CNA 1 further stated this was the first time she got Resident 1 on a wheelchair, but she saw Resident 1 up in a wheelchair with the PT and other CNAs and that is why she knew Resident 1 could be in a wheelchair. CNA 1 stated Resident 1 did not have a behavior of pushing himself on the floor except the day of the incident. CNA 1 further stated Resident 1 could not stand up because he had contractures (a permanent stiffening and shortening of muscles, tendons, or skin that prevents a joint or body part from moving normally) on both legs.During an interview on 9/8/25, at 10:51 AM, with License Nurse (LN) 1, LN 1 stated Resident 1 was demanding to get up in a wheelchair and 2 CNAs helped him. LN 1 further stated Resident 1 usually would lay in bed, but the family requested to get him up. LN 1 stated Resident 1 was on therapy, and she saw the rehab staff use a Hoyer lift before. LN 1 further stated she looked at the therapy notes and called the DOR and DON to ask if Resident 1 could be in a wheelchair. LN 1 stated that the details on resident transfer and assist instructions were usually in the plan of care and it would include how the resident could be transferred. LN 1 further stated the nursing staff could also check the H&P (History and Physical, a formal assessment by a physician that documents the resident's medical history, current condition, and a physical exam to guide their individualized plan of care), the therapy orders and the care plan. LN 1 stated the rehab instructions for the residents should be in the rehab care plan. LN 1 further stated she usually checked the care plan or asked the PT in person. LN 1 stated Resident 1 did not want to participate in activities and only saw him up on a wheelchair when the family was visiting or during therapy sessions. LN 1 further stated there was a special request from Resident 1's family to get him up and for him to attend the activities but he never wanted to except for that day he requested to be in a wheelchair (7/27/25). LN 1 stated Resident 1 was sitting upright in a standard regular wheelchair on the day of the incident. LN 1 stated Resident 1 was in front of the nurses' station when he became agitated and started pushing himself forward. LN 1 further stated that Resident 1 did not usually do things like pushing himself forward and he did not have a behavior for it. LN 1 stated the purpose of the care plan was to meet the residents' goals and interventions and that. This included staff from all departments could get instructions on what to do and had the ability to check if there were changes with the interventions. LN 1 further stated the instructions for transfers, number of persons needed for assist, and the ADLs should all be in the care plan. LN 1 stated she only communicated with the rehab department verbally for instructions. LN 1 stated Resident 1 was a high risk for falls because he could not stand. During a joint interview on 9/8/25, at 12:46 PM, with the DOR and the PT, the DOR stated the Dycem was used as resistance to prevent Resident 1 from sliding on the wheelchair and having Resident 1 in a reclining position would also prevent him from falling forward. The DOR further stated if Resident 1 was left unsupervised in a wheelchair it could be a risk for fall. Both the DOR and the PT stated Resident 1 could not lean forward all the way. The PT stated she did not document that the Dycem needed to be used for Resident 1 and she just put it in her treatment notes that Resident 1 was able to tolerate 2 hours sitting in a wheelchair during therapy sessions. The PT further stated Resident 1 needed constant supervision and visual monitoring with staff by the nurse's station whenever he sat in a wheelchair. The DOR stated the specific rehab instructions for Resident 1's care were not documented because the Dycem and reclining wheelchair were already in place, and they had open communication with the nursing staff. The PT stated she verbalized to the nursing staff that Resident 1 was able to tolerate 2 hours of sitting and needed 2-persons to get him out of bed. The PT confirmed this was not documented. The PT stated Resident 1's back always needed to be supported. The PT further stated Resident 1 was provided with a wheelchair in a 75-degree angle and it could be readjusted. The PT stated she expected the nursing staff to keep Resident 1 in a reclining position with a Dycem underneath him and he needed someone to be with him. The PT further stated she never encountered Resident 1 trying to get out from the wheelchair. The PT stated Resident 1 was comfortable in a 60-75-degree position when sitting in a wheelchair. The DOR confirmed that no one called her on the day of the incident to ask for instructions regarding Resident 1's rehab plan of care.During an interview on 9/8/25, at 1:40 PM, with the Director of Nursing (DON), the DON stated he expected open communication between the rehab department and the nursing department regarding the plan of care for the residents. The DON further stated if the nursing staff had questions regarding a resident's level of care when the rehab staff were not at the facility then nursing staff could always call the DOR. The DON explained that the DOR was available 24/7 (24 hours a day, 7 days a week) and the staff could also use their critical judgment or check the doctor's order. The DON stated the standard practice was for the nursing staff to check the resident's plan of care. The DON further stated the care plan should detail the level of care, goals, and facility interventions for the resident's progress. The DON stated it served as a guide in managing resident care by outlining necessary actions to achieve the set goals. The DON further stated the type of wheelchair, certain devices and specific instructions for residents should be reflected in the care plan and in the therapy notes. The DON stated the rehab department communicated with the nursing staff and he expected what was communicated between rehab and nursing should be also be documented in the care plan. The DON confirmed that the rehab care plan did not reflect the specific interventions for Resident 1. The DON stated the importance of updating the care plan was for residents to get proper enhanced care and it was also used as a communication tool between all the departments. The DON further stated the care plan was ever changing and updated frequently. The DON stated he did not remember what was communicated from the rehab department regarding the plan of care for Resident 1.A review of Resident 1's Care Plan Report, under the section titled, Focus, indicated, .Mobility Deficit as evidenced by: Requiring assistance or is dependent in: Mobility.Chair/Bed-to-Chair Transfer (total D [dependent]).Lying to Sitting on the Side of Bed (total D).Sit to Lying (total D). Further review of the document under the section titled, Interventions, date initiated on 6/21/25, indicated, .Keep most frequently use personal items and things needed during care.within resident's reach.A review of Resident 1's Care Plan Report, date initiated on 6/21/25, under the section titled, Focus, indicated, .High risk for falls and injury related to Attempting to get out of bed unassisted, Limitation of mobility, Presence of Contracture [is a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement], Bladder incontinence [loss of bladder control], Bowel incontinence [loss of bowel control], CVA [cerebrovascular accident or stroke] w/ [with] right hemiparesis. Further review of the document under the section titled, Interventions, indicated, .Have things needed by the resident within reach.A review of Resident 1's Care Plan Report, date initiated on 6/17/25, under the section titled, Focus, indicated, .Skilled PT [physical therapy] intervention needed to improve B LE [bilateral lower extremity] strength, ROM [range of motion], activity tolerance, balance and safety awareness. Further review of the document under the section titled, Interventions, indicated, .PT.qd [once daily] 5x/wk [5 times per week] for 8 wks [weeks].tx [treatment] may include therapeutic exercise, therapeutic activity, neuro re-education, manual tx, w/c mgt [ wheelchair management], patient education and caregiver training.A review of an undated facility policy and procedure (P&P) titled, Falls and Fall Risk, Managing, indicated, .the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .A review of an undated facility P&P titled, Safety and Supervision of Residents, indicated, .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Systems Approach to Safety.2. Resident supervision is a core component of the system's approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.A review of an undated facility P&P titled, Care Plans, Comprehensive Person-Centered, indicated, .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.The comprehensive person-centered care plan will.m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels. n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program.A review of the facility P&P titled, Documentation Requirements, revision date 1/1/17, indicated, .Each Rehabilitation Services resident/patient had medical record of care and treatment which includes subsequent referrals, initial evaluations and plan of care, copies of daily notes, copies of progress notes, and treatment care plans.A review of an undated facility policy and procedure (P&P) titled, Progress Notes, indicated, .Progress notes shall be maintained for each resident who is receiving specialized rehabilitative services. Progress notes reflect the resident's progress and response to his or her care plan, medication, etc. Progress notes must be recorded monthly and whenever changes occur in the resident's condition. Such information must be recorded by the Therapy Service responsible for entering such date on the appropriate progress record.

The facility failed to store, prepare, distribute and serve food in accordance with professional standards and facility policy for food service when: 1. An Ice machine was not cleaned per manufacturer's guidelines and facility policy. 2. Lunch meal foods were not handled and served safely under sanitary conditions during a trayline observation. 3. Coffee machine water filter was expired for more than 1.5 years. 4. Serving ladles and scoop handles were damaged and not maintained in food safe manner. 5. A Griddle top collection tray cup had black sticky grime, brown stains and food residue inside of it. 6. Curry powder seasoning was out of date and code. 7. Parsley was found to be discolored with a tannish brown color on the leaves and stems. These failures had the potential to cause widespread foodborne illness in the 61 residents eating facility prepared meals. Cross reference F802 Findings: 1. During an interview [DATE] at 10:50 AM with the Maintenance Director (MTD), the MTD stated the ice machine was cleaned every three months. During an interview on [DATE] at 2:08 PM with Dietary Services Manager (DSM), the DSM stated the kitchen staff only cleaned the visible areas of the ice machine. The DSM also stated the kitchen staff did not clean the internal portions of the ice machine. During a kitchen observation and interview on [DATE] at 2:19 PM, the inside of an ice machine was observed to be dirty where the water tray loads and the ice making grid. Black and brown substances and debris material was on the ice machine chute, internal walls, water tray, and the ice bin. The external filter on the back of the ice machine was filthy with gray lint and debris. The MTD and DSM acknowledged the internal areas with black and brown debris inside the ice machine and the dirty filter. During an interview on [DATE] at 3:45 PM with Registered Dietitian (RD) 1, RD 1 stated ice machines should be clean and not have black mold inside of it. RD 1 stated the kitchen staff should clean the ice machine. RD 1 also stated a dirty ice machine could lead to dirt or mold getting into the ice. RD 1 further stated that ice was considered food and did not want residents to swallow dirty ice as it could lead to food-borne illnesses. During a review of the facility's policy and procedure titled, ICE MACHINE CLEANING PROCEDURES dated XX/23 indicated, .The ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacturer's recommendations, and the date recorded when cleaned. According to the 2022 Federal FDA Food Code section ,d+[DATE].11 indicated Equipment Food-Contact Surfaces and Utensils. Ice bins and components of ice makers need to be cleaned: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold .Ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms . 2. During a trayline observation on [DATE] at 12:49 PM, two cooks and two dietary aides were observed preparing food to be served. [NAME] (CK) 1 was observed placing her bare thumb on the inside of a disposable foam dish where meatloaf was being plated. CK 2 was observed preparing plates of food without gloves on. Dietary Aides (DA) 1 and 2 were observed placing food trays onto food carts without gloves on. During an interview on [DATE] at 2:08 PM with the Dietary Services Manager (DSM), the DSM stated that she wanted the kitchen staff to wear gloves during food preparation services. The DSM also stated that it would be cross-contamination risk if staff are not wearing gloves preparing food. During an interview on [DATE] at 3:45 PM with Registered Dietician (RD) 1, RD 1 stated that she wanted the kitchen staff to wear gloves during food preparation services. RD 1 also stated it would pose a cross-contamination risk if staff were not using gloves. According to the Food and Drug Administration (FDA) Food Code 2022, Section ,d+[DATE].11 Preventing Contamination from Hands, .food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment . During a review of a facility provided in-service titled, Personal Hygiene dated [DATE], in the section, Food Handling indicated, .Never touch the food contact area of plates, bowls, glasses or cups. 3. During an initial kitchen tour on [DATE] at 10:05 AM, a water filter system on the coffee machine was observed to be dated [DATE] and expired according to manufacturer's information. During an interview on [DATE] at 11:10 AM with [company name] Vendor Technician (VTC) 2, VTC 2 stated he recommends the coffee water filter system be changed within a one-year timeframe. VTC 3 changed out the coffee water filter system because it was 18 months old. During an interview on [DATE] at 2:08 PM with the Dietary Services Manager (DSM), the DSM stated that the coffee water filter system should be changed out yearly. During an interview on [DATE] at 3:45 PM with Registered Dietician (RD) 1, RD 1 stated that the coffee water filter system should be changed regularly. RD 1 also stated that the coffee may not be as fresh and that the flavor profile may change. During a review of the facility's policy and procedure titled, Maintenance Service revised ,d+[DATE], in the section, Policy Interpretation and Implementation indicated, .Maintenance personnel shall follow the manufacturer's recommended maintenance schedule . 4. During an initial kitchen tour on [DATE] at 8:45 AM, eight scoops and ladles were noted to have rubber handles that were melted down with black grime and debris deeply engrained in the hard rubber. During an interview on [DATE] at 9:19 AM PM with the DSM, the DSM stated the cooks were constantly burning the handles of the scoops and ladles while they cooked. During an interview on [DATE] at 2:08 PM with the DSM, the DSM stated that serving ladles and scoops should be in good working condition. The DSM also stated that particles could get into the food items. The DSM further stated that staff safety could be at risk because of the damaged utensils. During an interview on [DATE] at 3:45 PM with RD 1, RD 1 stated that burned ladles and scoops could impact staff safety. During a review of the facility's policy and procedure titled, KITCHEN SAFETY dated XX/23 indicated, .Maintain cutlery in good condition. During a review of the facility's policy and procedure titled, SANITATION dated XX/23 indicated, .All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas . 5. During the initial kitchen tour on [DATE] at 8:45 AM, a collecting tray cup located underneath the griddle with an opening at top of the griddle equipment, had black sticky grime, brown stains, and food residue inside of it. During an interview on [DATE] at 2:08 PM with the DSM, the DSM stated that the grill should be cleaned every time it is used. The DSM also stated she would not want to see a buildup of food residue. During an interview on [DATE] at 3:45 PM with RD 1, RD 1 stated that the griddle should be cleaned after every use. RD 1 also stated the griddle should be deep cleaned at least once a week. RD 1 further stated that she did not want food particles in the collecting duct of the griddle. According to Food and Drug Administration (FDA) Food Code 2022, ,d+[DATE].12 Cleaning, Frequency and Restrictions . (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean .(B)Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing . According to FDA Food Code 2022, Section ,d+[DATE].11. Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils . (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . During a review of the facility's policy and procedure titled, Food Preparation and Service revised ,d+[DATE] indicated, .Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned . During a review of the facility's policy and procedure titled, RANGES AND OVENS dated XX/23 indicated, .Range drip pans must be emptied and washed on a routinely scheduled basis . Grills must be cleaned after each use . Always empty and wash the grease catch pan after each use . 6. During an initial kitchen tour on [DATE] at 8:45 AM, a container of curry powder was noted to have an open date of [DATE]. During an interview on [DATE] at 2:08 PM with the DSM, the DSM stated that expired curry powder could lead to spices losing its flavor. During an interview on [DATE] at 3:45 PM with RD 1, RD 1 stated that she did not want expired food items in the kitchen. RD 1 also stated that spices that are expired could lose flavor. During a review of an undated facility provided letter from [company name], the letter indicated, .Spices are generally considered Best Used By in ,d+[DATE] months . During a review of a facility provided in-service titled, DRY STORAGE OF FOOD AND SUPPLIES dated [DATE], in the section, Procedures for Dry Storage, the section indicated, .Dry food items which has been opened such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc., will be tightly closed, labeled, and dated. These items are to be used per times specified in the Dry Food Storage Guidelines . During a review of the facility's undated policy and procedure titled, DRY GOOD STORAGE GUIDELINES dated XX/23 indicated spices such as curry powder have a shelf life of one year once opened. 7. During an initial kitchen tour on [DATE] at 10:05 AM, parsley was found discolored and wilting in a reach-in refrigerator. During an interview on [DATE] at 2:08 PM with the DSM, the DSM stated that she would prefer vegetables to fresh and not wilted. The DSM also stated she would not want to serve parsley that was discolored. During an interview on [DATE] at 3:45 PM with RD 1, RD 1 stated vegetables should be tossed out if they are wilting or discolored. During a review of the facility's policy and procedure titled, STORING PRODUCE dated XX/23 indicated, .Keeping fresh vegetables tightly wrapped with as little air in the bag/container as possible will keep them fresh longer . Remove the wilted or spoiled portions of lettuce, celery, and other fresh vegetables in the refrigerator often so they don't cause the rest of the vegetable to spoil.

Based on observation, interview and record review, the facility failed to ensure that food was served at an acceptable texture and palatability (taste) for six of six residents (Resident 12, Resident 55, Resident 22, Resident 26, Reisdent 16, and Resident 25) on a pureed (to blend, chop, mash, or strain a food until it reaches this soft consistency) diet when; 1. The cook did not follow a pureed recipe as written for the preparation of dilled zucchini and carrots; and 2. Pureed food items were not of correct texture and consistency. These failures had the potential to affect meal and food intake which could impair the nutrition status for the six residents on a pureed diet. Findings: 1. During a concurrent kitchen observation and interview on 10/29/24 at 12:49 PM with [NAME] (CK) 2, a small metal pan with puree dilled carrots and zucchini vegetables were placed on a steam table. The puree carrot and zucchini mixture was noted to have a dark brownish color. [NAME] (CK) 2 stated that she put the puree vegetable mixture in the oven to keep it warm before 10:00 AM. CK 2 then used a blender to prepare another batch of puree carrots and zucchini vegetables, and the color of the mixture was green. During an interview on 10/31/24 at 2:08 PM with the Dietary Services Manager (DSM), the DSM stated that she wanted the cooks to cook the puree food items evenly to avoid discoloration. The DSM stated that the oven may have been too hot which led to a brownish color for the puree dilled carrots and zucchini. During an interview on 10/31/24 at 3:45 PM with Registered Dietitian (RD) 1, RD 1 stated that she expected the cooks to use and follow standard recipes and to not change from the recipes. RD 1 stated placing food items in the oven for too long would result in overcooking of food. RD 1 further stated that food items would lose nutritional value. During a review of facility provided recipe titled, RECIPE: DILLED CARROTS AND ZUCCHINI, dated 2024, in the section, DIRECTIONS, indicated, .Simmer carrots in boiling water or steam until almost tender .Add zucchini and continue to cook until both are tender. Drain. Add margarine and dill . 2. During a test tray concurrent observation and interview on 10/30/24 at 12:29 PM with the DSM and the Corporate Registered Dietitian (RD 2), a puree of a beef entree was taste tested . The DSM and RD 2 confirmed that the puree beef entree was thin and not a mashed potato consistency. The DSM confirmed there was extra gravy poured on the beef pureed entree and that it may be too much. During an interview on 10/31/24 at 2:08 PM with the DSM, the DSM stated that she wanted the puree food items to be mashed potato-like in consistency. The DSM stated that there could be a choking hazard and aspiration (when something you swallow goes down the wrong way and enters your airway [trachea or windpipe] or lungs) risks if the pureed food items were too watery in consistency. During an interview on 10/31/24 at 3:45 PM with RD 1, RD 1 stated that pureed food items should hold its shape and not be runny. A review of a facility policy and procedure titled Food Preparation, dated 2023, in the section PROCEDURE, indicated, .The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared .Prepare foods as close as possible to serving time in order to preserve nutrition, freshness, and to prevent overcooking .

Based on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. Two Cooks and two Dietary Aides did not use proper food safety and sanitation practices to prevent cross-contamination; and 2. Weekly thermometer temperature calibrations were not completed by kitchen staff per facility policy. These failures had the potential to expose residents to bacterial contamination, that could result in food borne illnesses for all residents who consume food from the kitchen. The census was 61. Findings: 1. During a tray line observation on 10/29/24 at 12:49 PM, two cooks and two dietary aides were observed not wearing gloves and using their bare hands while plating the lunch meal food to be served. [NAME] (CK) 1 was observed placing her bare thumb on the inside of a foam container while placing a portion of meatloaf into the space of the container touched by her thumb. CK 2 was observed preparing small dessert plates of sherbet squares without gloves or having washed her hands prior to preparing the dessert plates. Dietary Aide (DA) 1 and DA 2 were observed placing food trays onto food carts without gloves on. During an interview on 10/31/24 at 2:08 PM with the Dietary Services Manager (DSM), the DSM stated the kitchen staff should wear gloves during food preparation services. The DSM also stated that it would be a cross-contamination risk if staff did not wear gloves when preparing food. During an interview on 10/31/24 at 3:45 PM with Registered Dietitian (RD) 1, RD 1 stated the kitchen staff needed to wear gloves during food preparation services because it would pose a cross-contamination risk if staff were not using gloves. According to the Food and Drug Administration (FDA) Food Code 2022, Section 3-301.11 Preventing Contamination from Hands, .food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment . According to the 2022 Federal Food Code, section 2-301.14, titled When to Wash, indicated, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. During a review of a facility provided in-service titled, Personal Hygiene, dated 4/4/24, in the section, Food Handling, indicated, .Never touch the food contact area of plates, bowls, glasses or cups . During a review of a facility provided in-service titled, Food Safety, dated 6/10/24, in the section, Safe Use of Disposables, indicated, .Handle containers as little possible. In waited surface, servers should keep fingers away from any food-contact surfaces of cups, plates, or other containers . During a review of the facility's policy and procedure titled, Food Preparation and Service, revised 12/2022, in the section, Food Distribution and Service, indicated, .Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks . 2. During the initial kitchen tour on 10/29/24, a review of the facility WEEKLY THERMOMETER CALIBRATION CHART, dated 2024, indicated the last two thermometer calibrations occurred on 9/30/24 and on 10/21/24. The WEEKLY THERMOMETER CALIBRATION CHART also indicated, .All thermometers should be calibrated at least once a week . During a concurrent observation and interview on 10/29/24 at 10:25 AM with CK 2, CK 2 stated the cooks calibrate the thermometers on different days, it depended on the cooks' schedule. CK 2 further stated sometimes it may be a few weeks before they calibrated the thermometers. During an interview on 10/31/24 at 2:08 PM with the DSM, the DSM acknowledged the thermometer calibration log was not completed weekly, according to the chart instructions. The DSM stated the kitchen staff should have calibrated the thermometers every week. The DSM also stated food items may not be at correct temperatures if the thermometers were not calibrated weekly. During an interview on 10/31/24 at 3:45 PM with RD 1, RD 1 stated that she would have preferred the kitchen staff to calibrate the thermometers weekly. RD 1 also stated that the food items may not have the correct temperatures if the thermometers were not calibrated. According to the 2022 Federal Food Code, section 4-204.112 titled Temperature Measuring Devices, indicated, .The importance of maintaining time/temperature control for safety foods at the specified temperatures requires that temperature measuring devices be easily readable. The inability to accurately read a thermometer could result in food being held at unsafe temperatures. Temperature measuring devices must be appropriately scaled per Code requirements to ensure accurate readings . During a review of a facility provided in-service titled, Thermometer Calibration dated 11/21/23, in the section, Calibrating a Thermometer indicated, .Thermometers should be calibrated regularly to ensure accurate temperatures .

Based on observation, interview and record review, the facility failed to ensure needs were accommodated for 8 of 21 sampled residents (Resident 36, Residents 40, Resident 21, Resident 38, Resident 1, Resident 23, Resident 50, and Resident 39), when: 1. Residents 40, Resident 21, Resident 38, Resident 1, and Resident 39 call light did not work and were not provided alternative means to contact staff, and for Resident 23 and Resident 50 staff did not respond timely to calls made by Resident 23 and Resident 50 who were given and alternative means to contact staff; and 2. Resident 36's call light (device used to contact staff for assistance) was not within reach. This failure had the potential to result in Resident 36, Residents 40, Resident 21, Resident 38, Resident 1, Resident 23, Resident 50, and Resident 39 experiencing frustration and anxiety about calling for assistance, and not having needs met. Findings: 1. Review of Resident 40's admission record indicated Resident 40 was admitted with diagnoses including Ataxic Gait (uncoordinated movements when walking), Acute Respiratory Failure with Hypoxia (not enough oxygen for the tissues in the body), pain, and history of falling. Review of Resident 21's admission record indicated Resident 21 was admitted with diagnosis including repeated falls and apraxia (unable to perform learned tasks or movements). Review of Resident 38's admission record indicated Resident 38 was admitted with diagnoses including type two diabetes mellitus (the body's inability to produce insulin), pain, and transient ischemic attack (an episode of decreased blood flow to the brain). Review of Resident 1's admission record indicated Resident 1 was admitted with diagnoses including epilepsy (seizure disorder), acute embolism and thrombosis (blood clots) of the deep veins, malignant neoplasm of the cerebral meninges (a tumor that grows on the membrane that surrounds the brain). Review of Resident 39's admission record indicated Resident 39 was admitted with diagnosis including muscle weakness, dysphagia (inability to swallow), pain, neuralgia (sharp shocking nerve pain), and neuritis (inflammation of the nerves). Review of Resident 23's admission record indicated Resident 23 was admitted with diagnoses including Acute Respiratory Failure with Hypoxia, muscle weakness, shortness of breath, pain, and abnormalities of gait and mobility. Review of Resident 50's admission record indicated Resident 50 was admitted with diagnosis including difficulty walking, muscle weakness, and pain. During a concurrent observation and interview with Resident 50 on 10/29/24, at 10:42 AM, Resident 50 had a hand bell on her bedside table and indicated this was given to her due to the call light not working. Resident 50 indicated she experienced longer wait times when calling for staff assistance due to having the hand bell instead of a call light. Resident 50 indicated she was unsure if staff heard her bell when she rang it, and must continuously ring the bell for assistance especially when her pain level was high and she needed to use the restroom. Resident 50 stated her preference would be the call light with the button to alert staff. During an observation on 10/31/24, at 12:05 PM, in Resident 38, Resident 39, and Resident 23's rooms, all call lights were noted to be nonfunctional with no call bell in sight. During a concurrent observation and interview with Certified Nursing Assistant (CNA 3), on 10/31/24, at 12:16 PM, CNA 3 confirmed call lights for Residents 40, Resident 23, Resident 21, Resident 38, Resident 1, and Resident 39 were not in functional and working condition. CNA 3 indicated the one resident in each room with the hand bell was the one who would ring the hand bell for the other residents when they were in need of staff's attention. CNA 3 indicated the call system in these rooms had been down for about 6-12 months and having a call light system that is not functioning properly, placed the residents at risk for falling and prevented them from being able to contact staff when they needed assistance. During a concurrent interview and observation with CNA 3, on 10/31/24, at 12:26 PM, CNA 3 acknowledged one out three residents in the room had an alternative device in the form of a call bell and this resident (Resident 366) was responsible for notifying staff when her roommates needed assistance. Resident 366 had curtains from wall to wall wrapped around her bed. When asked how Resident 366 would notify staff if there was no visibility of her roommates, CNA 3 acknowledged the discrepancy. During an interview with the Administrator (ADM) on 11/1/24, at 10:31 AM, the ADM explained, when a call light issue arose, the maintenance director would take care of it. The ADM stated if the maintenance director was unable to fix the issue, then the issue would be priced and escalated to corporate. The ADM stated the non-functioning call light system was escalated to corporate and the repairs were denied due to the costs and because the entire system was not down. The ADM stated the status of the call lights did not meet his expectations and acknowledged each resident should have their own functioning call light kept within reach. Review of a facility policy titled Accommodation of Needs, revised March 2021, indicated, .Our Facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity well-being . maintaining hearing aids, glasses, and other adaptive devices for residents. Review of a facility policy titled Quality of Life- Homelike Environment, revised May 2017, indicated, .Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs belongings to the extent possible . 50977 2. During a concurrent observation and interview on 10/30/24 at 10:26 AM in Resident 36's room, Resident 36 stated she used her call light to reach staff for assistance. When asked to reach for her call light she felt around her bed and stated that it was nowhere on the bed. Resident 36's call light was observed to be underneath her bed. During an observation on 10/30/24 at 4:10 PM Resident 36's call light was observed on the floor out of arms reach of Resident 36. During a concurrent observation and interview with Licensed Nurse (LN) 1, in Resident 36's room, LN 1 stated call lights should be within reach of residents. LN 1 further stated when call lights were not within reach, residents were not able to ask for help when they need it, and this increased residents risk for falls. LN 1 confirmed Resident 36's call light was on the floor under the bed. During an interview on 10/31/24 at 9:58 AM, with Certified Nursing Assistant (CNA)1, CNA 1 stated call lights should always be by the residents. CNA 1 further stated that she checks every time they are in the resident rooms for call light placement and if they are out of reach resident needs may not be met. During an interview on 11/1/24 at 8:30 AM, with the Director of Nursing (DON), the DON stated that he expected call lights to be operable and within reach of the resident. The DON further stated that if call lights were not within reach, there was a potential for staff to be unaware of resident needs. Review of Resident 36's fall care plan, initiated on 12/13/23, in the section Interventions, indicated, .Have things needed by the resident within reach including call light .initiated 12/13/23 . A review of facility policy and procedure titled, Call Light Answering, indicated, .It is the policy of this facility to provide the resident a means of communication with nursing staff .Leave the resident comfortable. Place the call device within resident's reach before leaving room .The nursing staff will check the placement of the call light during care .

Based on observation, interview, and record review, the facility failed to ensure residents received snack foods that met their preferences, including two unsampled residents (Resident 19 and Resident 63), based on facility policy. This failure had the potential to lead to decreased food intake which could impair the resident's nutrition and health status. The facility census was 61. Cross reference F805 Findings: During a review of the facility's resident council meeting minutes from April 2024-October 2024, the meeting minutes indicated several concerns about not receiving regular snacks and nourishments. 1. During the resident council meeting on 10/30/24 at 10:27 AM with ten anonymous facility residents, the residents were asked Do you receive snacks at bedtime or when you request them? and the residents stated no, they run out of snacks, peanut butter and jelly, crackers, chocolate cookies, white bread, and dietary preferences for medical preferences are not met. The resident council attendees also stated the food here could be a lot better .we complained about meals and food but that's the only thing that never changes . 2. Review of Resident 19's Admission Record indicated Resident 19 was admitted to the facility with diagnoses which included, essential hypertension (high blood pressure), gastro-intestinal esophageal reflux disease (GERD) (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach, called the esophagus), and constipation (difficulty having bowel movements). Review of Resident 19's Minimum Data Set (MDS, an assessment tool) indicated Resident 19 had a BIMS (Brief Interview of Mental Status) of 13, where 13-15 points means a person's cognition (thinking ability) was intact. During an interview on 10/30/24 at 9:23 AM, with Resident 19, the resident stated she did not receive alternative meals and foods that she likes, including cottage cheese, oatmeal, and yogurt. Resident 19 stated she had not spoken with the Registered Dietitian (RD) about her food preferences. 3. Review of the facility's Admission Record Sheet indicated Resident 63 was admitted to the facility with diagnoses including cellulitis (an infection beneath the skin tissues) of left lower limb, hyperlipidemia (large amounts of fat in the blood), hypertension (high blood pressure), and constipation (difficulty having bowel movements). Review of Resident 63's MDS indicated Resident 63's BIMS was 15, where 13-15 points means a person's cognition was intact. During an observation and interview with Resident 63 on 10/30/24 at 5:04 PM, Resident 63 was lying in bed watching the television. Resident 63 stated he liked the peanut butter and jelly sandwiches, but the facility always serves them as snacks. Resident 63 stated he preferred cheese and meat sandwiches, and sometimes crisp rice cereal treats, but they keep telling him they ran out all of them. During an interview with LN 6 on 10/30/24 at 3:03 PM, LN 6 stated the snacks come to the units around 7:00 PM and they include PBJ (peanut butter and jelly) sandwiches, gelatin, and honey crackers, about 12 snack items mixed up in the batch. During an interview with LN 7 on 10/30/24 at 3:09 PM, LN 7 stated the residents receive evening snacks like Turkey/ham sandwiches, PBJ sandwiches, pudding, crisp rice cereal treats, gelatin, cereal mix, and graham crackers. LN 7 stated the kitchen had soda or juice available in the evening if needed for residents with diabetes. During an interview with LN 8 on 10/30/24 at 3:14 PM, LN 8 stated the kitchen is open every day after 7:00 PM to give residents snacks like granola bars, PBJ sandwiches, and crackers. During an interview on 10/31/24 at 9:26 AM with the Administrator (ADM) and the Director of Nursing (DON) about resident snacks, the DON stated the Dietary Services Manager (DSM) and the Registered Dietician (RD) will check to make sure the standard snacks are offered like graham crackers and sandwiches to residents. The ADM and DON each stated they should make sure they ask the residents about their alternative food and snack preferences. The ADM and the DON both stated the facility should offer a variety of foods like tuna sandwiches and other foods. During an interview on 10/30/24 at 3:58 PM with the RD and the DSM about the resident snacks at the facility, the DSM stated she did an initial screening with resident about their food preferences. The DSM stated she did not attend the resident council meetings and did not know the snacks were not being offered to residents consistently at night. The RD also stated she was unaware the residents were not receiving their snacks but stated it was important for them to receive snacks to help meet their nutrition needs. Review of the facility's policy tilted Food Preferences, dated 2023, indicated, .Resident's food preferences will be adhered to .Substitutes for all foods disliked will be given from the appropriate food group .Food preferences can be obtained from the resident, family, or staff members. Updating of food preferences will be done as the resident's needs change and/or during the quarterly review . Review of the facility's policy and procedure titled Accommodation of Needs, dated 2001, indicated, .Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being .Policy Interpretation and Implementation .The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered . Review of the facility's policy titled NOURISHMENT POLICY, dated 2023, indicated, .Nourishments or between meal snacks shall be provided when required by the diet prescription. Bedtime snacks of a nourishing quality will be offered routinely to all residents unless contraindicated .Note that suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care and diet order .

Based on interview and clinical record review, the facility failed to ensure one of two sampled residents (Resident 2) was free from sexual abuse when escalation of Resident 1's monitored inappropriate sexual behavior was not addressed or reported to the consulting psychiatrist (MD 2). Further, an anti-psychotic medication (a drug used to alter behavior) was reduced and then discontinued without input from MD 2. This failure resulted in Resident 1's engagement in non-consensual oral sex on 4/4/16 with Resident 2. Findings: Clinical record review revealed Resident 1 had resided at the Facility for almost two years. Review of a Minimum Data Set (MDS-an assessment tool) dated 2/8/16 revealed Resident 1 had a Brief Interview for Mental Status (BIMS-a cognition test with a score of 15 being the highest cognitive level) of 15. Resident 1 was under the care of a primary doctor (MD 1) and a consultant Psychiatrist (MD 2) since 2014. Further clinical record review of past history, revealed Resident 1 was diagnosed with [REDACTED]. Clinical record review of Resident 1's past medical history revealed an IDT (Interdisciplinary Team) Notes form, dated 7/17/14, that revealed Resident 1's first sexually inappropriate, non-consensual sexual activity with a peer on 7/17/14, resulted in Resident 1 receiving a psychiatric consultation, evaluation, and medication adjustment. Resident 1 was placed on one to one supervision until medications have become effective and behavior has stabilized. Resident 1's [MEDICAL CONDITION] medications history included [MEDICATION NAME] as well as [MEDICATION NAME], and an antidepressant. The [MEDICAL CONDITION] and anti-depressant medications were discontinued and restarted at different times since July 2014 through the present. On 7/22/14, Resident 1 was also prescribed [MEDICATION NAME] (a female hormone that reduces sexual drive in males) for sexual aggression. Review of [MEDICAL CONDITION] Drug Summary sheets from July 2014 through the present, revealed the following: Resident 1's behavioral medications of [MEDICATION NAME], and [MEDICATION NAME] were all discontinued in 2014. [MEDICATION NAME] (an antipsychotic) 0.5 milligrams, one tablet daily replaced [MEDICATION NAME] for the treatment of [REDACTED]. A fax dated 3/3/16, sent to the MD 1, read: Currently on [MEDICATION NAME] 0.5 ml (milliliters-a unit of measurement) QD (every day) for [MEDICAL CONDITION] m/b (manifested by) combativeness. Resident has had a reduction in behaviors and we would like to try a GDR (gradual dose reduction) to [MEDICATION NAME] 0.25 ml QD X (times) 1 week & (and) D/C (discontinue). MD 1's response was Ok and dated 3/3/16. The [MEDICATION NAME] was discontinued on 3/31/16. An interview was conducted with the Director of Nurses (DON) on 4/8/16 at 2:45 p.m. The DON stated she Didn't see the earlier [DIAGNOSES REDACTED]. An interview conducted with the Director of Nursing (DON) on 4/11/16 at 2:35 p.m. disclosed, the monitoring of sexually inappropriate behavior should be linked to a medication. Review of the March 2016 MAR (medication administration record) revealed 27 episodes of sexually inappropriate behavior occurred between 3/13/16, through 3/31/16 (the day the medication was discontinued). There was no documented evidence in the clinical record that either MD 1 or MD 2 were notified of the continued episodes of Resident 1's documented sexually inappropriate behavior. In an interview with the DON on 4/11/16 at 2:35 p.m., the DON stated she Was told the sexual comments and episodes had stopped. Clinical record review revealed Resident 2 was diagnosed with [REDACTED]. On 4/4/16 Resident 2 was sexually abused by Resident 1. Resident 1 ' s clinical record had a Behavior Note dated 4/4/16 and timed at 1:00 p.m., which read .Resident (Resident 1) was witnessed at 0400 (4 a.m.) at roommates bedside performing fell atio (oral sex) on Resident 2, who was diagnosed with [REDACTED]. Resident noted with increased sexual aggression even to CNA (Certified Nurses' Assistant) taking care of him. Please Advise . MD 1's response dated 4/4/16 was Please ask (MD 2) to eval (evaluate) pt (patient). Resident 1's room was changed to a room with an alert and oriented male resident. The Behavior Note dated 4/4/16 disclosed that during a discussion with Resident 1, he was aware of what he had done, and stated, What I did was an abomination (something that causes disgust or hatred). Resident 1 stated how sorry he was. A care plan for behavior problem r/t (related to) poor impulse control m/b (manifested by) sexual inappropriate verbalizations, and Resident had episode of with sexual act was initiated on 2/2/16, (prior to the discontinuation of the [MEDICATION NAME] on 3/3/16). Interventions included administration of medications as ordered, provide opportunities for positive interaction, attention, and to stop and talk with him as passing by, discussion of Resident 1's behavior, explain/reinforce why behavior is inappropriate and/or unacceptable, monitoring of behavior episodes, document behavior and potential causes, and monitor episodes of aggressive behavior every shift, tally by hash marks in the MAR. The March 2016 MAR indicated [REDACTED]. The care plan had no intervention to notify either MD 1 or MD 2 of any escalation in sexually inappropriate behavior and was not updated until 4/4/16, the date Resident 1 sexually abused Resident 2. There was no documented evidence the facility updated the care plan interventions after Resident 1's increase in sexually inappropriate behavior between 3/13/16 and 3/31/16. A Behavioral Note dated 4/4/16 at 11:57 p.m. disclosed Resident 1 was on every 15 minute monitoring by facility staff. The note indicated Resident 1 stated in part, .That was just a onetime thing .all guys are going to mess up a few times in there (sic) life . Review of Physician's Progress Notes dated 4/5/16 disclosed MD 2's note which read in pertinent part, Concern: oral sex with peer .Probably due to pharmacist request for decrease [MEDICAL CONDITION] .Restart [MEDICATION NAME] .please stop bothering (primary care physician) send pharmacy rec (request) to me. Review of physician orders [REDACTED]. Review of a facility policy and procedure dated 2/13 titled, Psychotherapeutic Drug Management, read in pertinent part, Procedure .d) The physician shall review the monthly psychotherapeutic summary and determine if the resident should remain on the same dose or an adjustment should be made . The facility failed to ensure the monthly data was gathered which resulted in MD 1 not being able to review the data for sexually inappropriate behavior, as it was not attached to a medication, or sent on the fax with the request for a gradual dose reduction. Continued record review of a Psychopharmacologic Drug Summary sheet for the [MEDICATION NAME] prescribed for [MEDICAL CONDITION] manifested by combativeness showed no monthly totals of the aggressive or sexually inappropriate behaviors were completed by the facility staff; therefore, data was not available to MD 1 or MD 2, since January of 2016 to the present. An interview was conducted with the consultant psychiatrist (MD 2) on 4/14/16 at 1:05 p.m. MD 2 stated that the monitoring data for aggression and sexual behavior were both linked to the [MEDICAL CONDITION] diagnosis, and should have been monitored as such. MD 2 stated the fact that the gradual dose reduction requests go to the primary care doctor (MD 1) rather than the consultant, Remains a problem as it excluded any input from the consultant. MD 2 also stated, I probably would not have done a dose reduction given knowledge of (Resident 1's) history. He concluded, I feel it (the sexual abuse toward another resident) was preventable. The following citation is written as a result of entity reported incident #CA 872. Unannounced visits were made to the facility on [DATE], 4/11/16, and 4/14/16 to investigate an allegation of non-consensual sexual abuse. The Department determined the facility failed to ensure one of two sampled Residents (Resident 2) was free from sexual abuse when: Escalation of Resident 1 ' s monitored inappropriate sexual behavior was not addressed or reported to the consulting psychiatrist (MD 2); and an anti-psychotic medication (a drug used to alter behavior) was reduced and then discontinued without input from MD 2. These failures resulted in Resident 1 ' s engagement in non-consensual oral sex on 4/4/16 with Resident 2. Clinical record review revealed Resident 1 had resided at the Facility for almost two years. Review of a Minimum Data Set (MDS-an assessment tool) dated 2/8/16 revealed Resident 1 had a Brief Interview for Mental Status (BIMS-a cognition test with a score of 15 being the highest cognitive level) of 15. Resident 1 was under the care of a primary doctor (MD 1) and a consultant Psychiatrist (MD 2) since 2014. Further clinical record review of past history, revealed Resident 1 was diagnosed with [REDACTED]. Resident 1 ' s [MEDICAL CONDITION] medication history included [MEDICATION NAME] as well as [MEDICATION NAME], and an antidepressant. The [MEDICAL CONDITION] medications were discontinued and restarted at different times since July 2014 through the present. On 7/22/14, Resident 1 was also prescribed [MEDICATION NAME] (a female hormone) for sexual aggression. Review of [MEDICAL CONDITION] Drug Summary sheets from July 2014 through the present, revealed the following: Resident 1 ' s behavioral medications: [REDACTED]. [MEDICATION NAME] (an antipsychotic) 0.5 milligrams, one tablet daily replaced the [MEDICATION NAME] for the treatment of [REDACTED]. A fax, dated 3/3/16, sent to the MD 1, read: Currently on [MEDICATION NAME] 0.5 ml (milliliters-a unit of measurement) QD (every day) for [MEDICAL CONDITION] m/b (manifested by) combativeness. Resident has had a reduction in behaviors and we would like to try a GDR (gradual dose reduction) to [MEDICATION NAME] 0.25 ml QD X (times) 1 week & (and) D/C (discontinue). MD 1 ' s response was Ok and dated 3/3/16. The [MEDICATION NAME] was discontinued on 3/31/16. An interview was conducted with the Director of Nurses (DON) on 4/8/16 at 2:45 p.m. The DON stated she Didn ' t see the earlier [DIAGNOSES REDACTED]. An interview conducted with the DON on 4/11/16 at 2:35 p.m. disclosed, the monitoring of sexually inappropriate behavior should be linked to a medication. Review of the March 2016 MAR (medication administration record) revealed 27 episodes of sexually inappropriate behavior occurred between 3/13/16, through 3/31/16 (the day the medication was discontinued). There was no documented evidence in the clinical record that either MD 1 or MD 2 were notified of the continued and escalating episodes of Resident 1 ' s documented sexually inappropriate behavior. In an interview with the DON on 4/11/16 at 2:35 p.m., the DON stated she Was told the sexual comments and episodes had stopped. Clinical record review revealed Resident 2 was diagnosed with [REDACTED]. On 4/4/16 Resident 2 was sexually abused by Resident 1. Resident 1 ' s clinical record had a Behavior Note dated 4/4/16 and timed at 1:00 p.m., which read .Resident was witnessed at 0400 (4 a.m.) at roommates bedside performing fell atio (oral sex) on Resident 2, who was diagnosed with [REDACTED]. Review of a fax document dated 4/4/16, disclosed Resident found naked beside another ' s (sic) Resident bed while giving oral sex. Resident (Resident 1) noted with increased sexual aggression even to CNA (Certified Nurses ' Assistant) taking care of him. Please Advise . MD 1 ' s response dated 4/4/16 was Please ask (MD 2) to eval (evaluate) pt (patient). Resident 1 ' s room was changed to a room with an alert and oriented male resident. The Behavior Note dated 4/4/16, disclosed that during a discussion with Resident 1, he was aware of what he had done, and stated, What I did was an abomination (something that causes disgust or hatred). Resident 1 stated how sorry he was. A care plan for behavior problem r/t (related to) poor impulse control m/b (manifested by) sexual inappropriate verbalizations, and Resident had episode with sexual act was initiated on 2/2/16 (prior to the discontinuation of the [MEDICATION NAME] on 3/31/16). Interventions included administration of medications as ordered, provided opportunities for positive interaction, attention, and to stop and talk with him as passing by, discussion of Resident 1 ' s behavior, explain/reinforce why behavior is inappropriate and/or unacceptable, monitoring of behavior episodes, document behavior and potential causes, and monitor episodes of aggressive behavior every shift tally by hash marks in the MAR. The March 2016 MAR indicated [REDACTED]. The care plan had no intervention to notify either MD 1 or MD 2 of any escalation in sexually inappropriate behavior and was not updated until 4/4/16; the date Resident 1 sexually abused Resident 2. There was no documented evidence the facility updated the care plan interventions after Resident 1 ' s increase in sexually inappropriate behavior between 3/13/16 and 3/31/16. A Behavioral Note dated 4/4/16 at 11:57 p.m. disclosed Resident 1 was on every 15 minute monitoring by facility staff. The note indicated Resident 1 stated in part, .That was just a one time thing .all guys are going to mess up a few times in there (sic) life . Review of Physician ' s Progress Notes dated 4/5/16 disclosed MD 2 ' s note which read in pertinent part, Concern: oral sex with peer .Probably due to pharmacist request for decrease [MEDICAL CONDITION] Restart [MEDICATION NAME] .please stop bothering (primary care physician) send pharmacy rec (request) to me. Review of physician orders [REDACTED]. Review of a facility policy and procedure dated 2/13 titled, Psychotherapeutic Drug Management, read in pertinent part, Procedure .d) The physician shall review the monthly psychotherapeutic summary and determine if the resident should remain on the same dose or an adjustment should be made . There was no documented evidence that the monthly behavioral data for Resident 1 was gathered, which resulted in MD 1 not being able to review the data for sexually inappropriate behavior, as it was not attached to a medication, or sent on the fax with the request for a gradual dose reduction. Continued record review of a Psychopharmacologic Drug Summary sheet for the [MEDICATION NAME] prescribed for [MEDICAL CONDITION] manifested by combativeness showed no monthly totals of the aggressive or sexual inappropriate behaviors were completed by the facility staff; therefore, data was not available to MD 1 or MD 2, since January of 2016 to the present. An interview was conducted with the consultant psychiatrist (MD 2) on 4/14/16 at 1:05 p.m. MD 2 stated that the monitoring data for aggression and sexually inappropriate behavior were both linked to the [MEDICAL CONDITION] diagnosis, and should have been monitored as such. MD 2 stated the fact that the gradual dose reduction requests go to the primary care doctor (MD 1) rather than the consultant Remains a problem as it excluded any input from the consultant. MD 2 also stated, I probably would not have done a dose reduction given knowledge of (Resident 1 ' s) history. He concluded, I feel it (the sexual abuse toward Resident 2) was preventable. Therefore, The Department determined the facility failed to ensure one of two sampled Residents (Resident 2) was free from sexual abuse when: Escalation of Resident 1 ' s monitored inappropriate sexual behavior was not addressed or reported to the consulting psychiatrist (MD 2); and an anti-psychotic medication (a drug used to alter behavior) was reduced and then discontinued without input from MD 2. These failures resulted in Resident 1 ' s engagement in non-consensual oral sex on 4/4/16 with Resident 2. The above violations had a direct relationship to the health, safety, or security of patients.