Every finding on record at Manzanita Healthcare Center

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner for a census of 94 residents, when:1. Opened and expired food items were available for use and not labeled; and2. The dishwasher's temperature log for April 2026 had no temperature and chlorine monitoring for breakfast and lunch for two days.These failures had the potential to result in foodborne illnesses among vulnerable residents.Findings:1. During a concurrent observation and interview on 4/12/26 at 8:23 a.m. with [NAME] 1 in the walk-in refrigerator, the following items were stored opened without labeling: a pancake waffle syrup, almond extract bottles, whipped cream bag and a browning seasoning sauce bottle. A lime juice bottle with expiration date 4/9/26 and two thickened lemon flavor water containers with best by date 12/5/25 and 2/25/26 were also found. [NAME] 1 confirmed the opened food items were not labeled and stated it should have been labeled with open date and best by date or expiration date. [NAME] 1 further stated there should not be any expired food item.2. During a concurrent interview and record review on 4/12/26 at 8:51 a.m. with the Dietary Supervisor (DS), the dishwasher temperature log for April 2026 was reviewed. DS confirmed there was no temperature and chlorine monitoring for breakfast and lunch on 4/10/26 and 4/11/26. DS stated the dishwasher temperature log should have been monitored for each shift (breakfast, lunch, and dinner) daily. During an interview on 4/15/26 at 9:32 a.m. with Nursing Consultant (NC), NC expected dietary staff to follow the dishwasher monitoring of temperature and chlorine level of 50 to 100 parts per million (ppm, a unit of measurement) and to monitor it daily before each meal, breakfast, lunch, and dinner. A review of the facility's policy titled, Labeling and Dating of Foods, dated 2023, indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 94 residents, when: 1. Licensed Nurse (LN) 1 did not sanitize a reusable tray between Resident 114 and Resident 115's wound treatment; 2. LN 2 did not wear the required personal protective equipment (PPE, wearable gear like gowns, gloves and masks to protect individuals from physical, chemical, and airborne dangers in workplaces) while repositioning a resident on enhanced barrier precautions (EBP, an infection control method); 3. Certified Nurse Assistant (CNA) 1 and CNA 2 did not wear proper PPE when assisting a resident on neutropenic precautions (used to protect residents from getting infections because their immune system cannot properly fight bacteria); and 4. CNA 4 did not wear N95 mask (an approved respirator to seal tightly around the nose and mouth, filtered at least 95% of airborne particles) while providing care for Resident 43 with coronavirus disease (COVID 19, a contagious virus disease spread through the air). These failures decreased the facility's potential to prevent cross-contamination (movement or transfer of harmful bacteria from one person, object, or place to another) and spread of infections among staff and residents.Findings: 1. A review of Resident 114's clinical record indicated Resident 114 was admitted to the facility in April 2026 with diagnoses including left foot open wound and acute osteomyelitis (a sudden, severe infection of the bone typically caused by bacteria) of left ankle and foot. A review of Resident 115's clinical record indicated Resident 115 was admitted to the facility in January 2026 with a diagnosis of cutaneous abscess (a painful tender lump filled with pus due to a bacterial infection) of right foot. During an observation on 4/12/26 at 9:16 a.m., LN 1 prepared supplies for Resident 114's wound dressing treatment at the medication cart. LN 1 placed the supplies on a reusable tray, placed the tray on Resident 114's bed and changed Resident 114's left foot wound dressing. LN 1 finished Resident 114's dressing and returned the tray back to the medication cart without sanitization. LN 1 was then observed preparing wound treatment supplies for Resident 115. LN 1 placed the supplies on the same unsanitized tray, placed the tray on Resident 115's bed and changed Resident 115's right foot dressing. LN 1 then returned the tray back to the medication cart without sanitization. During an interview on 4/12/26 at 9:54 a.m. with LN 1, LN 1 confirmed she did not sanitize the reuseable tray between Resident 114 and Resident 115's wound dressing treatments. LN 1 stated not sanitizing the tray between resident care could have increased the cross contamination and infection control risk. During an interview on 4/13/26 at 1:23 p.m. with Infection Preventionist (IP), IP stated all multiple use items such as reusable trays should be sanitized between each resident. IP further stated cross contamination could occur if items were not properly sanitized between each resident's care. During an interview on 4/13/26 at 2:05 p.m. with Director of Nursing (DON), DON expected nurses to sanitize equipment when used across multiple residents and between each use. DON stated not sanitizing the equipment increased the risk of cross contamination and spread of infection among residents. A review of the facility's policy and procedure titled, Infection Prevention and Control Program, dated 10/2018, 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 infection . 2. A review of Resident 103's admission Record, indicated Resident 103 was admitted to the facility in March 2026 with multiple diagnoses including post cervical spine fusion (a surgical procedure performed from the back of the neck to stabilize the cervical spine) and right knee pain. A review of Resident 103's Order Summary Report (OSR), dated 3/23/26, indicated Resident 103 was on EBP due to a right knee wound. A review of Resident 103's care plan, dated 3/23/26, indicated EBP should be implemented when giving high risk care activities to Resident 103 due to his right knee wound. During a concurrent observation and interview on 4/13/26 at 8:10 a.m. with LN 2 inside Resident 103's room, Resident 103 requested assistance to reposition his right leg in bed. LN 2 responded by lifting Resident 103's right leg, adjusting the two pillows placed under it, and then moving the leg into a new position. LN 2 confirmed she was not wearing a gown while assisting Resident 103. During an interview on 4/15/26 at 10 a.m. with the IP, IP stated staff should follow infection prevention and control practices for resident safety and to prevent the spread of infection among residents. A review of the facility's policy titled, Enhanced Barrier Precautions, dated 8/2022, indicated, Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control interventions to reduce the spread of multi-drug-resistant organisms to residents . EBPs employs targeted gown and glove use during high contact resident care activity. 3. A review of Resident 112's admission Record, indicated Resident 112 was admitted to the facility in April 2026 with diagnoses including acute and chronic respiratory failure with hypoxia (occurs when the lungs cannot properly pass oxygen into the blood or fail to remove carbon dioxide waste from the blood) and interstitial pulmonary disease (a condition that cause inflammation and scarring in the lung tissue surrounding the air sacs). A review of Resident 112's OSR, dated 4/15/26, indicated Resident 112 had an order for neutropenic precautions and was receiving mycophenolate mofetil (medication that acts as an immunosuppressant). During an observation on 4/12/26 at 12:13 p.m. outside Resident 112's room, CNA 1 was passing lunch trays. CNA 1 went into Resident 112's room without wearing a gown, gloves, and mask. During an observation on 4/12/26 at 12:15 p.m., CNA 2 entered Resident 112's room and provided assistance while wearing a pair of gloves and a mask. During an interview on 4/12/26 at 12:18 p.m. with CNA 2, CNA 2 confirmed she was wearing a mask and gloves. CNA 2 stated she did not wear a gown because she only helped Resident 112 brushing their teeth and to set up the lunch tray. CNA 2 further stated wearing a gown was unnecessary. During an interview on 4/15/26 at 8:46 a.m. with IP, IP expected staff to always wear a mask, gown, and gloves when assisting residents on neutropenic precautions. IP further stated wearing proper PPE was important to prevent the resident on neutropenic precaution from getting sick. A review of the facility's policy titled, Isolation – Categories of Transmission-Based Precautions, revised 9/2022, indicated, Neutropenic precaution . These precautions are practically important for . individuals receiving immunosuppressant medications . PPE: Gloves, gown, surgical masks . 4. A review of Resident 43's admission Record, indicated Resident 43 was admitted to the facility in 2026 with a diagnosis of COVID 19. During a concurrent observation and interview on 4/13/26 at 11:07 a.m. with CNA 4 inside Resident 43's room, CNA 4 and another CNA were transferring Resident 43 from bed to chair and assisting with activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). CNA 4 was wearing a surgical mask, gown and gloves. CNA 4 confirmed she should have used N95 mask instead of a surgical mask. During an interview on 4/15/26 at 9:07 a.m. with the IP, IP stated she expected staff to wear N95 mask, gloves, gown, and face shield or goggle when assisting with ADLs care for a resident with COVID 19. IP stated without N95 mask, staff could increase the chance of cross contamination to other residents. A review of the facility's policy titled, Coronavirus Disease (COVID-19) – Using Personal Protective Equipment, dated 5/2023, indicated, An N95 respirator (or equivalent or higher- level respirator) is donned before entry into the resident room or care area.

Based on observation, interview, and record review, the facility failed to ensure food was prepared in a manner to maintain nutritive value for a census of 94 residents, when the carrots' recipe was not followed. This failure decreased the facility's potential to maintain the nutritive value of the food being served.Findings:A review of Resident 58's admission Record, indicated Resident 58 was admitted to the facility in 2025.A review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 3/5/26, indicated Resident 58 had no memory impairment.A review of Resident 50's admission Record, indicated Resident 50 was admitted to the facility in 2026.A review of Resident 50's MDS, dated [DATE], indicated Resident 50 had no memory impairment.A review of Resident 119's admission Record, indicated Resident 119 was admitted to the facility in 2026. A review of Resident 119's MDS, dated [DATE], indicated Resident 119 had no memory impairment.During an interview on 4/12/26 at 9:01 a.m. with Resident 58, Resident 50, and Resident 119, all residents stated food was not flavored and tasted bad.During a concurrent observation and interview on 4/14/26 at 10:14 a.m. with [NAME] 1 in the kitchen, [NAME] 1 was observed cooking carrots on the stove. [NAME] 1 stated she placed just carrots in the pan.During an observation on 4/14/26 at 11:05 a.m. [NAME] 1 removed the carrots from the stove and cooked it for 50 minutes. [NAME] 1 then drained the carrot juice in the sink, added a half cup of lemon juice, eight ounces (oz, a unit of measurement) of melted butter, and sprinkled on some parsley, garlic and herb on the cooked carrots. [NAME] 1 did not add salt to the cooked carrots. A review of the facility's document titled, Recipe: Fresh Carrots, dated 2026, indicated the cooking time for fresh carrots was 10-20 minutes and to add margarine, lemon juice and seasonings such as salt, parsley and other seasoning after cooking. The recipe indicated using one tablespoon of salt for 96 servings of carrots.During a concurrent interview and record review on 4/15/26 at 9:12 a.m. with Dietary Supervisor (DS), the recipe for carrots was reviewed. DS confirmed the cooking time for carrots was 10 to 20 minutes.During an interview on 4/15/26 at 9:32 a.m. with Nursing Consultant (NS), NS stated following the recipe for cooking was important since it helped dietary staff to cook food for residents and to maintain its nutritive guideline and diet balance.

Based on interview and record review, the facility failed to ensure an alleged violation of abuse was reported immediately for two of 27 sampled residents (Resident 41 and Resident 52), when the Department did not receive a report of the alleged violation after the abuse incident's occurrence.This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment.Findings:A review of Resident 52's admission Record, indicated Resident 52 was admitted to the facility in December 2025 with a diagnosis of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 41's admission Record, indicated Resident 41 was admitted to the facility in March 2026 with diagnoses including difficulty in walking and generalized muscle weakness. A review of Resident 41's Minimum Data Set (MDS- a federally mandated assessment tool), dated 3/26/26, indicated Resident 41's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 15 out of 15 with good memory.During an interview on 4/12/26 at 9:13 a.m. with Resident 41, Resident 41 stated Resident 52 hit him with a wheelchair several times and attempted to punch him.A review of Resident 52's Progress Notes, dated 3/7/26, documented by Licensed Nurse (LN) 4, indicated Resident 52 had an episode of verbal aggression towards roommate (Resident 41). Resident 52 was getting out of the room when he reversed the wheelchair and bumped into Resident 41's chair. Resident 52 became verbally aggressive towards Resident 41 when Resident 41 told him to stay away to avoid the accident. The notes further indicated Resident 52 tried to punch Resident 41.A review of Resident 41's Census List, dated 4/15/26, indicated prior to 3/7/26 Resident 41 and Resident 52 were roommates and on 3/7/26 Resident 41 was moved to a different room.During an interview on 4/13/26 at 3:04 p.m. with Certified Nurse Assistant (CNA) 3, CNA 3 stated Resident 52 was upset and Resident 41 happened to be in the hallway. CNA 3 further stated Resident 52 was a little aggressive towards Resident 41.During an interview on 4/15/26 at 9:25 a.m. with LN 4, LN 4 stated she was passing medication when she heard Resident 52 talking very loud towards Resident 41 and stating, get out of my way. LN 4 further stated Resident 52 tried to punch Resident 41.During a concurrent interview and record review on 4/13/26 at 3:37 p.m. with Director of Nursing (DON), Resident 52's progress note, dated 3/7/26, was reviewed. DON stated based on the progress note the incident was considered reportable. DON further stated the incident was not reported and should have been reported.During an interview on 4/15/26 at 11:42 a.m. with Administrator (ADM), ADM expected staff to report to him, as an abuse coordinator, any alleged abuse or suspected abuse. ADM stated alleged abuse, or suspected abuse should have been reported to officials within two hours. A review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 9/2022, indicated, If resident abuse . is suspected, the suspicion must be reported immediately to the administrator and to other officials . within two hours of an allegation involving abuse .

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored and secured for a census of 94 residents, when Licensed Nurse (LN) 3 left medications unattended on top of the medication cart.This failure increased the residents' potential for unauthorized access to medications.Findings:During an observation on 4/13/26 at 4:35 p.m. with LN 3 during medication pass, LN 3 was inside a resident's room administering medications. LN 3 left medications on top of medication cart D unattended. The items included two bubble packs, one bottled liquid medication and one canister of powdered medication.During a concurrent observation and interview on 4/13/26 at 4:42 p.m. with the Director of Nursing (DON), DON acknowledged that medications were left unsecured on top of medication cart D while LN 3 was in a resident's room administering medications. DON stated LN 3 should have locked the medications in the cart before going into the resident's room to prevent unauthorized access and ensure resident safety.During an interview on 4/13/26 at 4:46 p.m. with LN 3, LN 3 confirmed she forgot to put away the medications left on top of the cart after preparing them. LN 3 stated she should have secured the medications inside the cart before entering the resident's room.A review of the facility's policy titled, Medication Labeling and Storage, revised in 2/2023, indicated, The facility stores all medications and biologicals under . applicable federal and state requirements . The nursing staff is responsible for maintaining medication storage . Medications are stored in an orderly manner in cabinets, drawers, carts .

Based on observation, interview, and record review, the facility failed to provide services consistent with professional standards of quality for one of 27 sampled residents (Resident 104), when Resident 104's psyllium husk (a bulk forming laxative used to treat constipation and cholesterol management) powder order was not prescribed or administered in accordance with the manufacturer's guidelines.This failure increased Resident 104's potential to have unmet health needs.Findings:A review of Resident 104's admission Record, indicated she was admitted to the facility in March 2026 with a diagnosis of constipation with unspecified intestinal obstruction.During an observation on 4/13/26 at 4:35 p.m. with Licensed Nurse (LN) 3, LN 3 prepared medications for Resident 104 including psyllium husk powder. LN 3 placed a teaspoon (tsp. unit of measurement) of psyllium husk powder in a small cup and added an unspecified amount of water. After mixing the medications, LN 3 administered it to Resident 104, who remarked that the drink was too sweet. A review of Resident 104's Order Summary Report (OSR), dated 3/27/26, indicated an order for psyllium husk powder to be administered two times daily for constipation. The order did not specify the amount of liquid to be mixed with each tsp. of powder, as required by the manufacturer's instructions.A review of the manufacturer's instruction for the administration of psyllium husk powder found on the back of the canister indicated, put one serving [a tsp.] into an empty glass and fill glass with eight ounces (oz. unit of measurement) of water. Stir briskly and drink promptly.During a concurrent interview and record review on 4/13/26 at 4:46 p.m. with LN 3, Resident 104's OSR, dated 3/27/26, and the manufacturer's instructions found on the back of the canister were reviewed. LN 3 stated she did not measure the amount of water used when mixing the powder. LN 3 further stated since the order did not specify the quantity of water required, she used 100 milliliters (ml-unit of measurement) of water every time she prepared it.During an interview on 4/15/26 at 10 a.m. with the Director of Nursing (DON), DON stated nurses must verify orders were accurately written and consult with the doctor or pharmacy consultant when necessary to clarify instructions to ensure specific guidelines were followed, therefore reducing the risk of adverse reactions or medication errors among residents.A review of the facility's policy titled, Administering Medications, revised in 4/2019, indicated, medications are administered in a safe manner as prescribed, the individual administering should check the label three times for right medication and right method of administration before giving the medication. If medication has been identified as having potential consequences to the resident, the person preparing or administering will contact the prescriber and discuss the concerns.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) did not develop a pressure injury or pressure sore (PI, a localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) when they failed to follow and implement preventative interventions that included to turn and re-position frequently, monitor and assess for signs of skin breakdown, and, to use pressure relieving devices(s) for her chair and bed as outlined in their Care Plan Report (CP), titled Skin integrity care plan and Skin assessment and prevention of pressure injuries policy and procedures (P&P). This failure resulted in Resident 1 to have developed facility acquired pressure injuries (PI that developed while a resident in the facility due to lack of assessment and treatment) and had the potential to have caused complications such as pain and sepsis (a life-threatening blood infection). Findings:During a review of Resident 1's admission Record, (AR), the AR indicated that Resident 1 was admitted to the facility in November 2022 with diagnoses that included Type 2 Diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and Psoriasis (skin disease, rash with itchy, scaly patches). During a review of Resident 1's Minimum Data Set (MDS a federally mandated resident assessment tool) dated 8/5/25, Section C, Cognitive Patterns (mental processof acquiring knowledge and understanding) showed a score of 5 out of 13 which suggested severe cognitive impairment. During a review of Resident 1's MDS, dated [DATE], Section GG Functional Abilities, indicated, Resident 1 needed Substantial/maximal assistance (resident unable to perform these activities without full help from others), with toileting hygiene, upper and lower body dressing, roll left and right, sit to lying, lying to sitting on side of bed, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. Resident 1 was completely Dependent, with the facility staff for Shower/bathe self, and Putting on/taking off footwear. During a review of Resident 1's MDS, dated [DATE], Section H, Bladder and Bowel, indicated, Resident 1 was Always incontinent (unable to control) of bowel movements and urine. During a review Resident 1's MDS, dated [DATE], Section M, Skin Condition indicated, Resident 1 was at risk of developing pressure ulcers/injuries, and the facilitydocumented B. Pressure reducing device for bed. C. Turning/repositioning program for Resident 1 under Skin and Ulcer/Injury Treatments. During a review of Resident 1's Care Plan Report (CP), dated 5/3/24, with a focus of altered skin integrity had interventions that included: Monitor for any signs of skin breakdown (sore, tender, red, or broken areas), Pressure relieving device(s) for chair and bed, Turn and re-position frequently, and Weekly Skin Checks refer to weekly summary as indicated. During a review of Resident 1's Braden Scale, (BS, assessment tool for predicting pressure ulcer risk) dated 8/5/25, the BS showed Resident 1's Braden Scale score was indicative of-at risk for developing a pressure ulcer. During the review of the facility's policy and procedures (P&P), titled Skin assessment and prevention of pressure injuries, dated 2001, it indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. 1. Repeat the risk assessment weekly and upon any changes in condition. Mobility/Repositioning 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team (professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) . Monitoring 1. Evaluate, report ad document potential changes in the skin. During a review of Resident 1's Order Summary Report, (OSR), contained current orders at time of transfer to the hospital, the OSR did not indicate a physician's order to reposition Resident 1 frequently and did not have physician's order for a pressure-relieving mattress or device for her chair as indicated in her care plan with a focus on Altered Skin Integrity, the facilities P&Ps titled Skin assessment and prevention of pressure injuries, and the MDS section M. During a phone interview with Resident 1's Responsible Party (RP, person in charge of decision making) on 11/5/25, at 9:43 a.m., the RP stated, Resident 1 was brought to the Emergency Department (ED, name of the hospital) on 8/17/25. She was unresponsive and had low blood pressure. The RP further stated the Emergency physician discovered Resident 1 had severe stage III (Full-thickness loss of skin. Dead and black tissue may be visible) wounds on her bottom, We were never told about the open wounds. The RP further stated he visited Resident 1 in the facility [name of the facility] every week and stayed for a couple of hours at Resident 1's bedside. RP also stated that his sister visited Resident 1, and she was not told by the facility that Resident 1 had stage III wounds on her bottom. RP also had indicated in the complaint that, She had been complaining about pain on her bottom for months. Additionally, when she had a doctor appointment on August 4, 2025, and was transferred to the medical transport, she was in extreme pain and distress, unable to sit up in her wheelchair, lying over the arm of her wheelchair, barely able to stay in it. During a review of Resident 1's record from [name of the hospital] ED (emergency department) titled Wound Care Note (WCN), dated 8/18/25, the WCN indicated thefollowing: . Location: Sacrum (triangular bone in the lower back between hip bones) . Wound Category: Pressure yes.Unstageable x (when unable to determine stage of ulcer due to physician being unable to see the base of the wound) . Additional wound: Location: Left ischium (above the back side of the thigh and beneath the buttocks. A pressure injury can develop here when you sit too long without shifting your weight) . Wound Category: Pressure yes. Stage 3 x. Non-pressure Additional wound: Location: Right ischium. Wound Category: Pressure yes. Pressure Injury: Stage 2 x (Partial-thickness loss of skin, presenting as ashallow open sore or wound) .Pain: Yes. During a review of Resident 1's record from [name of the hospital] ED titled Physician Note (PN), dated 8/19/25, the PN indicated, Unstageable pressure injury sacrum, stage II pressure injury right ischium, stage III pressure injury left ischium.This wound was present on admission. Category: Other Wounds. Location: Sacrum. Discovery Time: 08/17/2025 21:18. During an interview and record review with Medical Records Asst (MRA), and Licensed Nurse 1 (LN 1) on 11/6/25 at 11:44 a.m., MRA found Resident 1's Shower Day Skin Inspection, (SDSI, with a drawing of a naked human body, anteriorly and posteriorly to mark and label skin changes noted during a shower) sheets were dated 8/2/25, 8/7/25, 8/9/25, 8/11/25, 8/13/25, 8/14/25. LN 1 confirmed the SDSI sheets were Resident 1's shower sheets. LN 1 stated the Certified Nursing Assistant (CNAs) should mark (with an x or shading) and label the SDSI sheets of their observations during a shower. The process would then have the CNAs informing the nurse of any unusual or new redness or sores. The process then should be that the nurse would assess the resident's skin areas as identified by the CNAs. The LNs should then collaborate with the Treatment Nurse (TN). LN 1 confirmed this did not happen. During a continued interview and record review with LN 1 and MRA on 11/6/25 at 11:44 a.m., LN 1 stated Resident 1's SDSI sheet dated 8/11/25 was marked as open area at the posterior buttocks (back of the bottom) and SDSI sheet dated 8/16/25 was circled and marked Red at the posterior buttocks. LN 1 stated that the remainder of the SDSI sheets were all marked with shading at the posterior buttocks area but were not labeled with words such as open or red as it should have been. LN 1 stated that nurses should have assessed, documented and informed the Treatment Nurse (TN) of Resident 1's changes in her skin as indicated on the shower sheets. LN 1 further stated that if redness and open skin areas were left untreated, they could get infected and result in possible pressure sores. LN 1 continued to say that the nurses are also expected to complete Resident 1's Weekly Nursing Summary (WNS) assessments to evaluate skin changes, and other health status changes. LN 1 stated that the last completed WNS was 7/31/25, and that the nurses did not conduct the WNS for Resident 1 for the month of August 2025. LN 1 emphasized the importance of completing the WNS assessment to capture Resident 1's health decline or change of condition. The MRA confirmed that she did not have copies of the WNS assessment sheets. During an interview with LN 3 on 11/12/25 at 12:39 p.m., LN 3 acknowledged that she signed Resident 1's SDSI sheets however she cannot recall the dates. LN 3 said she doesn't perform skin assessments unless the CNA reported to her that there was a difference between resident's current skin condition from the previous skin assessment. LN 3 continued to say, CNA 2 wrote down open area on 8-11-25 in the SDSI sheet. LN 3 stated if there is an open skin on the sacrum area and it is not treated, it could get infected and may lead to a pressure sore as it was on the boney part of the human body. During an interview with LN 2 on 11/6/25 at 1:05 p.m., LN 2 stated Resident 1 was dependent on staff with her Activities of Daily Living (ADL, refers to basic self-care tasks like bathing, dressing, and eating) needs. Resident 1 was unable to turn to her side without the help from the staff, and the facility staff used the Hoyer lift (a mechanical device used to lift and/or transfer a person from place to place) to transfer Resident 1 to bed, wheelchair, and shower chair. LN 2 confirmed she signed Resident 1's SDSI sheets dated 8/9/25 and 8/14/25. LN 2 stated that although it was not labeled with words indicating the problem, the SDSI sheets were marked with black ink at the posterior buttocks which indicated an issue with that area. LN 2 verbalized, a signed SDSI sheet meant that she was aware of Resident 1's skin changes, and LN 2 should have assessed and documented her findings and informed the TN. However, LN 2 was not sure if she had assessed Resident 1's skin as the process (after identifying skin abnormality on the shower sheet) required. During an interview with CNA 1 on 11/6/25 at 1:33 p.m., CNA 1 acknowledged she gave showers to Resident 1 on 8/2/25, 8/7/25, 8/9/25, 8/13/25, 8/14/25. CNA 1 stated that Resident 1 was unable to turn to sides, recline on her bed without the assistance from the nursing staff. CNA 1 admitted that she saw redness and a rash on 8/2/25, 8/7/25, 8/9/25, 8/13/25, 8/14/25 to Resident 1's skin on her posterior buttocks as she marked on the SDSI sheet. However, CNA 1 stated she did not label with words her markings on the SDSI sheets, I should have labeled it, so they [nurses] know what I saw. During an interview with the Director of Nursing (DON) on 11/6/25 at 1:51 p.m., the DON acknowledged that CNA 1 and CNA 2 gave showers to Resident 1 as indicated on the SDSI sheets. The DON further acknowledged LN 2 and LN 3 signed the SDSI sheets acknowledging they received and reviewed the reports for Resident 1. The DON stated the facility's process was for the nurses to review the SDSI sheets, assess and document the resident's skin as reported by the CNA on the SDSI sheets, and then the nurse should collaborate with the TN for further physician order/treatments. The DON confirmed that all SDSI sheets (on 8/2/25, 8/7/25, 8/9/25, 8/13/25, 8/14/25) indicated an unusual finding on posterior buttocks of Resident 1. The DON further stated that these assessments/findings were not documented in the resident's chart such as on the Treatment Administration Record (TAR, tool nurses use to document and manage wound care treatments) and progress notes as the process indicated. The DON stated the expectation is for the nurses to physically check the resident's skin for any skin change as indicated on the SDSI sheets. The DON further confirmed that there were no WNS done for Resident 1 for August 2025, and said, there should be WNS completed by the nurses for Resident 1 every week. This tool would help nurses identify early signs of changes in skin condition. The DON stated that if the process was not followed when a sore or redness was identified then an open sore left untreated, could get worse and become infected. During an interview with CNA 2 on 11/12/25 at 1:18 p.m., CNA 2 stated Resident 1 was incontinent with urine and bowel, and needed help in changing her briefs, and assistance in taking a shower. CNA 2 further stated Resident 1 cannot walk, and needed assistance to turn to sides, CNA 2 used the Hoyer lift to bathe and transfer Resident 1. CNA 2 acknowledged that she noted an open skin tear and redness to Resident 1's posterior buttocks and indicated it on the SDSI sheets. CNA 2 continued to say that she informed LN 3 about her observations of Resident 1's skin condition as documented on SDSI sheets. During an interview with the TN on 11/12/25 at 1:41 p.m., the TN stated that she was familiar with Resident 1 and emphasized that if an open area or skin tear was left untreated, it could get infected, grow and may progress to a pressure sore or unstageable sore. The TN continued to say that Resident 1 should have been repositioned every two hours, checked her skin integrity regularly, placed a cushion on Resident 1's wheelchair to help prevent pressure, and placed a pressure-relieving mattress especially to bed bound or bedridden residents. During a review of Resident 1's TAR, dated 8/1/25 - 8/31/25, the TAR did not have documentation of treatments regarding wound care on the residents bottom or a repositioning or turning protocol. During the review of the facility's policy and procedures, titled Bath/Shower, dated 2001, indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition the resident's skin. During the review of the facility's policy and procedures, titled Care Plans, Comprehensive Person-Centered, (CPCPC), dated 2001, the CPCPC indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 9. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change.10. The interdisciplinary team review and updates the care plan: a. when there has been a significant change in the resident's condition.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) did not develop a pressure injury or pressure sore (PI, a localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) when they failed to follow and implement preventative interventions that included to turn and re-position frequently, monitor and assess for signs of skin breakdown, and, to use pressure relieving devices(s) for her chair and bed as outlined in their Care Plan Report (CP), titled Skin integrity care plan and Skin assessment and prevention of pressure injuries policy and procedures (P&P). This failure resulted in Resident 1 to have developed facility acquired pressure injuries (PI that developed while a resident in the facility due to lack of assessment and treatment) and had the potential to have caused complications such as pain and sepsis (a life-threatening blood infection). Findings:During a review of Resident 1's admission Record, (AR), the AR indicated that Resident 1 was admitted to the facility in November 2022 with diagnoses that included Type 2 Diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and Psoriasis (skin disease, rash with itchy, scaly patches). During a review of Resident 1's Minimum Data Set (MDS a federally mandated resident assessment tool) dated 8/5/25, Section C, Cognitive Patterns (mental processof acquiring knowledge and understanding) showed a score of 5 out of 13 which suggested severe cognitive impairment. During a review of Resident 1's MDS, dated [DATE], Section GG Functional Abilities, indicated, Resident 1 needed Substantial/maximal assistance (resident unable to perform these activities without full help from others), with toileting hygiene, upper and lower body dressing, roll left and right, sit to lying, lying to sitting on side of bed, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. Resident 1 was completely Dependent, with the facility staff for Shower/bathe self, and Putting on/taking off footwear. During a review of Resident 1's MDS, dated [DATE], Section H, Bladder and Bowel, indicated, Resident 1 was Always incontinent (unable to control) of bowel movements and urine. During a review Resident 1's MDS, dated [DATE], Section M, Skin Condition indicated, Resident 1 was at risk of developing pressure ulcers/injuries, and the facilitydocumented B. Pressure reducing device for bed. C. Turning/repositioning program for Resident 1 under Skin and Ulcer/Injury Treatments. During a review of Resident 1's Care Plan Report (CP), dated 5/3/24, with a focus of altered skin integrity had interventions that included: Monitor for any signs of skin breakdown (sore, tender, red, or broken areas), Pressure relieving device(s) for chair and bed, Turn and re-position frequently, and Weekly Skin Checks refer to weekly summary as indicated. During a review of Resident 1's Braden Scale, (BS, assessment tool for predicting pressure ulcer risk) dated 8/5/25, the BS showed Resident 1's Braden Scale score was indicative of-at risk for developing a pressure ulcer. During the review of the facility's policy and procedures (P&P), titled Skin assessment and prevention of pressure injuries, dated 2001, it indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. 1. Repeat the risk assessment weekly and upon any changes in condition. Mobility/Repositioning 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team (professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs) . Monitoring 1. Evaluate, report ad document potential changes in the skin. During a review of Resident 1's Order Summary Report, (OSR), contained current orders at time of transfer to the hospital, the OSR did not indicate a physician's order to reposition Resident 1 frequently and did not have physician's order for a pressure-relieving mattress or device for her chair as indicated in her care plan with a focus on Altered Skin Integrity, the facilities P&Ps titled Skin assessment and prevention of pressure injuries, and the MDS section M. During a phone interview with Resident 1's Responsible Party (RP, person in charge of decision making) on 11/5/25, at 9:43 a.m., the RP stated, Resident 1 was brought to the Emergency Department (ED, name of the hospital) on 8/17/25. She was unresponsive and had low blood pressure. The RP further stated the Emergency physician discovered Resident 1 had severe stage III (Full-thickness loss of skin. Dead and black tissue may be visible) wounds on her bottom, We were never told about the open wounds. The RP further stated he visited Resident 1 in the facility [name of the facility] every week and stayed for a couple of hours at Resident 1's bedside. RP also stated that his sister visited Resident 1, and she was not told by the facility that Resident 1 had stage III wounds on her bottom. RP also had indicated in the complaint that, She had been complaining about pain on her bottom for months. Additionally, when she had a doctor appointment on August 4, 2025, and was transferred to the medical transport, she was in extreme pain and distress, unable to sit up in her wheelchair, lying over the arm of her wheelchair, barely able to stay in it. During a review of Resident 1's record from [name of the hospital] ED (emergency department) titled Wound Care Note (WCN), dated 8/18/25, the WCN indicated thefollowing: . Location: Sacrum (triangular bone in the lower back between hip bones) . Wound Category: Pressure yes.Unstageable x (when unable to determine stage of ulcer due to physician being unable to see the base of the wound) . Additional wound: Location: Left ischium (above the back side of the thigh and beneath the buttocks. A pressure injury can develop here when you sit too long without shifting your weight) . Wound Category: Pressure yes. Stage 3 x. Non-pressure Additional wound: Location: Right ischium. Wound Category: Pressure yes. Pressure Injury: Stage 2 x (Partial-thickness loss of skin, presenting as ashallow open sore or wound) .Pain: Yes. During a review of Resident 1's record from [name of the hospital] ED titled Physician Note (PN), dated 8/19/25, the PN indicated, Unstageable pressure injury sacrum, stage II pressure injury right ischium, stage III pressure injury left ischium.This wound was present on admission. Category: Other Wounds. Location: Sacrum. Discovery Time: 08/17/2025 21:18. During an interview and record review with Medical Records Asst (MRA), and Licensed Nurse 1 (LN 1) on 11/6/25 at 11:44 a.m., MRA found Resident 1's Shower Day Skin Inspection, (SDSI, with a drawing of a naked human body, anteriorly and posteriorly to mark and label skin changes noted during a shower) sheets were dated 8/2/25, 8/7/25, 8/9/25, 8/11/25, 8/13/25, 8/14/25. LN 1 confirmed the SDSI sheets were Resident 1's shower sheets. LN 1 stated the Certified Nursing Assistant (CNAs) should mark (with an x or shading) and label the SDSI sheets of their observations during a shower. The process would then have the CNAs informing the nurse of any unusual or new redness or sores. The process then should be that the nurse would assess the resident's skin areas as identified by the CNAs. The LNs should then collaborate with the Treatment Nurse (TN). LN 1 confirmed this did not happen. During a continued interview and record review with LN 1 and MRA on 11/6/25 at 11:44 a.m., LN 1 stated Resident 1's SDSI sheet dated 8/11/25 was marked as open area at the posterior buttocks (back of the bottom) and SDSI sheet dated 8/16/25 was circled and marked Red at the posterior buttocks. LN 1 stated that the remainder of the SDSI sheets were all marked with shading at the posterior buttocks area but were not labeled with words such as open or red as it should have been. LN 1 stated that nurses should have assessed, documented and informed the Treatment Nurse (TN) of Resident 1's changes in her skin as indicated on the shower sheets. LN 1 further stated that if redness and open skin areas were left untreated, they could get infected and result in possible pressure sores. LN 1 continued to say that the nurses are also expected to complete Resident 1's Weekly Nursing Summary (WNS) assessments to evaluate skin changes, and other health status changes. LN 1 stated that the last completed WNS was 7/31/25, and that the nurses did not conduct the WNS for Resident 1 for the month of August 2025. LN 1 emphasized the importance of completing the WNS assessment to capture Resident 1's health decline or change of condition. The MRA confirmed that she did not have copies of the WNS assessment sheets. During an interview with LN 3 on 11/12/25 at 12:39 p.m., LN 3 acknowledged that she signed Resident 1's SDSI sheets however she cannot recall the dates. LN 3 said she doesn't perform skin assessments unless the CNA reported to her that there was a difference between resident's current skin condition from the previous skin assessment. LN 3 continued to say, CNA 2 wrote down open area on 8-11-25 in the SDSI sheet. LN 3 stated if there is an open skin on the sacrum area and it is not treated, it could get infected and may lead to a pressure sore as it was on the boney part of the human body. During an interview with LN 2 on 11/6/25 at 1:05 p.m., LN 2 stated Resident 1 was dependent on staff with her Activities of Daily Living (ADL, refers to basic self-care tasks like bathing, dressing, and eating) needs. Resident 1 was unable to turn to her side without the help from the staff, and the facility staff used the Hoyer lift (a mechanical device used to lift and/or transfer a person from place to place) to transfer Resident 1 to bed, wheelchair, and shower chair. LN 2 confirmed she signed Resident 1's SDSI sheets dated 8/9/25 and 8/14/25. LN 2 stated that although it was not labeled with words indicating the problem, the SDSI sheets were marked with black ink at the posterior buttocks which indicated an issue with that area. LN 2 verbalized, a signed SDSI sheet meant that she was aware of Resident 1's skin changes, and LN 2 should have assessed and documented her findings and informed the TN. However, LN 2 was not sure if she had assessed Resident 1's skin as the process (after identifying skin abnormality on the shower sheet) required. During an interview with CNA 1 on 11/6/25 at 1:33 p.m., CNA 1 acknowledged she gave showers to Resident 1 on 8/2/25, 8/7/25, 8/9/25, 8/13/25, 8/14/25. CNA 1 stated that Resident 1 was unable to turn to sides, recline on her bed without the assistance from the nursing staff. CNA 1 admitted that she saw redness and a rash on 8/2/25, 8/7/25, 8/9/25, 8/13/25, 8/14/25 to Resident 1's skin on her posterior buttocks as she marked on the SDSI sheet. However, CNA 1 stated she did not label with words her markings on the SDSI sheets, I should have labeled it, so they [nurses] know what I saw. During an interview with the Director of Nursing (DON) on 11/6/25 at 1:51 p.m., the DON acknowledged that CNA 1 and CNA 2 gave showers to Resident 1 as indicated on the SDSI sheets. The DON further acknowledged LN 2 and LN 3 signed the SDSI sheets acknowledging they received and reviewed the reports for Resident 1. The DON stated the facility's process was for the nurses to review the SDSI sheets, assess and document the resident's skin as reported by the CNA on the SDSI sheets, and then the nurse should collaborate with the TN for further physician order/treatments. The DON confirmed that all SDSI sheets (on 8/2/25, 8/7/25, 8/9/25, 8/13/25, 8/14/25) indicated an unusual finding on posterior buttocks of Resident 1. The DON further stated that these assessments/findings were not documented in the resident's chart such as on the Treatment Administration Record (TAR, tool nurses use to document and manage wound care treatments) and progress notes as the process indicated. The DON stated the expectation is for the nurses to physically check the resident's skin for any skin change as indicated on the SDSI sheets. The DON further confirmed that there were no WNS done for Resident 1 for August 2025, and said, there should be WNS completed by the nurses for Resident 1 every week. This tool would help nurses identify early signs of changes in skin condition. The DON stated that if the process was not followed when a sore or redness was identified then an open sore left untreated, could get worse and become infected. During an interview with CNA 2 on 11/12/25 at 1:18 p.m., CNA 2 stated Resident 1 was incontinent with urine and bowel, and needed help in changing her briefs, and assistance in taking a shower. CNA 2 further stated Resident 1 cannot walk, and needed assistance to turn to sides, CNA 2 used the Hoyer lift to bathe and transfer Resident 1. CNA 2 acknowledged that she noted an open skin tear and redness to Resident 1's posterior buttocks and indicated it on the SDSI sheets. CNA 2 continued to say that she informed LN 3 about her observations of Resident 1's skin condition as documented on SDSI sheets. During an interview with the TN on 11/12/25 at 1:41 p.m., the TN stated that she was familiar with Resident 1 and emphasized that if an open area or skin tear was left untreated, it could get infected, grow and may progress to a pressure sore or unstageable sore. The TN continued to say that Resident 1 should have been repositioned every two hours, checked her skin integrity regularly, placed a cushion on Resident 1's wheelchair to help prevent pressure, and placed a pressure-relieving mattress especially to bed bound or bedridden residents. During a review of Resident 1's TAR, dated 8/1/25 - 8/31/25, the TAR did not have documentation of treatments regarding wound care on the residents bottom or a repositioning or turning protocol. During the review of the facility's policy and procedures, titled Bath/Shower, dated 2001, indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition the resident's skin. During the review of the facility's policy and procedures, titled Care Plans, Comprehensive Person-Centered, (CPCPC), dated 2001, the CPCPC indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 9. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' condition change.10. The interdisciplinary team review and updates the care plan: a. when there has been a significant change in the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented for a census of 85 residents, when flying insects were observed in four residents' rooms.This failure decreased the facility's potential to maintain a pest free environment for the residents.Findings: A review of Resident 1's admission Record, dated 8/12/25, indicated Resident 1 was admitted to the facility in July 2025 with a diagnosis of anxiety (a common mental health condition characterized by excessive worry, fear, and unease). Resident 1 had mental capacity to make own decisions.A review of Resident 2's admission Record, dated 8/12/25, indicated Resident 2 was admitted to the facility in August 2025 and had mental capacity to make own decisions.During a concurrent observation and interview on 8/12/25 at 11:45 a.m. with Resident 1, Resident 1's room in Unit C was observed. Numerous small insects were observed flying around and landing on Resident 1's bed, personal belongings, pillows, a window next to her bed, and on the side table. When a curtain divider was touched, multiple insects flew around Resident 1. Resident 1 expressed her frustration regarding the frequent presence of insects around her face, nose, ears, and food. Resident 1 stated her previous roommate reported the situation to the staff, but the problem persisted and worsened.During a concurrent observation and interview on 8/12/25 at 11:55 a.m. with Resident 2 (shared the same room with Resident 1), Resident 2's room in Unit C was observed. Numerous insects were observed flying and landing on Resident 2 while resting in bed and on the side table, walls, and curtains adjacent to Resident 2's bed. Resident 2 stated she was constantly bothered by the insects around her face, nose, and ears. Resident 2 also stated some insects crawled into her nose while she was asleep and kept disrupting her sleep. Resident 2 further stated the issue was brought up to housekeeping but no improvement was noticed.During a concurrent observation and interview on 8/12/25 at 12:01 p.m. with Licensed Nurse 1 (LN 1), Resident 1 and Resident 2's room was observed. LN 1 confirmed several insects were present on multiple surfaces in the room, under the sink, and around both residents.During a concurrent observation and interview on 8/12/25 at 12:20 p.m. with the Director of Nursing (DON), all the rooms in Unit C were inspected. DON confirmed there were flying insects in four rooms in Unit C and the insects were observed flying on windows, walls, curtains, around residents, and on their belongings.During a concurrent interview and record review on 8/12/25 at 2:40 p.m. with the Maintenance Supervisor (MS), a work order #1607, dated 8/7/25, was reviewed. MS confirmed a high priority order was requested on 8/7/25 regarding little moths flying around in room esp. [especially] window area. MS also confirmed the room listed in the work order was one of the four rooms observed to currently have insects in Unit C and agreed the issue was not resolved. During an interview on 8/12/25 at 3:40 p.m. with the DON, DON confirmed that four residents' rooms in Unit C were infested by insects and expected staff to report the issue to the managers and to log it in the maintenance log system. DON agreed that insects disrupted the residents' rest and sleep, which might have impacted their health and well-being.A review of the facility's policy titled, Pest Control, dated May 2008, indicated, Our facility shall maintain an effective pest control program . to ensure that the building is kept free of the insects . Maintenance service assist, when appropriate and needed, in providing pest control services.

Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 1) when Resident 2 punched Resident 1 in the stomach which caused Resident 1 to fall and hit her head. This failure resulted in an injury to Resident 1's head. Findings: Resident 1 was admitted to the facility late 2021 with diagnoses which included memory loss, weight loss, muscle wasting, and depression. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 3/10/25, the MDS indicated a Brief Interview for Mental Status (BIMS, a standardized test that screens for cognitive impairment) score of 9/15 which showed moderate cognitive impairment. During a review of Resident 1's eINTERACT Change in Condition Evaluation [eCOCE], dated 4/7/25 at 5 p.m. the eCOCE indicated, .Resident was punched by other resident in the stomach, fell down, hit back of her head on the metal door frame, bleeding a lot. Send out via 911 . During a review of Resident 1's Order Summary Report [OSR], dated 4/8/25, the OSR indicated, Monitor laceration to head . During an observation on 4/14/25 at 2:52 p.m. of Resident 1's scalp with Licensed Nurse 2 (LN 2), Resident 1 had a small area of dried dark material on the back of her head and yellow discoloration on her left shoulder. Resident 2 was admitted to the facility mid 2023 with diagnoses which included memory impairment caused by impaired blood flow to the brain, behavioral disturbances, progressive degenerative disorder that caused a decline in memory, thinking and behavior, and a language disorder. During a review of Resident 2's MDS dated [DATE], the MDS indicated a BIMS score of 0/15, which showed severe cognitive impairment. During a review of Resident 2' s eCOCE dated 4/7/24 at 5:37 p.m. the eCOCE indicated, . resident [Resident 2] was witnessed making contact with other resident [Resident 1] stomach resulting in resident [Resident 1] to lose balance and fall to floor . During a review of Resident 2's Care Plans (CP) dated 12/30/24-4/7/25, the CPs indicated Resident 2 had multiple episodes of physical aggression, increased agitation and aggression. During an interview on 4/14/25 at 12:20 p.m. with the Unit Secretary (US), the US stated she witnessed Resident 2 walked past Resident 1 and punch her in the stomach, which caused Resident 1 to fall to the floor and hit her head on the door frame. The US stated Resident 1 had a history of being aggressive. During an interview on 4/14/25 at 12:37 p.m. with the Social Services Director (SSD), the SSD stated Resident 1 was able to walk around the facility and had hit other residents in the past. During an interview on 4/14/25 at 2:42 p.m. with the Director of Nursing (DON), the DON confirmed Resident 1 had a repeated history of aggression and stated, Safety for the resident's is our top priority, we don't want residents to get hurt. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, dated 7/17, the P&P indicated, .Resident safety and supervision and assistance to prevent accident are facility-wide priorities .Resident supervision is a core component of the systems approach to safety .

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 96 residents, when: 1. Controlled drug (medication that may be abused or cause addiction) record form was not filled out and signed immediately at the time of medication administration for Resident 445; and 2. Unused or expired, controlled drugs were not destroyed according to the facility's policy. These failures had the potential for diversion or misuse of residents' controlled medications. Findings: 1. During a concurrent inspection of medication cart A on [DATE] at 11:14 a.m. with Licensed Nurse 4 (LN 4), a controlled drug count for Resident 445's hydromorphone (a medication used for pain), two milligrams (mg; unit of measure) was inaccurate. There were 10 tablets of hydromorphone two mg in the medication bubble pack and the controlled drug log indicated there should be 11. During an interview on [DATE] at 11:15 a.m. with LN 4, LN 4 stated she gave Resident 445 hydromorphone earlier and forgot to sign the medication control count sheet after giving the medication to the resident. LN 4 acknowledged the medication control count sheet needed to be completed at the time of medication administration. During an interview on [DATE] at 2:41p.m. with Director of Nursing (DON), DON stated the medication control count sheet needed to be completed at time of medication administration. A review of the facility's policy and procedure (P&P) titled, Controlled Substances Policy, revised in 2019, indicated, Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift . Upon administration: a. The nurse administering the medication is responsible for recording: (1) name of resident receiving the medication; (2) name, strength and dose of the medication; (3) time of administration; (4) method of administration; (5) quantity of the medication remaining; and (6) signature of nurse administering medication. 2. During an inspection of the unused and expired controlled medications storage area on [DATE] at 9:55 a.m. in the DON's office, it was discovered upon removing the lid on the container used to store destroyed controlled medication, that pills of various sizes, shapes and colors were identifiable, legible and not destroyed. The method being used by the facility to render the medications destroyed entailed placing them in a container of liquid. During an interview on [DATE] at 9:56 a.m. with DON, DON acknowledged that the pills in the controlled medication storage container were identifiable, and not destroyed. A review of the facility's P&P titled, Controlled Substances Policy, revised in 2019, indicated, . Upon Disposition: b. Medications that are opened and subsequently not given (refused or only partly administered) are destroyed. Waste and/or disposal of controlled medication are done in the presence of a nurse and a witness who also signs the disposition sheet Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift . Upon administration: a. The nurse administering the medication is responsible for recording: (1) name of resident receiving the medication; (2) name, strength and dose of the medication; (3) time of administration; (4) method of administration; (5) quantity of the medication remaining; and (6) signature of nurse administering medication .

Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed five percent (%; unit of measure) for two of five sampled residents (Resident 140 and Resident 36). 1. Licensed Nurse 2 (LN 2) administered Resident 140's extended release (ER) isosorbide mononitrate (medication used to treat chest pain) 30 milligrams (mg; unit of measure) tablet not in accordance with physician order, when LN 2 crushed the ER tablet and released the medication all at once instead of gradually over time. This error had a potential to lead to an overdose or severe side effects. 2. LN 2 administered Resident 140's delayed release (DR) pantoprazole (a medication used to treat indigestion) 40 mg tablet not in accordance with physician order, when LN 2 crushed the DR tablet and released the medication all at once instead of gradually over time. This error had a potential to lead to an overdose or severe side effects. 3. LN 2 omitted administering Resident 140's physician ordered medication, amlodipine (a medication used to treat high blood pressure and heart disease) five mg tablet. This omission had the potential to lead to an increase in blood pressure, and/or an adverse outcome to Resident 140. 4. LN 3 did not administer Resident 36's scheduled ordered dose of 180 mg of simethicone (a medication used to treat abdominal bloating) due to the facility's failure to attain and have available the physician ordered dosage of the medication. This failure had the potential to lead to pain and/or discomfort to Resident 36. As a result, four errors were identified out of 28 opportunities, during the observation of medication administration. The medication error rate was 14.29%. Findings: 1. During an observation of medication administration on 2/3/25 at 8:35 a.m., LN 2 was observed to prepare and administer Resident 140's morning medications which included one isosorbide mononitrate extended release 30 mg tablet. LN 2 was observed to crush six medication tablets. Reconciliation of the observation of medication administration with Resident 140's current physician orders indicated an order for isosorbide mononitrate ER 30 mg tablet to be given by mouth daily at 8 a.m. The order did not contain instructions to crush the medication. A review of Resident 140's isosorbide mononitrate ER 30 mg pharmacy label, stated Do Not Crush. 2. During an observation of medication administration on 2/3/25 at 8:35 a.m., LN 2 was observed to prepare and administer Resident 140's morning medications which included one pantoprazole delayed release 40 mg tablet. LN 2 was observed to crush six medication tablets. Reconciliation of the observation of medication administration with Resident 140's current physician orders indicated an order for pantoprazole delayed release 40 mg to be given by mouth daily at 7 a.m. The order did not contain instructions to crush the medication. During an interview on 2/3/25 at 3:15 p.m. with LN 2, LN 2 stated it was not an acceptable practice to crush delayed release medications without an order. LN 2 acknowledged that the medication was not ordered to be crushed. During an interview on 2/4/25 at 10:05 a.m. with the Director of Nursing (DON), DON stated extended or delayed release medications were not supposed to be crushed. 3. During an observation of medication administration on 2/3/25 at 8:35 a.m., LN 2 was observed to prepare and administer Resident 140's morning medications which did not include Resident 140's amlodipine five mg tablet. Reconciliation of the observation of medication administration with Resident 140's current physician orders indicated an order for amlodipine five mg to be given by mouth daily. A review of Resident 140's Medication Administration Record (MAR), dated 2/3/25, indicated amlodipine five mg tablet was given at 8 a.m. During an interview on 2/3/25 at 3:15 p.m. with LN 2, LN 2 acknowledged only six oral medications were administered to Resident 140. If amlodipine five mg was administered, it would have been seven oral medications administered to Resident 140. LN 2 stated medications should have been administered as prescribed by the physician. During an interview on 2/4/25 at 10:05 a.m. with the DON, DON stated I have already heard about the amlodipine not being given to one of our residents. DON further stated medications were to be administered as ordered and Resident 140 should have received her amlodipine as prescribed. 4. During an observation of medication administration on 2/3/25 at 9:46 a.m., LN 3 was observed preparing Resident 36's morning medications, which did not include simethicone 180 mg capsule since the medication was unavailable. During an interview on 2/3/25 at 9:50 a.m. with LN 3, LN 3 stated she did not have the correct dose of simethicone in the medication cart to administer it to Resident 36. Reconciliation of the observation of medication administration with Resident 36's current physician orders indicated an order for simethicone 180 mg capsule by mouth after meals for gas. During an interview on 2/4/25 at 10:05 a.m. with the DON, DON stated the correct dose of medication was not available to be administered which required staff to contact the physician and revise the order accordingly. DON acknowledged that the ordered medication should have been available for LN 3 to administer it to Resident 36. A review of the facility's policy and procedure titled, Administering Medications Policy, revised in 2019, indicated, Medications are administered in a safe and timely manner, and as prescribed . Medications are administered in accordance with prescriber orders, including required time frame.

Based on observation, interview, and record review, the facility failed to ensure medications were stored correctly, when: 1. A medication was stored in the refrigerator, not according to manufacturer's specification; 2. A medication was stored at room temperature, not according to manufacturer's specification; and 3. A discontinued medication was not removed from the medication storage room and was still accessible to the staff. These failures had the potential for medication misuse, drug diversion, medication ineffectiveness, and medication administration errors. Findings: 1. During an inspection on 2/4/25 at 9:37 a.m. of the facility's medication storage room, a discontinued, unopened medication, cyanocobalamin 1,000 micrograms/milliliters (mcg/ml; a unit of measure) was found stored in the refrigerator, not according to manufacturer's required storage parameters. A review of the manufacturer's package insert with a revised date of 2017, cyanocobalamin 1,000 mcg/ml, indicated to be stored between 68 degrees (a unit of measure) - 77 degrees Fahrenheit (scale of temperature). During an interview on 2/4/25 at 9:42 a.m. with the Director of Nursing (DON), DON acknowledged that cyanocobalamin was found stored outside the manufacturer's required temperature range, and that all medications should have been stored at the required temperature range. A review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage Policy, dated 2023, indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. 2. During an inspection on 2/4/25 at 10:41 a.m. of the facility's medication cart A, a medication, acidophilus probiotic dietary supplement was found stored at room temperature in the medication cart, not according to manufacturer's required storage parameters. A review of the manufacturer's labeled sticker on the container, revised 2024, acidophilus probiotic dietary supplement was required to be refrigerated, with labeled instructions to Refrigerate After Opening the container. During an interview on 2/4/25 at 9:42 a.m. with the DON, DON acknowledged that all medications should have been stored at the required temperature range. A review of the facility's P&P titled, Medication Labeling and Storage Policy, dated 2023, indicated, The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls . Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurses' station or other secured location. 3. During an inspection on 2/3/25 at 9:46 a.m. of the facility's medication storage room, a discontinued medication, clonidine 0.2 milligrams (mg; unit of measure), was found stored under the sink on the floor. During a concurrent observation and interview on 2/4/25 at 9:47 a.m. with the DON, in the facility's medication storage room, DON acknowledged the tube of clonidine found under the sink on the floor, was a discontinued medication for a discharged resident, and stated discontinued medications should have been given to her for destruction by the facility staff. A review of the facility's P&P titled, Medication Labeling and Storage Policy, dated 2023, indicated, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items . medications are stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer . to prevent the possibility of mixing medications of several residents.

Based on observation, interview, and record review, the facility failed to ensure the nutritive value of food was maintained, when broccoli was cooked for over two hours prior to lunch meal service. This failure had the potential of leading to nutrient deficiency for the 96 residents receiving facility prepared meals. Findings: During an observation on 2/4/25 at 9:48 a.m., in the kitchen, [NAME] 1 poured frozen broccoli into a pan and placed it into the convection oven to cook. During an observation on 2/4/25 at 12:22 p.m., in the kitchen, lunch meal service started. Observation of the broccoli showed a light green color, with a soft, limp texture when served. During the lunch meal on 2/4/25 at 1:15 p.m., two test trays were placed on the final meal cart (a regular diet and a pureed texture). The two test trays were picked up at 1:30 p.m. Food items tasted were: Regular pork with gravy, pureed pork with gravy, regular seasoned broccoli, pureed seasoned broccoli, and polenta. The broccoli was extremely soft (mushy) when tasted by five surveyors. During an interview on 2/5/25 at 11 a.m. with Registered Dietitian (RD), RD stated the cook was expected to put the vegetables in the oven last, and if vegetables were cooked for a long period of time, vitamins and minerals from the vegetables would be dead. A review from Ohio State University (https://fcs.[NAME].edu>SNAP_Ed_newsletter_broccoli), indicated that overcooked broccoli loses nutrients. A review from Arkansas Cooperative Extension Service (https://www.uaex.uada.edu>news>fcs>fruits-veggies), indicated that broccoli had nutrients including carotenoids and fiber. Known for its anti-cancer properties, broccoli has tons of nutrients including vitamins A and C, fiber, folic acid, calcium, and potassium. Avoid overcooking because discoloration will occur, as well as strong flavors are likely to develop. For best flavor, cooked broccoli should be crisp. During an interview on 2/5/25 at 5:04 p.m. with Dietary Manager (DM), DM stated broccoli have been usually cooked 30 minutes before the start of meal service. During a review of Recipe: Seasoned Broccoli, dated 2024, indicated, Cooking Time: 10-20 minutes . Boil or steam broccoli until tender . Do not overcook, will turn brown and mushy .

Based on observation, interview, and record review, the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food service safety, when: 1. Three baking sheets, one frying pan, one container for scoops, stove knobs, convention oven, and mixer were found dirty; 2. Ten pans, two frying pans, and blender were stored wet; 3. Pipes under three-compartment sink found rusted and dirty, floors were discolored with white and gray buildup, and counter had a white discolored area; 4. Yellow cutting board found with two deep grooves of about one and a half to two inches in length; 5. Four bulk storage containers were found with lids not closed tightly; and 6. Fan in dish machine area was found with black build-up on the blades. These failures had the potential to lead to food borne illness for the 96 residents eating facility prepared meals. Findings: 1. During the initial kitchen tour on 2/3/25 at 8:31 a.m., three baking sheets were found stacked under the steam table with dark brown to black colored buildup in the corners and up the sides; a small frying pan was observed with dark brown/black colored buildup covering approximately 50% of the pan surface; a gray container holding clean scoops was found with a wet, yellow gel like substance inside; stove knobs were sticky, with visible food residue; and the convention oven was covered with food spills and food splatters on the inside. During an interview on 2/3/25 at 8:47 a.m. with Dietary Manager (DM), DM acknowledged baking sheets and small frying pan were old and stated he would discard. He confirmed the gray container with scoops had yellow residue inside next to the clean scoops. DM concurred the stove knobs and convention oven were dirty; he stated the cooks were to clean the stove knobs and oven every meal and scheduled for deep cleaning weekly. During a concurrent observation and interview on 2/3/25 at 9:07 a.m. with DM, a mixer that appeared ready to use, contained food residue stuck to the surface. DM concurred and stated the mixer had batter buildup. A review of the facility's policy titled, Sanitization, dated November 2022, indicated, in bullet 2. All utensils, counters, shelves and equipment are kept clean . free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . 3. All equipment, food contact surfaces and utensils are cleaned and sanitized . 8. When cleaning fixed equipment (e.g mixers .) the removable parts are: a. washed and sanitized and non-removable parts cleaned with detergent and hot water . A review of the United States Food and Drug Administration (FDA) Food Code 2022, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, 1/18/23 version, indicated, . (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 2. During the initial kitchen tour on 2/3/25 at 8:31 a.m., three half steam table pans, seven small steam table pans, and two frying pans were observed stored. These pans had water droplets on their inner and outer surfaces. During an interview on 2/3/25 at 8:47 a.m. with DM, DM acknowledged the pans were wet and stated pans needed to be fully dried before storing to avoid bacteria growth. During the same initial kitchen tour on 2/3/25 at 9:01 a.m., a covered blender was stored and appeared ready to use. When lid was removed, approximately half a tablespoon of clear liquid was observed at the bottom of the blender. During an interview on 2/3/25 at 9:07 a.m. with DM, DM confirmed blender had liquid residue inside. A review of the 2022 US FDA Food Code section 4-901.11, indicated, Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. 3. During a concurrent observation and interview within the initial kitchen tour on 2/3/25 at 8:44 a.m. with DM, the pipes underneath the three-compartment sink were found rusted and dirty. The floor under the three-compartment sink was discolored with white and gray buildup, and the counter next to the three-compartment sink had a white discolored area. DM acknowledged and was unsure why there were buildup and discoloration. A review of the facility's policy titled, Sanitization, dated November 2022, indicated, in bullet 1. All kitchens, kitchen areas and dining areas are kept clean . A review of the US FDA 2022 Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, 1/18/23 version, indicated, .(C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, food residue, and other debris. 4. During a concurrent observation and interview on 2/3/25 at 9:05 a.m. with DM, a yellow cutting board was found with two deep grooves of about one and a half to two inches in length. DM acknowledged the yellow cutting board had two deep grooves. A review of the facility's policy titled, Sanitization, dated November 2022, indicated, in bullet 2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . 12. Plastic ware . that cannot be sanitized or are hazardous because of chips, cracks . are discarded. Damaged or broken equipment that cannot be repaired is discarded . A review of the US FDA 2022 Food Code, section 4-501.12, titled, Cutting Surfaces, indicated, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. 5. During an observation on 2/3/25 at 9:14 a.m., in the dry storage area, four bulk storage containers containing sugar, flour, brown rice and panko were found with the lids not closed tightly, but resting on the containers. During a follow-up observation on 2/3/25 at 11:44 a.m., in the dry storage area, four bulk storage containers remained with lids not closed tightly. During an interview on 2/3/25 at 11:45 a.m. with DM, DM confirmed the lids on the four bulk storage containers were not closed tightly and stated he expected the lids to be fully sealed. During an interview on 2/5/25 at 10:58 a.m. with Registered Dietitian (RD), RD stated if lids were not tightly closed on the containers it could allow moisture, pests, or bacteria to enter the food products. A review of the US FDA 2022 Food Code, section 3-305.13, titled, Vended Time/Temperature Control for Safety Food, Original Container., 1/18/23 version, indicated, The possibility of product contamination increases whenever food is exposed . Once the original seal is broken, the food is vulnerable to contamination. 6. During an observation on 2/3/25 at 11:33 a.m., the fan in the dishwashing area directed over the clean drying dishes was observed with dust buildup of approximately an inch covering the tips of the blades. During a concurrent observation and interview on 2/4/25 at 9:21 a.m. with DM, DM was shown a photo of the fan in the dishwashing area from 2/3/25. DM acknowledged the fan was dirty and said he would have it cleaned. A review of the facility's policy titled, Sanitization, dated November 2022, indicated, in bullet 1. All kitchens, kitchen areas and dining areas are kept clean . 2. All utensils, counters, shelves and equipment are kept clean . A review of the US FDA 2022 Food Code, section 4-601.11, titled, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, 1/18/23 version, indicated, .(C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.

Based on interview and record review, the facility failed to provide a resident refrigerator and microwave for a census of 96 to ensure safe food storage and reheating of food for later consumption. This failure had the potential to prevent residents from enjoying favorite foods, reduced resident food options, and potentially lead to weight loss. Findings: During an interview on 2/5/25 at 12:13 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated outside food would be checked against the diet order before it would be given to the resident. If a resident had left over food, it could not stay in the room for more than two hours before the facility would discard it. CNA 1 further stated that they do not refrigerate food for residents, because there was not a refrigerator and microwave for resident use. During an interview on 2/5/25 at 12:18 p.m. with Licensed Nurse 1 (LN 1), LN 1 stated they advised family members against bringing perishable foods as the facility did not store or re-heat resident food. During an interview on 2/5/25 at 12:37 p.m. with CNA 2, CNA 2 stated residents were allowed to keep food in their rooms up to 24 hours, and after that it would be discarded. CNA 2 further stated facility did not store and re-heat resident food. During an interview on 2/5/25 at 5:25 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), ADON stated refrigerator and microwave were not available for residents' use. DON concurred that there had never been a resident refrigerator or microwave as long as she had worked for the facility. A review of the facility's policy titled, Foods Brought by Family/Visitors, dated March 2022, indicated, in bullet 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food . b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator . 8. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours are discarded .

Based on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition, when: 1. The Walk-in freezer was found with ice build-up on ceiling, floor, door, walls, and fan unit indicating potential temperature changes; 2. The dish machine's required minimum temperatures were not reached; and 3. The convection oven was not achieving the desired food temperature for the pork at or above 165 degrees Fahrenheit (F, a unit of measurement). These failures had the potential of leading to food borne illness for the 96 residents eating facility prepared meals. Findings: 1. During a concurrent observation and interview on 2/3/25 at 8:51 a.m. with Dietary Manager (DM) in the walk-in freezer, the walk-in freezer was observed with ice build-up on the fan unit, ceiling, and pieces of ice on the floor. DM stated maintenance was in earlier removing ice build-up in the freezer which may be the cause of the ice on the floor. During an observation on 2/3/25 at 11:38 a.m., in the walk-in freezer, the ice on the floor had been cleaned up. Ice build-up was still observed covering the ceiling, walls, and boxes on the racks. During a concurrent observation and interview on 2/4/25 at 8:57 a.m. with Environmental Services Director (ESD), in the walk-in freezer, the walk-in freezer was observed with ice build-up on ceiling, walls, and boxes. ESD acknowledged ice build-up and stated the ice on the floor on 2/3/25 was from him loosening the ice build-up elsewhere in the freezer. During a follow-up observation on 2/4/25 at 4:19 p.m., in the walk-in freezer, the walk-in freezer showed high condensation and poor visibility. The ice build-up was greater than the earlier observation, and a two-and-a-half-inch drip had developed over the door. During a subsequent interview on 2/4/25 at 4:20 p.m. with DM, DM acknowledged there was ice build-up in the freezer and confirmed that ice build-up in the freezer was not okay. During an interview on 2/5/25 at 10:50 a.m. with Registered Dietitian (RD), RD stated ice build-up in walk-in freezer could affect the quality of the food and possibly cause freezer burn. Facility unable to provide original walk-in freezer manual and referred surveyors to [NAME] Refrigerated Boxes as being like the freezer in use. A review of the service manual at [NAME] Refrigerated Boxes, Inc. Revised: 5/2013 (http://www.ballyrefboxes.com/bally_walk-incooler_freezer.asp), indicated in Routine Maintenance, that; D. Heater wires should be checked for proper function. Feel for warmth around the door frames on hinged entrance doors and pressure relief port doors, if applicable. Note: Condensation or Ice buildup around doors may indicate leakage or heater failure. Contact a serviceman immediately . F. Inspect refrigeration units frequently for proper function of evaporator & [and] condenser fan motors, drain pan heaters, defrost controls, and drain line heaters. Condensate water must never be permitted to drip on the Walk-In floor. Drain pan or drain line heater failure will result in ice buildup and Evaporator damage. Refer to the Refrigeration System Instructions for proper drain pan and condensate drain line instructions . 2. During a concurrent observation and interview on 2/3/25 at 9:24 a.m. with Dietary Aide 1 (DA 1), DA 1 demonstrated the dishwashing process. DA 1 explained the dish machine sanitized using high temperatures (150 F for wash cycle and 180 F for rinse cycle) and showed the temperature gauges that needed to be monitored. During multiple wash cycles, the wash temperature gauge did not move beyond 135 F. During the rinse cycle the temperature gauge did not reach the minimum temperature of 180 F. During a concurrent observation and interview on 2/3/25 at 9:30 a.m. with DM, DM ran another batch of dishes through the dish machine. During this cycle the wash temperature gauge reached 140 F, and the rinse temperature gauge reached 176 F. DM confirmed both cycles did not meet proper temperatures and stated he would contact the dish machine repair company to get it checked. During a follow up observation on 2/3/25 at 1:57 p.m., the dish machine was being used to clean/sanitize lunch dishes. DA 2 was asked to run a dish machine cycle. During the wash cycle, the wash temperature gauge did not reach the minimum temperature of 150 F and during the rinse cycle the temperature gauge did not reach the minimum temperature of 180 F. A review of the facility's policy titled, Sanitization, dated November 2022, indicated, in bullet 5. Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are: a. High-Temperature Dishwasher (Heat Sanitization): (1) Wash temperature (150-165 F); and (2) Rinse Temperature (180 F) . 3. During a concurrent observation and interview on 2/4/25 at 11:52 a.m. with [NAME] 1 and DM, prior to lunch meal service, the hot food temperatures were checked. The temperature of the pork entrees (regular texture, mechanical soft, and pureed) were all below 165 F. [NAME] 1 and DM confirmed the temperature and placed the pork entrees back into the convection oven. The textured pork entrees (mechanical soft and pureed) were removed from the convection oven and checked again at 12:04 p.m. [NAME] 1 and DM found the temperature at 142 F. DM placed the mechanical soft and pureed texture pork on the stove and was able to reach 165 F or above within a few minutes. The regular pork entree was removed from the convection oven at 12:12 p.m., and the temperature was at 159 F. DM placed the regular pork on the stove, and at 12:18 p.m. the pork temperature was at 170 F. During an interview on 2/5/25 at 4:38 p.m. with [NAME] 2, [NAME] 2 stated the convection oven was not reaching the higher temperatures for the dinner meal on 2/4/25. He further stated a repair company came to fix the convection oven after the dinner meal service. A review of the facility's policy titled, Sanitization, dated November 2022, indicated, in bullet 2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use . A review of the United States Food and Drug Administration (FDA) Food Code 2022 section 4-501.11 for Good Repair and Proper Adjustment indicated (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment . shall be kept . in accordance with manufacturer's specifications. The FDA Food Code 2022 further indicated that Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk .

Based on observation, interview, and record review, the facility failed to maintain respect and dignity for one of 22 sampled residents (Resident 439), when Resident 439's bilateral buttocks' sides were exposed in the hallway during transfer. This failure decreased the facility's potential to maintain Resident 439's respect and dignity. Findings: A review of an admission record indicated Resident 439 was admitted to the facility in 2024 with a diagnosis of panic disorder (a frequent and unexpected panic attack). During a concurrent observation and interview on 2/3/25 at 9:54 a.m. with Resident 439's daughter, Certified Nursing Assistant 3 (CNA 3) was wheeling Resident 439 on a shower chair in the hallway. Resident 439's bilateral buttocks' sides were not covered by the gown and were exposed to other residents, staff members, and Resident 439's daughter. Resident 439's daughter stated there was a respect and dignity issue when Resident 439's body was exposed. During an interview on 2/6/25 at 9:34 a.m. with the Director of Nursing (DON), DON stated staff should have covered Resident 439 with a blanket when transferred in the hallway; otherwise, Resident 439 will feel bad if left exposed to the public. A review of the facility's policy titled, Dignity, dated 2/2021, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self-worth and self-esteem.

Based on observation, interview, and record review, the facility failed to provide an appropriate communication method for one of 22 sampled residents (Resident 70), when Licensed Nurse 7 (LN 7) was unable to find a communication board to communicate with Resident 70. This failure decreased the facility's potential to address Resident 70's basic needs. Findings: A review of an admission Record indicated Resident 70 was admitted to the facility in 2024 with diagnoses including speech and language deficits. During a concurrent observation and interview on 2/4/25 at 8:53 a.m. with Resident 70 in her room, Resident 70 was unable to verbalize her needs and was using body language and gestures. During a concurrent observation and interview on 2/4/25 at 2:21 p.m. with LN 7 in Resident 70's room, LN 7 was unable to communicate with Resident 70 and started searching for the communication board inside Resident 70's room. LN 7 confirmed there was no communication board inside Resident 70's room and stated there should have been a communication board to help Resident 70 communicate with staff. During an interview on 2/6/25 at 9:29 a.m. with the Director of Nursing (DON), DON stated the communication board or chart should have been kept inside Resident 70's room to help her expressing her basic needs. A review of the facility's policy titled, Accommodation of Needs, dated 3/2021, indicated, In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed toward assisting the residents in maintaining independence . interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication .

Based on observation, interview, and record review, the facility failed to keep one of 22 sampled residents (Resident 64) free of unnecessary psychotropic medication (drug prescribed to affect the mind, emotions or behavior), when Resident 64 was receiving divalproex sodium (a psychotropic medication indicated for seizure treatment and mood disorders) for an inadequate indication. This failure increased Resident 64's potential for unwanted adverse effects such as sedation and falls. Findings: A review of an admission record indicated Resident 64 was 78-years old, admitted in May 2024 to the facility from an acute care hospital with diagnoses including worsening disease of the nervous system, anxiety, depression, and dementia (a progressive state of decline in mental abilities) with behavioral disturbance. A review of Residents 64's Care Plan, dated 5/16/24, indicated Resident 64 was at risk for fall and injury related to her diagnoses. A review of Resident 64's Minimum Data Sets (MDS-an assessment tool), dated 5/23/24, 8/23/24, and 11/23/24, indicated a Brief Interview of Mental Status (BIMS) score of four out of 15 with severely impaired cognition. MDS assessments further indicated Resident 64 exhibited no indicators of psychosis, such as hallucinations (sensory experience of something not present); delusions (an impression or belief not based on reality); or verbal or physical behavioral symptoms directed toward others. A review of Resident 64's active physician orders, dated 2/5/25, indicated the following psychotropic medications: 1. divalproex sodium oral capsule delayed release sprinkle 125 milligrams (mg; a unit of measure). Give two capsules by mouth two times a day for dementia with behavioral disturbances manifested by hallucination. 2. divalproex sodium oral capsule delayed release sprinkle 125 mg for dementia. Give three capsules by mouth in the evening for dementia with behavioral disturbances. A review of Resident 64's Medication Administration Record (MAR), dated 2/6/25, indicated Resident 64 was administered divalproex sodium 625 mg daily divided in multiple doses continuously in the morning and evening from 5/17/24 to 2/6/25 (still receiving currently), over a period of almost a year. A review of a letter from the Department of Health Care Services, dated 5/14/24, indicated Resident 64 did not have a serious mental illness. During an observation on 2/5/25 at 10:40 a.m., Resident 64 was awake, eyes open, lying in bed, looking forward, television on, appeared calm, and not in distress. During an interview on 2/5/25 at 10:42 a.m. with Home Health Aide 1 (HHA 1) with Yolo Hospice, HHA1 stated she worked with Resident 64 every Wednesday, felt safe caring for her, was not a danger to herself or others, and never saw her combative or hallucinating. HHA 1 further stated when she assisted Resident 64 for shower she sometimes could tell Resident 64 did not like water or was startled by it when turned on. HHA 1 also added when talking to Resident 64, she would not respond in a manner that signaled an understanding or ability to answer questions and seemed confused. During an interview on 2/5/25 at 10:50 a.m. with Certified Nursing Assistant 3 (CNA) 3, CNA 3 stated she routinely provided care four days a week to Resident 64, felt safe caring for her, was not a danger to herself or others, was very confused and sleepy, said few things sometimes, but was mostly very confused, did not yell out, was not combative, and guarded herself when her briefs needed change. CNA 3 further stated it took Resident 64 two hours to consume her breakfast because she fell asleep during her meal and dropped her fork and spoon, and did not usually eat her lunch because by the time she received it, she just have finished her breakfast. CNA 3 also added Resident 64 did not know how to use the call light, needed frequent assessment, monitoring and attendance to needs, and her room was located at the end of the hall. During an interview on 2/5/25 at 10:58 a.m. with Licensed Nurse 6 (LN 6), LN 6 stated she felt safe caring for Resident 64 and was not a danger to herself or others. During an attempt to interview the facility's Consultant Pharmacist (CP) on 2/5/25 at 11:44 a.m., the department was unable to get a hold of the CP. During an interview on 2/5/25 at 4:19 p.m. with Medical Doctor (MD), MD stated Resident 64 was prescribed divalproex sodium for dementia and behaviors, did not know if divalproex sodium was approved by Food and Drug Administration (FDA) as indicated for dementia with or without behaviors. A review of divalproex's manufacturer Prescribing Information (PI), last revised in 10/2011, did not indicate divalproex sodium was for treatment of dementia. PI further indicated divalproex was associated with the following side effects including but not limited to an increased risk of falls, headaches, drowsiness, dizziness, vision problems, insomnia (inability to sleep), and abnormal thinking. During an interview on 2/5/25 at 4:30 p.m. with the Director of Nursing (DON), DON was unable to explain why the facility's MD and CP had not reassessed Resident 64 for the unnecessary use and unapproved indication of divalproex to treat dementia. A review of the facility's policy and procedure titled, Psychotropic Medication Use, revised in 2022, indicated, Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record . Medications not classified as anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medication are not prescribed or administered as a substitution for another psychotropic medication unless there is a documented clinical indication consistent with clinical standard of practice . Categories of medications which affect brain activity such as antihistamines, anti-cholinergic medications, and central nervous system medications that are prescribed as a substitute for an adjunct to a psychotropic medication are monitored and managed as psychotropic medications . When determining whether to initiate, modify, or discontinue medication therapy, the IDT [Interdisciplinary team] conducts an evaluation of the resident. The evaluation will attempt to clarify whether: . a particular medication is clinically indicated to manage the symptoms or condition.

Based on interview and record review, the facility failed to establish a safe environment for one of four sampled residents (Resident 1) at risk for falls when Resident 1 experienced two consecutive falls and hospitalization s; the first on [DATE], and second on [DATE]. This failure resulted in Resident 1 falling on the bedroom floor on [DATE] and sustaining two broken ribs, an eyebrow laceration (cut), bleeding in the functional part of the brain, and subsequent death on [DATE] due to the irreparable brain bleeding. Findings: A review of Resident 1's Admission Record, indicated Resident 1 was [AGE] years old and originally admitted on [DATE], with diagnoses including but not limited to: unspecified fracture of lower end of femur (a break in the thigh bone near the knee), presence of left artificial hip joint, history of falling, and reduced mobility. During a review of Resident 1's Minimum Data Set [MDS - a standardized assessment tool that measures health status in nursing home residents], dated [DATE], the MDS indicated Resident 1 had a Brief Interview for Mental Status - BIMS, score of 3 (The BIMS test determines how well a resident is functioning cognitively (thinking, or conscious mental processes) and ranges from 0 - 15. A score of 3 indicates a severe cognitive impairment). The MDS indicated the following: 1. Resident 1 required extensive assistance of two persons for bed mobility, transferring, and toilet use; 2. Resident 1 was dependent on staff for bathing; 3. Resident 1 was not steady while walking or using the toilet and needed staff assistance to stabilize; and, 4. Resident 1 had impairment to one side of his lower extremity and needed the assistance of a wheelchair and a walker. During a review of a facility document titled, Care Plan History, dated [DATE], the care plan indicated, potential for falls and injury due to: impaired balance, left hip fx [fracture] . The approach for this problem related to the care plan included: call light within reach and answered promptly and ensure resident understands how to use call light. During a review of a facility document titled, Progress Note, dated [DATE], the progress note indicated Resident 1 needed a psychiatric evaluation and could not stay in one place. The note further indicated Resident 1 verbalized he wanted to go home. During a review of a facility document titled, Progress Note, dated [DATE], the progress note indicated, Resident 1 was found on the floor of the facility around 7 a.m. laying on his left side reporting he was in pain. The note indicated Resident 1 was transported to the General Acute Care Hospital (GACH) by medical transport. During a review of a facility document titled, Progress Note, dated [DATE], the Progress Note indicated Resident 1 was .observed on the floor in the bathroom after unassisted transfer using walker .PT [patient; sic] unsure of what happened but thinks that he slipped. During a review of Resident 1's History and Physical [H&P], from the GACH, dated [DATE], the H&P indicated Resident 1 had a fall at the Skilled Nursing Facility (SNF) the morning of [DATE] and noticed left hip pain. The H&P further stated Resident 1's x-ray showed periprosthetic fracture of the femur involving the distal stem of the left hip prosthesis area [broken bone that occurs around the bottom part of the implant of a total hip replacement]. During a review of Resident 1's Discharge Summary, from the GACH, dated [DATE], the Discharge Summary indicated Resident 1 had an operation to include: arthroplasty (a surgical procedure to restore the function of a joint) hip revision, ORIF (Open reduction and internal fixation; a type of surgery used to stabilize and heal a broken bone) left periprosthetic fracture revision hemiarthroplasty (surgical repair of a broken bone that occurs around the implants of a total hip replacement). Resident 1 was discharged back to the SNF. During a review of Resident 1's Care Conference Information, dated [DATE] and last updated [DATE], the Care Conference indicated a meeting was held the same day of the resident's fall on [DATE]. The note indicated a Certified Nursing Assistant (CNA) found Resident 1 on the floor in the bathroom. The note indicated Resident 1 was sent to the ER (emergency room ) for further evaluation. The note further indicated the interdisciplinary team (IDT) recommended education about using the call light when getting up. During a review of Resident 1's Minimum Data Set, dated dated [DATE], the MDS indicated, had a Brief Interview for Mental Status - BIMS, score of 5 (severe cognitive impairment). The MDS indicated the following: 1. Resident 1 required extensive assistance of one person for bed mobility, transferring, and toilet use; 2. Resident 1 was dependent on staff for bathing; 3. Resident 1 only performed surface to surface transfer; and, 4. Resident 1 had impairment to one side of his lower extremity and needed the assistance of a wheelchair and a walker. During a review of Resident 1's Progress Notes, dated [DATE], the progress note indicated Resident 1 was, seen and evaluated on the floor halfway [from the] bedroom lying down per staff pt [patient; sic] was walking and slip . Resident 1 was found to have a .head injury bleeding on the left forehead. The progress note indicated Resident 1 was transported to the GACH. During a review of Resident 1's ED [Emergency Department] Physician Notes, from the GACH, dated [DATE], the ED note indicated EMS (Emergency Medical Staff) stated Resident 1 fell of his bed to the ground which was about three feet off the ground. The progress note further indicated Resident 1 had a 3 cm (centimeter, a unit of measure) laceration (open cut) just inferior (below) to left eyebrow and 3 cm ulceration to left cheek. During a review of Resident 1's XR [X-ray, imaging that shows internal structures such as tissues, bones, and organs] Chest 1 View Portable, from the GACH, dated [DATE], the XR report indicated Resident 1 sustained two rib fractures of the left lateral eighth and ninth rib. The XR report also indicated Resident 1 did not have the rib fractures on a previous XR on [DATE]. During a review of Resident 1's CT [computerized tomography - provides more-detailed images compared to x-rays] Head wo [without] Con [contrast- dye injected into the vein to see body parts better], from the GACH, dated [DATE], the CT indicated Resident 1 had an acute intraparenchymal hemorrhage (ruptured blood vessel in the brain that causes bleeding into the functional tissue of the brain, disrupts normal blood flow and leads to loss of oxygen to the brain) in the right temporal lobe (right side of the brain that contains areas that manage or contribute to several abilities such as: language, memory and senses) measuring 5.6 by 3.1 by 3 cm. During a review of Resident 1's Assessment/Plan, from the GACH, dated [DATE], the Assessment/Plan indicated, the following recommendations from the GACH Medical Doctor (MD): hospice placement if Resident 1 survived GACH hospitalization , his condition was critical. The note indicated, Resident 1's overall prognosis (likely outcome) was poor. During an interview on [DATE] at 1:25 p.m., with Director of Nursing (DON), DON stated an interdisciplinary team (IDT) meeting was held on [DATE] to address Resident 1's first fall at the facility. The DON stated after Resident 1's return from the GACH on [DATE], the intervention in place to prevent Resident 1 from falling was for Resident 1 to use the call light, which was the same intervention Resident 1 had upon admission to the facility on [DATE]. The DON denied any other interventions in place for Resident 1. During a telephone interview on [DATE] at 3:58 p.m., with Licensed Nurse (LN) 4, LN 4 stated standard interventions to prevent residents from falling include: beds in the lowest position, call light in reach and a yellow arm band so other staff are aware resident was a fall risk. LN 4 further stated interventions for confused residents can include finding out why the resident was confused or assigning a staff member as a sitter. LN 4 stated fall mats, and PT (physical therapy) consults are beneficial in preventing falls with residents. LN 4 stated the process for a psychiatric consult was to notify the MD of the request for the consult. LN 4 confirmed there was no follow up for the request of a psychiatric consult. LN stated yes, the psychiatric consult might have prevented Resident 1's falls at the facility. During a review of the facility's policy and procedure (P&P) titled, Fall Prevention Program, revised [DATE], the P&P indicated, Fall risk care plans will be updated by nursing to reflect the potential problem .individualized interventions. During a review of Resident 1's Certificate of Death, dated [DATE], the certificate of death indicated, Immediate Cause (final disease or condition resulting in death) .(A) Intracranial Hemorrhage, as Resident 1's sole cause of death, with none listed under other significant conditions contributing to death .

Based on interview, clinical record review and document review, the facility failed to prevent physical abuse of Resident 1 when her clothing was forcibly removed by a Certified Nursing Assistant (CNA 1) against her will. This failure resulted in trauma to the resident's face and head. Resident 1 was transferred to the hospital for treatment. Findings: Resident 1 was an [AGE] year old admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS- an assessment tool used in nursing facilities) dated 6/5/13, revealed Resident 1 had long and short term memory problems, and moderately impaired ability to make daily decisions. This assessment revealed the resident had no behaviors including resisting care. Resident 1 required extensive one person assistance for dressing and toileting. Review of "Resident Progress Notes" dated 8/11/13 at 11:24 p.m. revealed CNA 2 informed Licensed Nurse 1 (LN 1) that she heard Resident 1 screaming "Please no, don't, please." CNA 2 went into the resident's room and Resident 1 was noted to be crying and asking for help and stated, "This lady (CNA 1) is hurting me." LN 1 was called into the room by CNA 2 at around 7:30 p.m. (just after the incident happened) and noted Resident 1 sitting in a wheelchair with LN 2 next to her. LN 1 noted bleeding to Resident 1's cheek from 3 skin tears. The skin tears measured 1.5 cm x 1 cm, 2 cm x 1 cm, and 3 cm x 1 cm with a bruise around them measuring 6 cm x 4 cm with swelling that was hard to the touch. Resident 1 told LN 1, "She hit me" (indicating CNA 1). Review of a document titled "REPORT OF SUSPECTED ELDER/DEPENDENT ADULT ABUSE" received by the Department on 8/14/13 indicated CNA 1 was alleged to have injured Resident 1 while providing care, as the resident sustained [REDACTED]. This report indicated the investigation began immediately after the incident on 8/11/13. The Social Services investigation revealed the Resident 1 was sitting in her wheelchair with skin tears to the left side of her face, which was swollen and discolored. The report indicated Resident 1 was wearing an undershirt covered with blood, and minimal blood was on the resident's clothing that had been removed. The resident had no blood under her fingernails, there was only blood around the toilet area. Residents around Resident 1's room were interviewed and none had heard anything unusual. Further review of the report revealed in an interview with CNA 1 the resident was agitated and resistive to care. Resident 1 was resisting having her blouse changed while CNA 1 was trying to assist her. CNA 1 stated she did not notice any skin tear until after her blouse came off. Resident 1 started crying after CNA 1 removed her blouse. CNA 1 stated that the resident's clothes were very tight and might have caused the skin tears. The conclusion of this report indicated CNA 1 was responsible for Resident 1's injuries. Review of CNA 1's personnel file on 8/14/13 revealed a disciplinary action dated 1/10/12 for resident "complaint of care being rendered." Under "Action Plan/Expectations" the goal was "proper/gentle care is being given." During an interview with LN 3 on 8/29/13 at 4:04 p.m., she stated the disciplinary action was for a resident complaint that CNA 1 was not giving post toileting care appropriately, she did not explain what she was going to do to the resident before she began, and for not leaving the call light within reach of the residents. During an interview with CNA 1 on 8/29/13 at 4 p.m., she stated that on 8/11/13 at about 7:30 p.m., a nurse had put Resident 1 on the toilet. When CNA 1 went in to assist her she was finishing up and CNA 1 offered to help. CNA 1 stated Resident 1 wanted to return to bed, but if she did, she wouldn't get up to take her clothes off and get ready for bed. The CNA began to remove the resident's sweater and the resident became agitated. CNA 1 stated she told the resident she was trying to help her and continued to remove the clothing. CNA stated after she removed the shirt, she saw the resident's face bleeding. During an interview with CNA 2, on 9/3/13 at 3 p.m., she stated that she was in another room assisting another resident to clean up after dinner and to get ready for bed. CNA 2 stated that about 7:30 p.m. on 8/11/13, she heard Resident 1 screaming, "Please don't! Help me! Help me!" When she entered the room, she asked what happened. Resident 1 stated, "She hit me, she hurt me." CNA 2 stated when she entered the bathroom, the resident was screaming and crying and trembling. CNA 2 stated she saw the blood on the left side of the resident's face and asked CNA 1 what happened. CNA 2 stated, at first CNA 1 told her she didn't know, and then said she might have ripped her skin when she pulled off her sweater, or her glasses could have got her. CNA 2 stated Resident 1's glasses were still on her face in the normal position. In an interview with LN 1 on 8/14/13 at 3 p.m., she stated CNA 2 came to tell her that Resident 1 was bleeding. LN 1 went to resident's room and saw her crying with blood on her face and went to get LN 2. In an interview with LN 2 on 8/14/13 at 2:50 p.m., she stated that at around 7:30 p.m. on 8/11/13 she was called to Resident 1's room to assess her her. LN 2 heard the resident crying and saying "she hurt me." LN 2 examined the resident's injuries. She stated Resident 1 sustained 3 skin tears to her left cheek within a large bruise. The resident also had a hard spot under her left mandible (jaw). LN 2 stated the resident was crying and insisting CNA 1 had hurt her. LN 2 stated she notified the resident's doctor and her daughter. In an interview with LN 4, the treatment nurse, on 8/14/13 at 3:10 p.m. she stated that Resident 1 had a large bruise on her left cheek that was swollen with 3 skin tears on the bruised area. LN 4 stated that she cleaned up the area, and kept the resident with her until she was sent to the hospital. LN 4 stated the resident kept saying "Be careful of the dark one, she'll get you" and expressed a fear the "dark one" would come back. Review of the acute care hospital records revealed a document titled "Emergency Documentation-MD" dated 8/12/13. Under the heading of "History of Present Illness" it indicated Resident 1 presented with facial abrasions (scraping away of skin as a result of injury) and underlying hematoma (collection of blood visible under the skin). Per Emergency Medical System (EMS) they were called to the nursing home because the resident reported being assaulted by a caretaker in the bathroom. Further review of this document under the heading "Physical Examination" it indicated "Left cheek with 3 abrasions (each abrasion is vertical, apx (approximately) 1 cm (centimeters) in diameter), no active bleeding; large hematoma below abrasions." Review of a document titled "History and Physical" dated 8/12/13 at 4:30 a.m. revealed under the heading of "Assessment 1. Trauma to the head, concern for elder abuse." Review of a document titled "Discharge Summary" dated 8/14/13 included discharge [DIAGNOSES REDACTED]. Possible elder abuse with evidence of head trauma, [MEDICAL CONDITION] (bleeding into the cranium) and a small contusion (bruise) on the pons. 2. Left sided facial abrasion as well as a laceration..." In an interview with the Administrator on 8/14/13 at 1:05 p.m., he stated that the facility investigation found CNA 1 responsible for Resident 1's injuries. He further stated, CNA 1 was terminated.

Based on observation, interview, and record review, the facility failed to immediately consult with the physician regarding the need to alter treatment for 1 of 17 sampled residents (11) in a census of 81, when Resident 11 experienced continued severe pain, despite having received the maximum dose of physician ordered pain medicine on 7/15/12. This failure resulted in unrelieved pain and an unplanned transfer to the emergency room for pain assessment. Findings: Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission MDS, dated [DATE], described the resident as having no cognitive impairment, scoring 12 out of 15 on the BIMS, and requiring staff assistance for all ADLs except eating. During an observation of Resident 11 on 7/18/12 at 10 a.m. she was alert and talkative and responded appropriately to questions. She was observed to have a cast on her left leg. During an interview of Resident 11 on 7/18/12 at 10 a.m. she stated she had difficulty with pain management on Sunday 7/15/12, "The nurse didn't put priority on calling the doctor." The resident reported she had been sent to the emergency roiagnom on Monday 7/16/12 for her pain and was there for over 8 hours. Resident 11 stated her knee became infected after replacement surgery and the replacement joint had been removed due to the infection. Resident 11 stated she currently had a cast on her leg to stabilize it since she could not have a new knee replacement for 3 months. Review of the clinical record for Resident 11 included: - A physician's orders [REDACTED]. Review of Resident Progress Notes for Resident 11 included: -7/15/12 at 3:38 p.m., "Medicated...with some relief. Resident was crying at the end of AM shift and stated, 'I am in pain every time I move, even small movements hurt my leg.' Notified resident that MD will be notified of her request to have pain meds to be scheduled routinely in the AM." There was no documented evidence the physician was notified of Resident 11's unrelieved pain on 7/15/12. -7/15/12 at 11:52 p.m., "Refused (treatment) due to (complained of) pain with movement." -The "Controlled Drug Record" for [MEDICATION NAME] documented the resident received [MEDICATION NAME] 2 mg at on 7/15/12 at: midnight; 4 a.m.; 6:45 a.m.; 10:25 a.m.; 1:30 p.m.; 4:45 p.m.; 8 p.m.; and 11 p.m. for pain. The record showed the resident received 3 more doses on 7/16/12: at 2 a.m.; 5 a.m. and 9 a.m.. -The Medication Nurse's Notes documented the [MEDICATION NAME] had been given for pain that was rated by the resident as a severity of 7 or 8 out of 10 (with ten being most severe). -Resident Progress Notes dated 7/16/12 at 11:30 a.m. "Notified by (night) RN resident requesting...routine (pain medication)...verbalized pain does not go away...intense pain in leg." In an interview with LN 2 on 7/18/12 at 2:25 p.m. she stated on the day shift, Sunday, 7/15/12, the resident was "Kind of upset, her leg hurt with any movement. She want(ed) to talk to the doctor. I told her we could ask the doctor to make the medicine routine. She wanted to see the doctor to tell him personally." LN 2 then agreed that it was not realistic for the resident to see the doctor personally to get her medications changed. LN 2 stated, "I did not call the doctor, I relayed the message to the PM nurse so we (could) call the doctor in the morning, I missed it." In an interview with LN 1 on 7/18/12 at 3 p.m. she stated on Monday 7/16/12 the resident, "Nearly screamed with slight change in position of her leg." In an interview with UM 2 on 7/19/12 at 3:30 p.m. she stated, "We notify the doctor," if a resident continued to have pain after the maximum ordered pain medication had been administered. UM 2 stated, "Yes, we should have informed the doctor on Sunday." Review of facility policy titled, "Pain Management" dated 12/21/10 included, "If the pain intervention is ineffective, as perceived by the resident, notify the physician for further orders." In an interview with the DON on 7/19/12 at 10:50 a.m. she stated the nurse "should notify the doctor," if the maximum medication dose was not effective.