Every finding on record at Meadowbrook Post Acute

Based on observation, interview and record review, the facility failed to maintain a safe and clean homelike environment, when the bathroom for two residents (Resident 1 and 2) and the bedroom for one resident (Resident 1) was observed with damaged drywall, missing tiles, and areas of walls not painted. This failure resulted in residents not being provided with a homelike environment in the bathroom and bedroom.Findings:On April 7, 2026, an unannounced visit to the facility was conducted to investigate a complaint related to administration/personnel, misappropriation of property, physical environment, quality of care/treatment and rehabilitation services.On April 7, 2026, at 10:20 a.m., an observation was conducted in Resident 1's room and bathroom. A white patch of dry primer was observed on the wall near the foot of Resident 1's bed. The area was not painted like the rest of the paint color in Resident 1's bedroom. The bathroom, shared between residents in room [ROOM NUMBER] and residents in room [ROOM NUMBER], was also observed. The bathroom had peeled paint on top of the sink right above the faucet, damaged drywall and missing paint around the light switch, missing tiles and grout at the shower area and a patch of dry, white primer around the toilet, not painted like the rest of the bathroom.On April 7, 2026, at 10:25 a.m., an observation and concurrent interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 came into Resident 1's room and confirmed the wall at the foot of Resident 1's bed was not painted. CNA 1 confirmed Resident 1's bathroom had peeled paint on top of the sink, damaged drywall and missing paint around the light switch, missing tiles and grout at the shower area and a patch of dry, and unpainted area on the wall around the toilet. CNA 1 stated the bedroom and the bathroom of Resident 1 were not like a homelike environment.On April 7, 2026, at 10:42 a.m., an observation and concurrent interview was conducted with the Maintenance Assistant (MA). The MA was observed in Resident 1's bathroom. The MA confirmed Resident 1's bathroom had peeled paint on top of the sink, damaged drywall and missing paint around the light switch, missing tiles and grout at the shower area and a patch of dry, and unpainted area on the wall around the toilet. The MA also confirmed the wall at the foot of Resident 1's bed was not painted. The MA stated this was not how the bathroom and the bedroom of a resident should look like. The MA stated Resident 1's bathroom and bedroom did not look like a homelike environment.On April 7, 2026, at 10:45 a.m., an observation and concurrent interview was conducted with the Administrator (ADM). The ADM observed Resident 1's bathroom with peeled paint on top of the sink, damaged drywall and missing paint around the light switch, missing tiles and grout at the shower area and a patch of dry, and unpainted area on the wall around the toilet, as well as the unpainted wall in Resident 1's bedroom. The ADM stated this was not OK, and Resident 1's bathroom and bedroom did not look like a homelike environment.On April 7, 2026, at 10:56 a.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was alert and oriented. Resident 1 was observed in his wheelchair, in his room. Resident 1 stated he did not like the damaged dry wall and the missing tiles from the bathroom, and the unpainted area on the wall in his bathroom and in his bedroom and stated he did not like it, it was not a homelike environment.Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), multiple sclerosis (a disease causing vision loss, numbness, fatigue, muscle weakness), and ataxia (loss of control of bodily movements, causing uncoordinated walking, speech and hand function).On April 7, 2026, at 11:09 a.m., a concurrent observation and interview was conducted with Resident 2. Resident 2 was alert and oriented. Resident 2 was observed in his wheelchair, outside of his room (room [ROOM NUMBER]). Resident 2 stated he shared a bathroom with room [ROOM NUMBER]. Resident 2 stated his bathroom had damaged dry wall, missing tiles, chipped paint, and did not look good.The facility policy and procedure titled, Bedrooms, dated January 2025, was reviewed. The policy indicated, .All residents are entitled to clean, comfortable, safe, and homelike bedrooms.

Based on observation, interview, and record review, the facility failed to provide specialized rehabilitative services, as ordered by the physician, for one resident (Resident 1), when it did not evaluate and treat Resident 1 for Physical Therapy (PT).This failure had the potential to result in Resident 1's difficulty in attaining and maintaining his highest practicable level of physical, mental, functional, and psycho-social well-being and to prevent and slow further decline in the resident's condition and physical function.Findings:On April 7, 2026, an unannounced visit to the facility was conducted to investigate a complaint related to administration/personnel, misappropriation of property, physical environment, quality of care/treatment and rehabilitation services.On April 7, 2026, at 10:56 a.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was alert and oriented. Resident 1 was observed in his wheelchair, in his room. Resident 1 stated he had multiple sclerosis (a disease causing vision loss, numbness, fatigue, muscle weakness). Resident 1 stated he did not have any physical therapy evaluation or treatment since his admission at the facility. Resident 1 stated he could use physical therapy to help with his condition.On April 7, 2026, at 11:23 a.m., an observation and concurrent interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 1 needed assistance with mobility, and with his activities of daily living. CNA 2 stated he did not see Resident 1 getting any PT since his admission.On April 7, 2026, at 12 p.m., an observation and concurrent interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 1 needed assistance with his mobility. LVN 1 stated he did not witness Resident 1 getting PT during his stay at the facility.Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), multiple sclerosis, and ataxia (loss of control of bodily movements, causing uncoordinated walking, speech and hand function).Resident 1's physician order, dated October 30, 2025, indicated, .Physical Therapy evaluation and treatment as indicated.On April 10, 2026, at 10:12 a.m., an interview was conducted with the Administrator (ADM). The ADM stated Resident 1 did not have a physical therapy evaluation or treatment since his admission at the facility. The ADM stated the physician's order for PT was not followed, and it should have been followed.The facility policy and procedure titled, Specialized Rehabilitated Services, dated December 2009, was reviewed. The policy indicated, . Our facility will provide rehabilitative services to residents. Specialized rehabilitative services include .Physical therapy . Therapeutic services are provided only upon the written order of the resident's attending physician .

Based on observation, interview, and record review, the facility failed to ensure the bathroom call light was functioning for two residents who shared the same bathroom (Resident 1 and Resident 2).This failure had the potential to result in accidents or injuries to Resident 1 and Resident 2. Findings:On April 7, 2026, an unannounced visit to the facility was conducted to investigate a complaint related to administration/personnel, misappropriation of property, physical environment, quality of care/treatment and rehabilitation services.On April 7, 2026, at 10:20 a.m., an observation was conducted in Resident 1's bathroom in room [ROOM NUMBER]. The bathroom from room [ROOM NUMBER] was shared with the residents from room [ROOM NUMBER]. The bathroom had a call light with a switch, for residents' use. The call light was pressed and was observed not working (no visual or audible alert).On April 7, 2026, at 10:25 am, an observation and concurrent interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 came into Resident 1's bathroom and confirmed the bathroom call light was not working. CNA 1 stated the bathroom call light should be functioning, for the safety of the residents, to prevent falls or accidents. CNA 1 stated Resident 1 needed assistance in the bathroom, to get in and out of his wheelchair.On April 7, 2026, at 10:35 a.m., an observation and concurrent interview was conducted with Licensed Vocational Nurse (LVN) 2. LVN 2 stated Resident 1 needed assistance in the bathroom. LVN 2 observed the bathroom call light shared between room [ROOM NUMBER] and 37 and stated it was not working. LVN 2 stated every bathroom should have a working call light for the safety of the residents, so the residents can call if needed.On April 7, 2026, at 10:42 a.m., an observation and concurrent interview was conducted with the Maintenance Assistant (MA). The MA was observed in Resident 1's bathroom (also shared with Resident 2). The MA confirmed the bathroom call light was not functioning and stated it should be functioning.On April 7, 2026, at 10:45 a.m., an observation and concurrent interview was conducted with the Administrator (ADM). The ADM observed Resident 1's bathroom call light and stated the bathroom call light was not functional and it should be functional.On April 7, 2026, at 10:56 a.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was alert and oriented. Resident 1 was observed in his wheelchair, in his room. Resident 1 stated he had multiple sclerosis (a disease causing vision loss, numbness, fatigue, muscle weakness). Resident 1 stated his bathroom light was not working, and he would use it if it was working. Resident 1 stated he needed help in the bathroom.Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), multiple sclerosis, and ataxia (loss of control of bodily movements, causing uncoordinated walking, speech and hand function).On April 7, 2026, at 11:09 a.m., a concurrent observation and interview was conducted with Resident 2. Resident 2 was alert and oriented. Resident 2 was observed in his wheelchair, outside of his room (room [ROOM NUMBER]). Resident 2 stated he shared a bathroom with room [ROOM NUMBER]. Resident 2 stated his bathroom call light was not working, and it would be nice if it had a functioning call light, just in case he needed to use it.Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included hereditary neuropathy (genetic disorder causing damage to nerves and leading to chronic muscle weakness), and kyphosis (poor posture - hunchback).The facility policy and procedure titled, Call System, Residents, dated September 2022, was reviewed. The policy indicated, .Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station.Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor .The resident call system remains functional at all times .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices were followed in accordance with professional standards of practice when the kitchen's double preparation (prep) sink was observed unsanitary with multiple dried food particles in both sinks and underneath the first prep sink was a red bucket filled with yellowish gray fluid.These failures had the potential to cause food-borne illnesses (stomach illness resulting from ingestion of contaminated food) in a medically vulnerable population for 53 out of 54 residents who received food prepared in the kitchen.Findings:1.On March 27, 2026, at 1:14 p.m., an initial tour of the kitchen was conducted with the Dietary Manager (DM). The kitchen's double prep sink was observed with a long cookie sheet covering both sinks with two signs one above each sink that indicated DO NOT USE UNDER REPAIR with multiple dried food particles in both sinks. Under the first prep sink was a red bucket filled with a yellowish gray fluid, and in the corner on the floor at the end of the double prep sinks was one wet yellow blanket The DM stated the kitchen has had a drainage issue with the prep sinks since March 18, 2026. The DM stated the maintenance supervisor was notified and attempted to repair the sinks without success. The DM stated a plumber came out on March 19, 2026, and stated the drainage pipe under the double prep sink which leads out of the facility was collapsed underneath the courtyard cement. The DM stated a second plumber came out on March 20, 2026, and stated the same as the first plumber that there was a collapsed pipe underneath the courtyard cement. The DM stated the kitchen staff were using bus tubs (plastic tubs) to clean the facility fruits and vegetables.At 1:36 p.m., an interview was conducted with the Administrator (ADM). The ADM stated the kitchen's double prep sinks became non-operatable on March 18, 2026. The ADM stated the maintenance supervisor attempted to repair the double prep sinks without success. The ADM stated a plumber conducted an estimate on March 18, 2026, and another plumber conducted a second estimate on March 20, 2026. Both plumbers stated the facility had a collapsed pipe. A concurrent observation of the kitchen's double prep sinks was conducted with the ADM, DM, Cook, and Director of Nursing (DON). The ADM stated the kitchen's double prep sinks were dirty, underneath the first prep sink was a red bucket filled with yellow grey water, and at the end of the double prep sinks in the corner of the floor was a wet yellow blanket.At 2:05 p.m., a concurrent observation and interview was conducted with the Cook. The [NAME] stated the kitchen's double prep sinks had been non-operatable, dirty with old, dried food, underneath the first prep sink was a red bucket filled with yellow grey water, and at the end of the double prep sinks in the corner of the floor was a wet yellow blanket since March 18, 2026. The [NAME] stated the kitchen's double prep sinks should not have dried food particles and the first prep sink should not have underneath it a red bucket filled with yellow grey liquid. The cook stated the kitchen should be in a sanitary condition at all times and it was not currently in a sanitary condition. At 2:18 p.m., an interview was conducted with the DON. The DON stated there had not been any residents complaining of signs and symptoms of food-borne illnesses (nausea, vomiting, and diarrhea). The DON stated there had not been any residents transferred from the facility to an acute care hospital of signs and symptoms of food-borne illness.A review of the facility policy and procedure titled, Sanitization, dated 2001, indicated .all kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris.

Based on observation, interview, and record review, the facility failed to maintain a safe environment and ensure adequate supervision was provided to prevent accidents for one of three residents reviewed (Resident 1), who was at risk for falls, self harm, and exhibited impulsive behavior, as indicated in the plan of care and facility policy.These failures resulted in Resident 1 having eight unwitnessed falls between July 2024 and December 2025. On May 13, 2025, Resident 1 sustained a hematoma (severe bruising with swelling) and a skin tear to her forehead. On December 21, 2025, Resident 1 was found on the floor under her roommate's bed, with two red, swollen eyes, which required Resident 1's transfer to the General Acute Care Hospital (GACH) for evaluation and treatment.Findings:On December 24, 2025, at 9:49 a.m., Resident 1 was observed at the GACH, alert and in bed with noticeable injuries to both eyes and hands. The resident's right eye was swollen with a reddish-black color, and the left eye was swollen with a bluish-black color. Additionally, there was purple discoloration on the outer side (lateral side) of her right hand and purple discoloration on her left hand between the index and middle fingers.The GACH emergency department (ED) note dated December 22, 2025, was reviewed and indicated, .female presents to ED for fall.patient currently at (name of skilled nursing facility).staff reported found patient on the floor yesterday around noon.unwitnessed fall.stated patient could not sit still for x-ray.and sent to ED.bilateral (both) black eyes.CT Brain (Computed Tomography-medical device used to scan the brain).no acute intracranial hemorrhage (bleeding inside the skull).admitted to tele unit (special-unit for remote vital sign monitoring) for observation.The left-hand x-ray report dated December 23, 2025, was reviewed and indicated .no radiograph evidence of acute process (fracture).On December 24, 2025, at 10:37 a.m., during a concurrent interview and review of the GACH ED notes with the GACH medical doctor (MD), the MD stated Resident 1 has dementia and requires a sitter (a trained caregiver providing one-on-one observation and support to patients at high risk of harm) for direction and staying in bed while at the GACH. The MD stated the family informed him of Resident 1's history of falls at the skilled nursing facility. The MD further stated that without a dedicated sitter Resident 1 was at risk for falling. On December 24 and 26, 2025, unannounced visits were made to the facility.On December 24, 2025, at 12:44 p.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated on December 21, 2025, she was Resident 1's assigned CNA. CNA 1 stated at 11:30 a.m., she noticed Resident 1 under her roommate's bed, both of her eyes were red and swollen. CNA 1 stated Resident 1 has a history of being found underneath her roommate's bed, which requires two CNAs to return Resident 1 back to her bed. CNA 1 stated Resident 1 also has a history of hitting herself against objects when she is upset. CNA 1 stated she did not report her 11:30 a.m., findings of Resident 1 being found under her roommate's bed with both eyes red and swollen to the LVN (Licensed Vocational Nurse). CNA 1 stated she told CNA 2 (Resident 1's assigned CNA for the evening shift (3-11 pm) to report Resident 1's swollen eyes since it was change of shift. CNA 1 stated she should have reported Resident 1's swollen eyes to the LVN prior to the shift change.During an interview on December 24, 2025, at 12:59 p.m., CNA 2 stated she was Resident 1's assigned CNA during the evening shift (3-11 pm) on December 21, 2025. CNA 2 stated she was informed by CNA 1 of Resident 1's eyes being swollen and purple. CNA 2 stated she informed the LVN. CNA 2 further stated Resident 1 is uncontrollable and the CNAs have reported it to the Assistant DSD (Director of Staff Development) who stated the resident is ok to come out of bed and that she could not be restrained. CNA 2 stated Resident 1 has never been assigned a one-on-one sitter even though the CNAs keep informing the DON (Director of Nursing) and the (DSD) Director of Staff Development that Resident 1 keeps getting hurt and getting out of bed.On December 24, 2024, Resident 1's medical records were reviewed.Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (loss of intellectual functioning), anxiety (excessive worry or fear), and history of falls.The history and physical completed on July 15, 2024, indicated Resident 1 does not have capacity to make decisions.The BIMS (brief interview for mental status) score dated October 20, 2025, indicated .severely impaired.The care plans were reviewed and indicated the following: -November 7, 2024, .resident has an actual unwitnessed fall.intervention.CNA to check and change resident every 2 hours and as needed.There was no documented evidence in Resident 1's medical record of Resident 1 being checked and changed by the CNAs every 2 hours.-March 14, 2025, .expected behavior related to movement to floor mat.history of falls.per daughter patients cultural (sic) is to sit on the floor every day and do activities and task.intervention.frequent visual monitoring.There was no documented evidence in Resident 1's medical record of Resident 1 having frequent visual monitoring.In addition, there was no documented evidence found in Resident 1's nursing progress notes for the months of March 2025 through December 2025 of frequent visual monitoring of Resident 1 as indicated in the care plan dated March 14, 2025.-May 13, 2025, .resident has an actual unwitnessed fall.goal.resident checked every 30 min and prn (as necessary).resident will be free of falls.There was no documented evidence in Resident 1's medical record of Resident 1 being checked every 30 minutes.In addition, there was no documented evidence found in Resident 1's nursing progress notes for the months of March 2025 through December 2025 of Resident 1 being checked every 30 minutes as indicated in the care plan dated May 13, 2025.The change of condition notes and nursing notes were reviewed and indicated Resident 1 had eight falls which occurred on the following dates:-October 4, 2024, at 4:30 p.m., .resident found sitting on the floor mat beside bed no injuries.md and daughter notified.-October 10, 2024, at 9:30 a.m., .resident was wet and therefore climbed out of bed.instructed CNA to check resident often to be sure resident is clean and dry.MD and daughter notified.-November 7, 2024, at 11:20 a.m., .resident was wet therefore climbed out of bed .instructed CNA to check resident often to be sure resident is clean and dry.MD and daughter notified.-December 4, 2024, at 9:31 a.m., .resident had an unwitnessed fall today at 8:00 a.m. bed was in lowest position floor mat in place.resident found sitting on her mat.MD and daughter notified.-February 19, 2025, at 10:46 a.m., .resident crawled out of bed onto floor mat.MD notified.daughter notified.-March 3, 2025, at 11:45 a.m., .resident was found in her room on her buttocks on floor around 10:40 a.m., md notified.daughter notified.-May 13, 2025, at 18:00 (6:00 p.m.) .fall.skin contusion (bruise).skin tear.top of scalp hematoma.top of scalp.skin tear.contusion .skin tear left side of forehead.neuro checks (assessment of nervous system).resident found on the floor bedside with lower part of body on floor mat.lower part of body on bare floor.head to toe assessment conducted noted with contusion/hematoma and skin tear on left side of forehead.assisted into bed and medicated for pain.MD notified.recommendations.neuro checks.skin care.clean skin tear with NS (normal saline).apply TAB (triple antibiotic ointment).medicate for pain.notified RP.The nursing note dated May 19, 2025, at 7:10 p.m., indicated .family at bedside and requested resident be sent to (name of hospital) for evaluation of s/p (status post) fall (May 13, 2025), MD notified and order to send to hospital.resident present with contusion/hematoma s/p unwitnessed fall.resident transferred.The (named hospital) emergency room note dated May 19, 2025, indicated .fall on May 13 from the bed to the floor.CT head.small left frontal scalp hematoma.recommend follow up CT in 6 hours.family declines (follow up CT).impression fall.closed head injury.acute nonintractable (treatable) headache.The change of condition note dated December 21, 2025, at 5:00 p.m., indicated .at 1620 (4:20 p.m.) CNA and nurse discussed discoloration (eye discoloration).notified RN (Registered Nurse) of findings.PM (evening) CNA reports AM (morning) CNA reported around 8:30 a.m., discoloration.MD notified at 16:37 p.m. (4:37 p.m.).stat x-ray to orbital (eyes) bilaterally (both) neuro checks.The nurse note dated December 22, 2025, at 8:27 a.m., indicated .resident assessed by RN supervisor.x-ray unable to be completed.Resident would not stay still for x-ray.resident sent to (named hospital). The physician order dated December 22, 2025, indicated .May send out to hospital for orbital head x-ray.On December 26, 2025, at 3:10 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated whenever a resident is found on the floor it is considered a fall. The DON stated the facility process for falls is for nursing to document a change of condition and an IDT meeting is conducted to develop a plan of care for the resident. The DON stated Resident 1 is known for thrashing herself back and forth in the bed, banging on the wall and bed rails, and being found underneath her roommate's bed.The DON stated Resident 1 had six falls without injury, occurring on October 4 and October 10, 2024; November 7, 2024; December 4, 2024; February 19, 2025, and March 3, 2025. The DON also stated Resident 1 had two other documented falls that resulted in injury, on May 13 and December 21, 2025. A review of Resident 1's care plans dated October 10, 2024, and November 7, 2024, was conducted. The DON stated both care plans indicated check and change Resident 1 every 2 hours. The DON stated there was no documented evidence Resident 1 was being checked and changed every 2 hours. The DON stated there should be documentation of nursing checking and changing the resident every 2 hours.Resident 1's care plan dated March 14, 2025, and May 13, 2025, was reviewed. The DON stated the care plan dated March 14, 2025, indicated frequent monitoring and the care plan dated May 13, 2025, indicated monitoring every 30 minutes. The DON stated there was no documented evidence in Resident 1's medical record, including the CNA task report and the nursing progress notes, that Resident 1 was frequently monitored or monitored every 30 minutes.The DON stated there should have been documentation of Resident 1's monitoring. The DON further stated Resident 1's falls were avoidable if nursing had been frequently monitoring Resident 1 as indicated in the care plan. The DON stated the facility did not follow its own policies and procedures for keeping Resident 1 safe.A review of the facility policy and procedure titled, Safety and Supervision of Residents, revised July 2017, indicated .The care team shall target interventions to reduce individuals risk related to hazards in the environment including adequate supervision.Implementing interventions to reduce accident risk and hazards shall include the following.ensuring that interventions are implemented.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices were followed in accordance with professional standards of practice when one large cookie sheet pan had black crusted residue. This failure had the potential to cause food-borne illnesses (stomach illness resulting from ingestion of contaminated food) in a medically vulnerable population.Findings: On September 22, 2025, at 8:57 a.m., during the initial kitchen tour with the Dietary Manager (DM), one large sheet pan was observed with black crusted residue on the edges and corners of the pan. On September 24, 2025, at 9:34 a.m., two large size sheet pans with freshly baked cookies were observed on top of the metal kitchen table. One large sheet pan was observed with black crusted residue on the edges and corners of the pan. In a concurrent interview with the cook, she stated the large sheet pans were old. She stated the large sheet pans should not have black crusted residue. She stated the black crusted residue could come off when serving food to the residents. During an interview on September 24, 2025, at 9:27 a.m., with the DM, he stated some of the pots and pans were old. He stated food residue built-up over time. He stated the crusted black residue could come off and could stick in the food when served to the residents. He stated all food equipment should be free from residue. A review of the U.S. Food and Drug Administration's (FDA) Food Code 2022, Annex 3.4-602.12, indicated, .Cooking and Baking Equipment.Food-contact equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use.A review of the U.S. FDA Food Code 2022, 4-603.12, indicated, .Precleaning of utensils, dishes, and food equipment allows for the removal of grease and food debris to facilitate the cleaning action of the detergent. Depending upon the condition of the surface to be cleaned, detergent alone may not be sufficient to loosen soil for cleaning. Heavily soiled surfaces may need to be presoaked or scrubbed with an abrasive.

Based on interview and record review, the facility failed to ensure a care plan was developed and/or initiated to address the long term use of the medication potassium chloride (potassium supplement) for one of six residents reviewed (Resident 33) for appropriate medication use.This failure has the potential for Resident 33 to not be monitored for the effectiveness and/or side effects of the medication. Findings:On September 24, 2025, Resident 33's record was reviewed. Resident 33 was admitted to the facility on [DATE], with diagnoses including hypertension (high blood pressure) and localized edema (a condition where fluid accumulates in a specific area of the body, causing swelling).The active physician orders indicated the following:-Potassium Chloride ER (extended-release) Tab to be given 40 milliequivalent (mEq- unit of measurement) by mouth one time a day for potassium supplement, date ordered June 22, 2021; and -Lasix (medication used to treat edema and hypertension by increasing urination and preventing the body from absorbing excess salt) 40 milligrams (mg- unit of measurement) by mouth one time a day for generalized edema, date ordered August 18, 2025.The document titled, Care Plan Report, dated June 19, 2024, indicated, .Focus .Lasix .Resident at risk for adverse effects .Furosemide (generic name for Lasix) is a potent diuretic (medication that increases urination) that, if given in excessive amounts, can lead to profound diuresis (excessive production and excretion of urine by the kidneys) with water and electrolyte depletion. Therefore, careful supervision is required .Goal .Resident's risk for the use .will be monitored/identified by the licensed nurse. MD (Medical Doctor) will be promptly notified .Interventions .Monitor for potential risk/effects and alert MD when indicated .There was no documented evidence of a care plan initiated and/or developed to address the use of potassium chloride ER since it was ordered on June 22, 2021.On September 25, 2025, at 9:10 a.m., an interview with a concurrent record review was conducted with the Director of Nursing (DON). The DON stated:-Resident 33 had a physician's order for Potassium Chloride ER Tab to be given 40 mEq by mouth one time a day for potassium supplement. The DON stated Resident 33 was currently on the medication Lasix and the medication potassium chloride may be an adjunct (added as a supplement) to the Lasix use. -Resident 33 did not have an active care plan on the use of the medication potassium chloride supplement.-A care plan should have been initiated and/or developed when the medication potassium chloride tablet for supplement was ordered in June 22, 2021. This care plan would include monitoring the effectiveness and/or side effects of the medication.On September 25, 2025, at 11:25 a.m., an interview was conducted with the Minimum Data Set (MDS- an assessment tool) Nurse. The MDS Nurse stated:-She was responsible for reviewing and updating the residents' care plans during the comprehensive and quarterly assessments.-The potassium chloride tablet order was probably an adjunct to the Lasix medication use. -The indication for the of potassium chloride as a potassium supplement should have been reviewed and clarified with the Resident 33's physician when they did the comprehensive and quarterly assessments. The MDS Nurse stated this was not done.-Resident 33 did not have a care plan developed and/or initiated since the medication potassium chloride tablet was ordered on June 22, 2021. The MDS Nurse stated this should have been initiated and/or developed when medication potassium chloride was ordered on June 22, 2021.The facility's policy and procedure titled, Care Plans. Comprehensive Person-Centered, dated March 2022, was reviewed. The policy indicated, .A comprehensive person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The comprehensive, person-centered care plan .reflects currently recognized standards of practice for problem areas and conditions .Assessments of residents are ongoing, and care plans are revised as information about the residents and residents 'conditions change .The interdisciplinary team reviews and updates the careplan .at least quarterly, in conjunction with the required quarterly MDS assessment .

Based on observation, interview, and record review the facility failed to ensure physician orders were followed for two of two residents reviewed (Residents 7 and 38), when: 1a. For Resident 7, the medication insulin (a medication that regulates the amount of sugar in the blood), was administered outside of the physician ordered parameter; 1b. For Resident 7, the licensed nurses did not contact the physician for blood sugar levels outside of the physician's ordered parameter; 1c. For Resident 7, the medication glucagon (a medication for emergency treatment of very low blood sugar) was administered outside of the physician's ordered parameter; 2a. For Resident 38, the medication insulin was administered outside of the physician ordered parameter; and 2b. For Resident 38, the licensed nurses did not contact the physician for blood sugar levels outside of the physician's ordered parameter. These failures had the potential for Resident 7 and Resident 38 to experience avoidable episodes of hypoglycemia (low blood sugar) and/or hyperglycemia (high blood sugar).Findings: 1a. On September 24, 2025, Resident 7's medical record was reviewed. The admission record indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (high blood sugar), long term use of insulin (medication that regulates amount of sugar in the blood), and dementia (loss of intellectual functioning). The history and physical completed by the physician on December 7, 2023, indicated Resident 7 had no capacity to make decisions. The physician order dated September 1, 2025, indicated for Resident 7, the medication insulin lispro injection solution inject 6 units subcutaneously (underneath the skin) after meals for DM (diabetes mellitus) hold if blood sugar (BS) less than 150. The MAR (medication administration record) dated for the month of September 2025, indicated the following: On September 2, Resident 7 was administered the 8 a.m., dose of the medication insulin lispro injection solution 6 units with a blood sugar of 131, outside of the physician ordered parameters to hold if BS less than 150. On September 7, Resident 7 was administered the 8 a.m., dose of the medication insulin lispro injection solution 6 units with a blood sugar of 144, outside of the physician ordered parameters to hold if BS less than 150. On September 8, Resident 7 was administered the 12 p.m., dose of the medication insulin lispro injection solution 6 units with a blood sugar of 126, outside of the physician ordered parameters to hold if BS less than 150. On September 11, Resident 7 was administered the 8 a.m., dose of the medication insulin lispro injection solution 6 units with a blood sugar of 143, outside of the physician ordered parameters to hold if BS less than 150. On September 13, Resident 7 was administered the 8 a.m., dose of the medication insulin lispro injection solution 6 units with a blood sugar of 140, outside of the physician ordered parameters to hold if BS less than 150. On September 16, Resident 7 was administered the 8 a.m., dose of the medication insulin lispro injection solution 6 units with a blood sugar of 147, outside of the physician ordered parameters to hold if BS less than 150. On September 19, Resident 7 was administered the 8:00 a.m., dose of the medication insulin lispro injection solution 6 units with a blood sugar level of 117, outside of the physician ordered parameters of hold if BS less than 150. 1b. On September 24, 2025, Resident 7's medical record was reviewed. The physician order dated September 24, 2025, indicated, .insulin lispro injection solution inject per sliding scale: if blood sugar less than 70 or greater than 400 call MD (medical doctor). The care plan dated April 17, 2025, indicated, .focus.resident is at risk for hypoglycemia and hyperglycemia related to diabetes mellitus.intervention.diabetes medication as ordered by doctor .monitor/document for side effects and effectiveness.monitor for/document/report prn (as needed any sx/ss (signs and symptoms) of hyperglycemia. monitor for/document/report prn any s/sx of hypoglycemia.sliding scale as ordered. The accu-check (medical device that measures blood sugar) result dated September 16, 2025, at 16:24 p.m., indicated Resident 7 had a blood sugar of 62. This result was outside of the physician ordered parameters if BS less than 70 or greater than 400 call MD. The orders-administration note dated September 16, 2025, at 4:24 p.m., indicated no documented evidence that the physician was notified for Resident 7's blood sugar of 62. 1c. On September 24, 2025, Resident 7's medical record was reviewed. The physician order dated October 17, 2023, indicated for Resident 7, glucagon emergency injection kit 1 mg (mg-a unit of measurement) Inject 1mg subcutaneously as needed for blood sugar less than 60. The Medication Administration Record (MAR) dated September 25, 2025, at 5:09 a.m., indicated Resident 7 was administered the medication glucagon emergency injection kit 1mg for a blood sugar of 97, outside of the physician ordered parameters for BS less than 60. On September 24, 2025, at 2:46 p.m., a concurrent interview and record review was conducted with LVN 1. LVN 1 stated the facility process for administering insulin is to check the residents' blood sugar against the physician's order for insulin, and either administer or hold the insulin. LVN 1 stated Resident 7's physician order for the medication insulin lispro injection states to hold the insulin if the blood sugar is below 150. LVN 1 stated on the following days September 2, September 7, September 13, September 15, September 19, and September 23, 2025, Resident 7 's blood sugar was outside of the physician's ordered parameters and the medication insulin lispro injection should not have been administered to Resident 7. On September 25, 2025, at 9:46 a.m., a concurrent interview and record review was conducted with LVN 2. LVN 2 stated the facility process for residents with low blood sugars are to administer glucagon and notify the physician, DON and family, offer snacks to the resident and recheck the resident blood sugar after 5 minutes and monitor the resident. LVN 2 stated Resident 7's physician order for the medication glucagon was to administer when blood sugar was less than 70. LVN 2 stated on September 25, 2025, Resident 7's blood sugar was 97 and outside of the physician's ordered parameters and the medication glucagon should not have been administered. On September 25, 2025, at 10:22 a.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the expectations for the nursing staff were to follow the resident specific physician ordered parameters. If the residents' blood sugar is lower or higher than physician ordered parameters, the expectation is for nursing to notify the physician. The DON stated Resident 7 should not have been administered the medication insulin and the medication glucagon outside of the physician ordered parameters. The DON further stated that not following physician orders can result in undesired outcomes for the residents. 2a. On September 22, 2025, at 12 p.m., Resident 38 was observed lying in bed, awake and alert. In a concurrent interview with Resident 38, he stated he checked his own blood sugar level and self-administered the insulin. He also stated there were instances when his blood sugar was low and he would inform the nurses. He also stated the nurses would not do anything when his blood sugar was low. On September 23, 2025, at 1:08 p.m., Resident 38 was observed lying in bed, awake and alert. Resident 38 could not recall our conversation on September 22, 2025, regarding his low blood sugar. On September 25, 2025, Resident 38's record was reviewed. Resident 38 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus. The undated history and physical indicated Resident 38 did not have the capacity to make decisions. The Minimum Data Set (MDS – an assessment tool) dated July 25, 2025, indicated a BIMS (Brief Interview of Mental Status – cognitive assessment tool) score of 7 (severely impaired). The physician order dated May 25, 2025, indicated, .Insulin Aspart (a type of insulin).5 unit (sic) subcutaneously one time a day.hold if blood sugar is below 200. The Medication Administration Record (MAR) for August and September 2025 were reviewed. Resident 38 was administered Aspart insulin 5 units subcutaneously on the following dates: - August 24, 2025, with a blood sugar of 147; - August 25, 2025, with a blood sugar of 105; - August 30, 2025, with a blood sugar of 188; - September 6, 2025, with a blood sugar of 150; - September 11, 2025, with a blood sugar of 198; - September 12, 2025, with a blood sugar of 190; - September 18, 2025, with a blood sugar of 125; - September 23, 2025, with a blood sugar of 133; and - September 24, 2025, with a blood sugar of 128. On September 25, 2025, at 9:33 a.m., a concurrent interview and record review was conducted with the Registered Nurse (RN). She stated Resident 38 had a diagnosis of diabetes and had an order for Aspart (a type of insulin), 5 (five) u (a unit of measurement) inject subcutaneously (injection into the fatty tissue beneath the skin) once a day. She stated the insulin had a parameter to hold the administration if the blood sugar is below 200. She stated Resident 38 was given insulin on the following dates: - August 24, 2025, with a blood sugar of 147; - August 25, 2025, with a blood sugar of 105; - August 30, 2025, with a blood sugar of 188; - September 6, 2025, with a blood sugar of 150; - September 11, 2025, with a blood sugar of 198; - September 12, 2025, with a blood sugar of 190; - September 18, 2025, with a blood sugar of 125; - September 23, 2025, with a blood sugar of 133; and - September 24, 2025, with a blood sugar of 128. The RN stated the licensed nurses should have held the insulin for blood sugar below 200. The RN stated Resident 38 could have experienced hypoglycemia when he received insulin with a blood sugar below 200. During an interview on September 25, 2025, at 10:05 a.m., with the DON, she stated the licensed nurses should follow the physician's order. The DON stated Resident 38 could have experienced hypoglycemia. She stated the licensed nurses should have followed the physician's order and should have held the insulin when Resident 38's blood sugar was below 200. 2b. On September 25, 2025, at 9:33 a.m., a concurrent interview and record review was conducted with the RN. She stated Resident 38 had a diagnosis of diabetes and had an order for Aspart (a type of insulin), 5 (five) u (a unit of measurement) inject subcutaneously (injection into the fatty tissue beneath the skin) once a day. She stated the insulin had a parameter to hold the administration if the blood sugar is below 200. She stated there was no documentation the licensed nurses notified the physician when Resident 38's blood sugar was below 200. She stated the standard of practice was to notify the physician if the residents' blood sugar was below the ordered parameter. During an interview on September 25, 2025, at 10:05 a.m., with the DON, she stated the expectation was for the license nurse to notify the physician when the blood sugar was below the ordered parameter so the physician could make the necessary adjustment to prevent hypoglycemia. A review of the facility's policy and procedure titled Administering Medications, revised April 2019, indicated .Medications are administered in a safe and timely manner, and as prescribed .

Based on observation, interview, and record review, the failed to ensure, for two of two medication carts inspected for medication storage:1.Discontinued medications for Residents 7, 35, and 5, were not stored in the medication cart readily available for use; and2.Unidentified medication pills that were not in their original containers or packaging were not stored in the medication cart drawer.These failures had the potential risk for the residents to receive medications that were either discontinued or compromised. Findings:1. On September 24, 2025, at 1:03 a.m., an observation, with a concurrent interview, and record review was conducted with Licensed Vocational Nurse (LVN) 3. An inspection of the Medication Cart (MC) 1 was conducted with LVN 3. LVN 3 stated all medications stored in MC 1 were readily available for use. The following discontinued medications were observed stored in MC 1:- For Resident 5, 31 tablets of clonidine (medication used to treat hypertension) 0.2 milligrams (mg-unit of measurement) take one tablet by mouth every 12 hours for hypertension. In a concurrent interview, LVN 3 stated this medication was discontinued in December 4, 2024;- For Resident 35, 14 tablets of ibuprofen (pain medication) 400 mg take one tablet by mouth every six hours as needed for mild pain. In a concurrent interview, LVN 3 stated this medication was discontinued in February 6, 2024, and-For Resident 35, three tablets of ondansetron (medication used to prevent nausea and vomiting) take one tablet by mouth every eight hours as needed for nausea. In a concurrent interview, LVN 3 stated this medication was discontinued in April 8, 2025.LVN 3 stated these discontinued medications should not have been stored in MC 1 and readily available for use. LVN 3 stated these should have been removed from MC 1 by the licensed nurse because it was discontinued.On September 24, 2025, at 12:14 p.m., an observation with a concurrent interview and record review was conducted with LVN 2. LVN 2 stated medications stored in MC 2 were readily available for use. The following discontinued medications were observed stored in MC 2: - For Resident 7, three tablets of alprazolam (medication used to treat anxiety) 0.25 mg one tablet every six hours as needed for anxiety. In a concurrent interview, LVN 2 stated this medication was discontinued in April 8, 2025. LVN 2 stated the discontinued alprazolam medication should have been removed from MC 2 and turned in to the Director of Nursing (DON) for destruction. The facility's policy and procedure titled, Discontinued Medications, dated November 2022, was reviewed. The policy indicated, .Staff shall destroy discontinued medications or return them to the dispensing pharmacy in accordance with the facility policy .The nurse receiving the order to discontinue a resident's medication is responsible for recording the information (e.g writing discontinued date, dating and initialing MAR {medication Administration record}) and notifying the dispensing pharmacy of the discontinuation .Discontinued medications are destroyed or returned to the issuing pharmacy in accordance with facility policy and state regulations . 2. On September 24, 2025, at 1:03 p.m., an observation, with a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 3. An inspection of the Medication Cart (MC) 1 was conducted with LVN 3. LVN 3 stated all medications stored in the MC 1 were readily available for use.During the medication cart inspection, nine unidentified medication pills were found stored and scattered in the medication cart drawer next to the residents' bubble pack medications. These unidentified medication pills were variable in color and size and were not in their original container or packaging.In a concurrent interview, LVN 3 stated he was not able to identify what the nine unidentified scattered pills were. LVN 3 stated these should have been destroyed and not stored in the medication cart.On September 24, 2025, at 2:36 p.m., an interview was conducted with the DON. The DON stated the scattered unidentified medication pills should not have happened. The DON stated the scattered unidentified medication pills stored in the medication cart were not safe. The facility's policy and procedure titled, Medication Labeling and Storage, dated February 2023 was reviewed. The policy indicated, .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls .Medication storage .medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received .The nursing staff is responsible for maintaining medication storage and preparation areas i a safe, clean, and sanitary manner .If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .

Based on interview and record review, the facility failed to ensure the Registered Dietician (RD) conducted comprehensive nutritional assessments on-site from August 12, 2025, to September 25, 2025.This failure had the potential for the residents not to receive the correct nutritional comprehensive assessment that could result in receiving suboptimal nutrition services which could lead to decreased nutrition for vulnerable residents residing at the facility.Findings:During an interview on September 24, 2025, at 9:57 a.m., with the Dietary Manager (DM), he stated the Registered Dietician worked 100% remotely. He stated the RD would get information from the electronic medical records of the residents. He stated the RD would talk to him and the Director of Nursing (DON) over the telephone to get information regarding the residents. He stated the RD did not do any on-site visit. He stated the last on-site visit of the previous RD was on August 11, 2025.During a telephone interview with the RD, she stated she worked 100% remotely. She stated the previous RD's last day was August 11, 2025. The RD stated she started to help in July 2025. She stated she was responsible for identifying significant weight changes, notifying the Interdisciplinary Team (IDT - a group of professionals from different fields who collaborate to work toward a common goal, sharing knowledge and expertise), conduct Minimum Data Set (MDS - an assessment tool) assessments, and nutrition assessments for newly admitted residents and if there were significant changes.The RD indicated she was not aware she needed to perform a full assessment in-person. The RD stated she would review all notes in the resident's electronic record and collaborated with the nurses, the DON and the DM by talking to them on the telephone. She also stated she would talk to the DON for IDT meetings on the telephone. She stated if she had recommendations, she would put it in the nutritional risk assessment.During an interview on September 29, 2025, at 2:53 p.m., with the Administrator (ADM), he stated the facility had an RD that would come to the facility on a regular basis but quit. He stated an RD that worked 100% remotely started around mid August 2025. He stated the RD communicated with the DM and the DON via email or the telephone.The following residents were assessed by the RD remotely:- Resident 54;- Resident 55;- Resident 56;- Resident 57; and- Resident 58.A review of the facility document titled PERSONNEL MANAGEMENT, dated 2018, indicated, RESPONSIBILITIES OF THE CONSULTANT DIETICIAN.A Consultant Dietician.is a staff member who provides regularly scheduled on-premises consultation, to the Administrator, the FNS (Food and Nutrition Supervisor), the residents, and other facility personnel and staff.A review of the undated facility document received by the facility ADM from (Name of Nutrition Consulting Firm) on September 25, 2025, titled Key Responsibilities of Registered Dietician, indicated, .Ensure compliance with all applicable state and federal regulations.

Based on observation, interview, and record review, the facility failed to ensure for one of one resident (Resident 10) food brought from home was consistent with the pureed diet (food mashed or blended to a smooth, pudding like consistency) as ordered by the physician.This failure had the potential for Resident 10 to have a choking incident as a result of eating the food brought by the family from home.Findings:On September 22, 2025, at 12:39 p.m., during a meal observation, Resident 10 was observed in bed. A meal tray was observed on top of Resident 10's bedside table. The meal tray had a plate with a pureed diet. A banana and green grapes in a plastic container were observed on top of the bedside table. In a concurrent interview with Resident 10, he stated the fruit was brought in by his family. He stated he ate the grapes occasionally. He also stated he was not sure why he was given baby food.On September 23, 2025, at 2:45 p.m., a plastic container with green grapes was observed on top of Resident 10's bedside table. Resident 10 was not in his room.On September 23, 2025, Resident 10's record was reviewed. Resident 10 was admitted to the facility on [DATE], with diagnoses which included anxiety disorder and diabetes (high blood sugar).The history and physical dated August 22, 2025, indicated Resident was alert, cooperative and had no signs of cognitive impairment.The physician's order dated August 9, 2025, indicated, .Regular diet, pureed texture.During an interview on September 24, 2025, at 3:08 p.m., with Certified Nursing Assistant (CNA) 1, she stated when the family brought food from home, the process was to check with the licensed nurse if the resident was allowed to eat the food that the family brought from home.During an interview on September 24, 2025, at 3:18 p.m., with the Director for Staff Development (DSD), he stated the staff should check food brought by the family to ensure the resident was allowed to have them. He stated a resident on a pureed diet could have a choking incident if they ate the regular food.On September 24, 2025, at 3:25 p.m., the Registered Nurse (RN) was interviewed. She stated Resident 10's diet order was regular with pureed texture. She stated Resident 10's family must have brought in fruit when they came to visit. She stated the certified nursing assistants and licensed nurses should be checking food brought from home. She also stated Resident 10 could choke from having regular food. In a concurrent record review with the RN, she stated Resident 10 was admitted under hospice care (end of life care) from home and was on pureed diet. She stated the hospice recertification period from September 17 to November 15, 2025, indicated Resident 10 was recently downgraded from mechanical soft to pureed due to aspiration (choking) risk.During an interview on September 24, 2025, at 3:48 p.m., with the Director of Nursing (DON), she stated the staff should verify food brought from outside by a family member or a visitor and check with the licensed nurse if the food was allowed to be consumed by the resident.The facility policy and procedure titled, Foods Brought by Family/Visitors, revised March 2022, indicated, .Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents.Foods that present a potential choking hazard for residents with impaired cognitive function or swallowing difficulty are taken from the resident and returned to the family/visitor.

Based on observation, interview, and record review, the facility failed to ensure the nebulizer (a small device that converts liquid medication into an inhalable mist) used to administer respiratory treatment was changed after seven days, in accordance with the facility policy and procedure, for one (Resident 12) of one resident reviewed for oxygen use. This failure had the potential to result in bacterial growth that could affect the health of the vulnerable resident population.Findings: During an observation on September 22, 2025, at 11:33 a.m., Resident 12 was observed in bed, awake and alert. A nebulizer set-up was observed in a clear plastic bag, hanging on the wall. The clear plastic bag was labeled with Resident 12's name, room number and a date of 8/25. During an observation on September 24, 2025, at 10:05 a.m., a clear plastic bag was observed hanging on the wall labeled with Resident 12's name, room number and a date of 8/25. During an interview on September 24, 2025, at 10:19 a.m., with the Respiratory Therapist (RT), he stated all respiratory equipment including oxygen canula (a device used to deliver supplemental oxygen) and nebulizer set-up should be changed every week. The RT verified Resident 12's nebulizer set-up had a date of 8/25. In a concurrent record review with the RT, he stated Resident 12 had an order for nebulized treatment every four hours as needed. The RT stated the licensed nurses gave Resident 12's nebulized treatment. He stated the licensed nurse should check the date when the nebulizer set-up was last changed. He stated the licensed nurse should have changed the nebulizer set-up once a week. During an interview on September 24, 2025, at 10:33 a.m., with the Registered Nurse (RN), she stated respiratory set-up should be changed once a week. The RN stated the RT was responsible for changing all respiratory set-up but the licensed nurse who administered the nebulized treatment should check the date of the set-up before administering the nebulized treatment. The licensed nurse should have changed the nebulizer set-up once a week. During an interview on September 24, 2025, at 10:51 a.m., with the Director of Nursing (DON), she stated the RT was responsible for changing the respiratory set-up and the licensed nurse could also change the respiratory set-up. The DON stated the licensed nurse should check the date when it was last changed. The licensed nurse should have changed the nebulizer set-up according to the facility policy and procedure. On September 24, 2025, Resident 12's record was reviewed. Resident 12 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD - a group of lung disease that block airflow and make it difficult to breathe). The physician order dated August 25, 2025, indicated, .Albuterol Sulfate (medication used to treat and prevent narrowing of the airways) 2.5 mg (mg - a unit of measurement) Inhale orally via nebulizer every 4 hours as needed for sob (shortness of breath)/cough. The Medication Administration Record (MAR) for September 2025, indicated Resident 12 received nebulized treatments on September 3, 4, 8, 9, 10, 11, 14, 15, 16, 17, and 21, 2025. The facility policy and procedure, titled, Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, indicated, .Change equipment and tubing every seven days, or according to facility protocol.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was below five percent (%) when three medication errors out of 28 opportunities was observed for one of six residents (Resident 33) observed for medication administration.This failed facility practice resulted in a medication error rate of 10.71 percent (3 errors out of 28 opportunities) and has the potential for Resident 33 to experience the side effects of the medications not given as prescribed by the physician.Findings: On September 24, 2025, at 8:45 a.m., a medication pass observation on Resident 33 was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was observed verifying medication with the physician's orders in the electronic Medication Administration Record (eMAR) as she prepared the following medications:- One tablet of Metoprolol (medication used to treat high blood pressure) 25 milligrams (mg- unit of measurement);- One tablet of Lisinopril (medication used to treat high blood pressure) 10 mg;- One tablet of Calcium 500 mg ( calcium supplement);- One gel cap of docusate sodium (stool softener) 100 mg;- One tablet of Mirabegron Extended Release (medication used to treat overactive bladder) 50 mg;- One tablet of Ferrous sulfate (iron supplement) 325 mg;- Two tablets of potassium chloride (potassium supplement) ER (extended release) 20 mEq (milliequivalent - unit of measurement). The potassium chloride ER had a medication label instruction to give with food;- One tablet of celecoxib (pain medication) 200 mg. The celecoxib had a medication label instruction to give with food.- One capsule of gabapentin (medicating used to treat nerve pain) 300 mg;- One tablet of Dicyclomine (anti-spasmodic medication that works by relaxing muscles of the stomach and intestines to reduce cramping)) 10mg 1 tab;- One tablet of cranberry tablet (supplement) 425 mg;- One capsule of fish oil (supplement) 1000 mg; and- One capsule of acidophilus (medication used to help restore the normal balance of intestinal bacteria).On September 24, 2025, at 9:04 a.m., LVN 1 administered these medications to Resident 33. LVN 1 was observed to have administered the medications potassium chloride ER and celecoxib without food.On September 24, 2025, Resident 33's record was reviewed. Resident 33 was admitted to the facility on [DATE], with diagnoses including osteoarthritis (swelling and tenderness of one or more joints causing joint pain and stiffness), generalized abdominal pain, and Gastroesophageal Reflux Disease (GERD - happens when stomach acid flows back up to the esophagus causing a burning sensation in the chest.The active physician orders indicated the following:-Potassium Chloride ER Tab to be given 40 mEq by mouth and with food one time a day for potassium supplement, date ordered June 22, 2021;-Celecoxib Capsule 200 mg give 1 capsule by mouth two times and with food a day for pain management, date ordered July 20, 2021); and-Ferrous Sulfate Tablet 325 give 1 tablet by mouth and with food two times a day for anemia (a problem of not having enough health red blood cells to carry oxygen to the body tissues), date ordered June 22, 2021.On September 24, 2025, at 9:11 a.m., an interview was conducted with Resident 33. Resident 33 stated her last meal was at 7 AM this morning and she did not have snacks between breakfast and up until the time she took her morning medication with LVN 1 at 9:04 a.m.On September 24, 2025, at 9:14 a.m., an interview with a concurrent record review was conducted with LVN 1. LVN 1 reviewed Resident 33's physician orders for potassium chloride ER, celecoxib, and ferrous sulfate. LVN 1 stated she did not administer these medications with food to Resident 33 as ordered by the physician. LVN 1 stated Resident 33 may experience a GI (gastrointestinal) upset if these medications were taken without food. LVN 1 stated she should have administered these medications with food to Resident 33 as ordered by the physician.On September 25, 2025, at 9:10 a.m., an interview with a concurrent review was conducted with the Director of Nursing (DON). the DON reviewed Resident 33's physician orders for potassium chloride ER, celecoxib, and ferrous sulfate. The DON stated LVN 1 should have administered these medications with food as ordered by the physician. The DON stated if these medications were not administered with food, Resident 33 may experience stomach upset. The DON stated Resident 33 is at high risk of experiencing stomach upset because her diagnosis of chronic abdominal pain and GERD.According to the DailyMed (web based drug information reference):- .potassium chloride capsule, extended release .DOSAGE AND ADMINISTRATION .Because of the potential for gastric irritation .should be taken with meals .;- .CELEBREX (brand name of celecoxib capsule) .Gastrointestinal Risk .CELEBREX cause an increased risk of serious gastrointestinal adverse events including bleeding, ulceration (process of open sore forming on the skin or mucous membrane), and perforation (a hole or tear on the lining of the stomach) of the stomach or intestines, which can be fatal .; and-ferrous sulfate 325 mg .DIRECTIONS .Adults and children over 12 years age .1 tablet daily preferably with a meal or as directed by a doctor .The facility's policy and procedure titled, Administering Medications, dated April 2019 was reviewed. The policy indicated, .Medications are administered in a safe and timely manner, and as prescribed .medications are administered in accordance with prescriber's orders, including required timeframe .

Based on observation, interview, and record review, the facility failed to ensure one of six residents (Resident 33) observed for medication pass, was free from significant medication error when the medications celexocib (pain medication), potassium chloride (potassium supplement) ER (Extended Release), and ferrous sulfate tablet supplement, were not administered with food as ordered by the physicianThis failure had the potential for Resident 33 to experience the side effects of these medications. Findings:On September 24, 2025, at 8:45 a.m., a medication pass observation on Resident 33 was conducted with Licensed Vocational Nurse (LVN) 1. Included in the morning medications prepared by LVN 1 for Resident 33 were the following medications that had an instruction to give with food:- One tablet of Ferrous sulfate 325 milligrams (mg-unit of measurement);-One tablet of celecoxib 200 mg; and-Two tablets of potassium chloride ER 20 mEq (milliequivalent - unit of measurement).On September 24, 2025, at 9:04 a.m., LVN 1 administered these medications to Resident 33 without food. On September 24, 2025, at 9:11 a.m., an interview was conducted with Resident 33. Resident 33 stated her last meal was at 7 AM this morning and she did not have snacks between breakfast and up until the time she took her morning medication with LVN 1 at 9:04 a.m.On September 24, 2025, at 9:14 a.m., an interview with a concurrent record review was conducted with LVN 1. LVN 1 reviewed Resident 33's physician orders for potassium chloride ER, celecoxib, and ferrous sulfate. LVN 1 stated she did not administer these medications with food to Resident 33 as ordered by the physician. LVN 1 stated Resident 33 may experience a GI (gastrointestinal) upset if these medications were taken without food. LVN 1 stated she should have administered these medications with food to Resident 33 as ordered by the physician.On September 24, 2025, Resident 33's record was reviewed. Resident 33 was admitted to the facility on [DATE], with diagnoses including osteoarthritis (swelling and tenderness of one or more joints causing joint pain and stiffness), generalized abdominal pain, and Gastroesophageal Reflux Disease (GERD - happens when stomach acid flows back up to the esophagus causing a burning sensation in the chest)The current physician orders indicated the following:-Potassium Chloride ER Tab 40 mEq to be given by mouth and with food one time a day for potassium supplement, date ordered June 22, 2021; -Celecoxib Capsule 200 mg give 1 capsule by mouth and with food two times a day for pain management, date ordered July 20, 2021); and-Ferrous Sulfate Tablet 325 give 1 tablet by mouth and with food two times a day for anemia (a problem of not having enough health red blood cells to carry oxygen to the body tissues), date ordered June 22, 2021.The following care plans indicated: .Resident is at risk for GI distress or bleeding related to diagnosis of GERD .Revision Date .06/7/2025 .The resident will remain free from discomfort, complications or s/sx (symptoms) related to dx (diagnosis) of GERD .Give medications as ordered. Monitor/document side effects and effectiveness . Resident is at risk for low Hgb (hemoglobin- protein found in red blood cell that carries oxygen throughout the body)- and Hct (hematocrit - percentage of red blood cells in a person's blood) decreased total body iron content below normal levels related to ANEMIA Revision Date 06/19/2025 .Give medications as ordered. Monitor for side effects, effectiveness .Resident has potential for Alteration in Comfort/Pain related to: Chronic Pain Syndrome, Positioning discomfort, Osteoarthritis .Revision Date 06/07/2025 .Administer pain medication as per orders .On September 25, 2025, at 9:10 a.m., an interview with a concurrent review was conducted with the Director of Nursing (DON). the DON reviewed Resident 33's physician orders for potassium chloride ER, celecoxib, and ferrous sulfate. The DON stated LVN 1 should have administered these medications with food as ordered by the physician. The DON stated if these medications were not administered with food, Resident 33 may experience stomach upset. The DON stated Resident 33 is at high risk of experiencing stomach upset because of her diagnosis of chronic abdominal pain and GERD.According to the DailyMed (web based drug information reference):- .potassium chloride capsule, extended release .DOSAGE AND ADMINISTRATION .Because of the potential for gastric irritation .should be taken with meals .;- .CELEBREX (brand name of celecoxib capsule) .Gastrointestinal Risk .CELEBREX cause an increased risk of serious gastrointestinal adverse events including bleeding, ulceration (process of open sore forming on the skin or mucous membrane), and perforation (a hole or tear on the lining of the stomach) of the stomach or intestines, which can be fatal .; and-ferrous sulfate 325 mg .DIRECTIONS .Adults and children over 12 years age .1 tablet daily preferably with a meal or as directed by a doctor .The facility's policy and procedure titled, Administering Medications, dated April 2019, was reviewed. The policy indicated, .Medications are administered in a safe and timely manner, and as prescribed .medications are administered in accordance with prescriber's orders, including required timeframe .

Based on observation, interview, and record review, the facility failed to ensure the diet order was followed according to physician's order for one of 52 residents reviewed (Resident 5), when Resident 5 was observed to receive a pureed diet on September 22, 2025, during lunch.This failure had the potential to compromise Resident 5's nutritional and medical condition.Findings:On September 22, 2025, at 12:06 p.m., during meal observation, Resident 5 was observed in the dining room, lying in a Geri chair (geriatric chair - a recliner chair for individuals with limited mobility). Resident 5 was observed to have his lunch while being fed by Certified Nursing Assistant (CNA) 2. Resident 5 was observed to have a pureed diet (mashed or blended to a smooth, pudding-like consistency). In a concurrent interview with CNA 2, she stated she fed Resident 5 a pureed diet. Resident 5's meal ticket was verified with CNA 2. The laminated meal ticket indicated, .Resident's name.CCHO (Consistent Carbohydrate - diet with consistent amount of carbohydrates), regular consistency. The laminated meal ticket had Pureed, written in black marker.On September 24, 2025, Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing).Resident 5's Minimum Data Set (MDS - an assessment tool) indicated a BIMS (Brief Interview for Mental Status - a cognitive screening assessment tool) score of 3 (severe impairment).The physician order dated July 2, 2025, indicated, .CCHO diet, Mechanical Soft texture (a modified diet that consists of foods that are easy to chew and swallow), Regular consistency.Resident 5's Care Plan revised September 24, 2025, indicated, .Focus.Resident has alteration in nutritional status.Diet.CCHO diet, Mechanical Soft texture.Interventions/Tasks.Provide, serve diet as ordered.During an interview on September 24, 2025, at 12:33 p.m., with CNA 2, CNA 2 stated she fed Resident 5 lunch on September 22, 2025, and on September 23, 2025. CNA 2 stated Resident 5 had pureed diet on both days. CNA 2 stated on September 22, 2025, and September 23, 2025, Resident 5's laminated meal ticket had Pureed, written with black marker. She stated today (September 24, 2025) was the first time she saw Resident 5 receive a mechanical soft diet.During a concurrent interview and record review on September 24, 2025, at 12:40 p.m., with the Dietary Manager (DM), he stated he changed the laminated meal ticket for Resident 5 on September 23, 2025. He stated a staff member informed him Resident 5's laminated meal ticket had a smear from a black marker. He stated Resident 5 had an order for a CCHO, mechanical soft diet. The DM stated he was not aware Resident 5 was receiving a pureed diet. He stated Resident 5 should not have received a pureed diet when Resident 5's diet was changed to mechanical soft on July 2, 2025.During a concurrent interview and record review on September 24, 2025, at 2:39 p.m., with the Director of Nursing (DON), she stated Resident 5 had a diet order of CCHO diet, mechanical soft. She stated the expectation was for Resident 5 to receive the correct diet. She stated the nurses should be checking the resident's diet order list before the meal trays were passed. The DON stated the physician's order should be followed. She also stated she expected the DM to supervise the kitchen staff to ensure the residents were receiving the diet ordered by the physician.The facility policy and procedure titled, Therapeutic Diets, dated October 2017, indicated .Therapeutic diets are prescribed by the attending physician to support the resident's treatment.and in accordance with his/her goals.A therapeutic diet must be prescribed by the resident's attending physician.A therapeutic diet is considered a diet ordered by a physician.as part of treatment for a disease or clinical condition.

Based on observation, interview and record review, the facility failed to follow infection control measures for one of five residents reviewed for infection control (Resident 3) when one staff member was observed providing care for a resident (Resident 3) on Enhanced Barrier Precautions (EBP - measures used to reduce and prevent infections) without wearing recommended Personal Protective Equipment (PPE). This failure had the potential to result in spreading infection to a vulnerable resident population. On September 25, 2025, at 9:04 a.m., Licensed Vocational Nurse (LVN) 3 was observed entering Resident 3's room and handling her feeding tube (a tube inserted in the stomach, used to deliver nutrition for residents who cannot eat). LVN 3 was observed not wearing appropriate PPE (gown) when handling the feeding tube of Resident 3. An isolation cart was observed outside the room of Resident 3, with PPE readily available for staff to use (including gowns), and a posted sign indicating Resident 3 was on EBP.In a concurrent interview, LVN 3 stated Resident 3 was on EBP precautions, and she should have worn a protective gown when disconnecting the feeding tube of Resident 3. LVN 3 stated the PPE was needed to prevent infections.On September 25, 2025, at 9:22 a.m., the Director of Staff Development (DSD) was interviewed. The DSD stated LVN 3 should have worn appropriate PPE (gown) when handling the feeding tube of Resident 3, who was on EBP precautions. The DSD stated the gown was needed to prevent cross-contamination due to exposure to bodily fluids.Resident 3's record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty swallowing), gastrostomy (a surgical procedure that creates an opening in the stomach through the abdominal wall), and dementia (decline in mental capacity).The physician's order dated July 9, 2025, indicated, .Enhanced Bariier (sic) precautions related medical device - G-tube.The care plan for Resident 3, revised on January 13, 2025 indicated, .Enhanced Bariier (sic) precautions related medical device - G-tube. PPE: Gowns and Gloves during care . A review of the facility policy titled, Enhanced Barriers Precautions, revised December, 2025, indicated, .Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents.Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities .Enhanced barrier precautions apply when .A resident .has a wound or indwelling medical devices .Indwelling medical devices include .feeding tubes .EBPs employ targeted gown and glove use .

Based on observation, interview and record review, the facility failed to ensure the posted nurse staffing data was complete when the actual hours were not calculated and posted on a daily basis.This failure resulted in complete staffing information not being readily available to residents and the public.Findings:On July 17, 2025, at 8:35 a.m., an unannounced visit was made to the facility to investigate a complaint.On July 17, 2025, a review of the facility documents titled, Census and Direct Care Services Hours Per Patient Day (DHPPD) dated, July 7 thru July 16, 2025, indicated projected (Estimated) hours were documented. The lower portion of the document indicated, .Actual Direct Care Service Hours and DHPPD This section must be completed at the end of each 24-hour patient day. The sections for the actual direct care service hours, average patient census, actual DHPPD, actual total CNA (Certified Nursing Assistant) direct care service hours and actual CNA DHPPD were blank. On July 17, 2025, at 1:44 p.m., an interview was conducted with the Director of Staff Development (DSD), who stated, he is responsible for calculating and posting the DHPPD hours daily. The DSD stated, he does not calculate and document the Actual DHPPD hours, until the day after payday, because he does not have access to payroll hours, until then. The DSD stated paydays are on the 10th & 25th of the month.A review of the facilities DHPPD hours, observed posted on the wall at the North side Nurses Station, dated, July 17, 2025, untimed, indicated, a projection of the scheduled DHPPD hours met the minimum required hours. Further review indicated, no Actual hours were documented. On July 17, 2025, at 4:17 p.m., a concurrent interview with the DSD, and record review of the DHPPD posted hours, dated July 17, 2025, was conducted. The DSD verified, Actual hours were not calculated or documented, stating, he does not post the Actual hours from current or prior day, as he does not have access to payroll hours, until the day after paydays.

Based on interview and record review, the facility failed to ensure wound care treatments were provided to meet the needs of residents when four sampled residents ' (Residents 1, 2, 3, and 4) were not provided wound care treatment in accordance with the physician ' s orders. This failure had the potential for Resident 1, Resident 2, Resident 3, and Resident 4 ' s wounds to worsen and could lead to serious complications. Findings: On June 25, 2025, at 9:37 a.m., Resident 1 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), hypertension (high blood pressure), osteomyelitis right foot (bone infection), and chronic kidney disease (gradual loss of kidney functions). A review of Resident 1 ' s Order Summary Report from April 1, 2025, to June 25, 2025, indicated the following: a. Clean right foot stump wound with Normal Saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled. One time a day for wound care until 05/16/2025. Start date: 05/09/2025. b. Cleanse right foot stump wound with Normal Saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled. One time a day for wound care until 05/23/2025. c. Cleanse right foot stump wound with normal saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled. One time a day for wound care until 05/30/2025. d. Cleanse right foot stump wound with normal saline and pat dry apply betadine and cover with kerlix and secure with tape. Change as needed if becomes soiled. One time a day every other day for wound care for 14 days. Start date 05/31/2025 End date 06/14/2025. A review of Resident 1 ' s Treatment Administration Record (TAR) for the month of May 2025, indicated treatment for the right foot stump was not signed as provided on May 14, 16, and 17, 2025, at 9 a.m. On June 25, 2025, at 10:58 a.m., Resident 2 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included low back pain, congestive heart failure (heart can ' t pump blood well enough leading to fluid (congestion) build up in body), and hypertension (high blood pressure). A review of Resident 2 ' s TAR for the month of May 2025 indicated the following: a. Cleanse left heel wound with normal saline apply Betadine and leave area open to air. One time a day for wound management until 05/09/2025, Start date:05/03/2025. The TAR has no documentation indicating treatment for the left heel was provided on May 4,2025. b. Cleanse left heel wound with normal saline apply Betadine and leave area open to air. One time a day for wound management until 05/23/2025, Start Date: 05/16/2025. The TAR has no documentation indicating treatment was provided for the left heel on May 17, 2025. c. Cleanse left heel blister with normal saline and pat dry and apply betadine and leave open to air. One time a day for a wound care to left heel blister until June 6, 2025. The TAR has no documentation indicating treatment was provided to the left heel blister on May 31, 2025. On June 25, 2025, at 11:38 a.m., Resident 3 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), chronic obstructive pulmonary disease (lung disease that makes it hard to breath), and dysphagia (difficulty swallowing). A review of Resident 3 ' s TAR for the month of May 2025 indicated the following: a. Cleanse left great toe with normal saline and pat dry and apply triple Antibiotic and leave open to air. One time a day for treatment to left great toe for 14 days, Start Date: 05/16/2025. The TAR has no documentation indicating treatment was provided on May 16 and 17, 2025. On June 25, 2025, at 9:37 a.m., Resident 4 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included subdural hemorrhage (blood collects in brain), gangrene (death of body tissue), palliative care (specialized medical care). A review of Resident 4 ' s TAR for the month of May 2025 indicated the following: a. Left foot 4th gangrene toe. Cleanse with NS wound cleanser, pat dry, then apply betadine. Cover with clean dry dressing daily and prn for dislodgement and soiled dressing. Every 48 hours for wound care to left foot until 05/30/2025, Start date: 05/15/2025. The TAR has no documentation indicating treatment was provided to the left foot 4th great toe on May 17, 2025. On June 25, 2025, at 1:03 p.m., an interview and concurrent record review was conducted with the Treatment Nurse. The Treatment Nurse stated there was no documented evidence that the wound treatment was administered on Resident 1's right foot stump on May 14, 15, nd 17, 2025. The TN verified as well that no treatment was provided for Resident 2's left heel wound on May 4, 17, and 31, 2025. For Resident 3's left great toe, the treatment nurse verified no treatment was documented on May 16 and 17, 2025; and For Resident 4's left foot 4th gangrene toe, no treatment was provided on May 17, 2025. The Treatment Nurse stated that wound treatments should have been administered to Resident 1, Resident 2, Resident 3, and Resident 4. On June 25, 2025, at 2:04 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON verified there was no documented evidence that the wound treatment was administered on Resident 1, Resident 2, Resident 3, and Resident 4. The DON stated the facility process is for nursing to follow all physician orders and document that the order has been performed in the resident ' s chart. The DON stated that wound treatment should have been administered to Resident 1, Resident 2, Resident 3, and Resident 4. A review of the facility policy and procedure titled Charting and Documentation, revised July 2017, indicated .The following information is to be documented in the resident medical record .treatments or services performed . documentation of procedures and treatments will include care-specific details .date .time .procedure/treatment . assessment .unusual findings .resident tolerance of the treatment .refusal . signature .title of individual documenting .

Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes) when one of three sampled residents (Resident 1) was transferred to a general acute care hospital. This failure has the potential for the Ombudsman not be able to advocate for the residents in protecting their rights from inappropriate transfer and discharge. Findings: A review of Resident 1 ' s admission record indicated resident was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar), hypertension (high blood pressure), osteomyelitis right foot (bone infection), and chronic kidney disease (gradual loss of kidney functions). Further review of the record indicated the resident was transferred to an acute care hospital on June 10, 2025. A review of Resident 1 ' s Progress Note date June 10, 2025, at 1:45 p.m., indicated .received new orders .Resident sent out to[name of hospital] .gangrene right foot .physician made aware .resident family made aware . A review of Resident 1 ' s SBAR (Situation, Background, Assessment, and Recommendation) dated June 10, 2025, indicated .resident returned from medical appointment .received new orders to transfer resident to Inland Valley Hospital .gangrene right foot . On June 25, 2505, at 1:41 p.m., an interview and concurrent record review was conducted with the Social Worker (SW). The SW stated Resident 1 was transferred to a general acute care hospital on June 10, 2025, for gangrene of the right foot. The SW verified there was no documented evidence the ombudsman was notified of Resident 1's transfer to the hospital. The SW further stated the ombudsman should be notified of transfers and she should have followed up on the transfer to assure the ombudsmen was notified. On June 25, 2505, at 1:46 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON) and the Administrator. The DON stated the facility process is for nursing to fax the ombudsman when a resident is being transferred or discharged and the SW is to follow up on all transfer and discharge for notification of the ombudsman. The DON stated the ombudsman should have been notified. The Administrator verified there was no documented evidence the ombudsman was notified of Resident 1 transfer June 10, 2025. The Administrator stated the facility should have notified the ombudsman of Resident 1 transfer. A review of the facility policy and procedure titled Transfer or Discharge, Facility-Initiated, dated October 2022, indicated .Notice of Transfer or Discharge .when residents are sent emergently to an acute care setting .the notice is given as soon as it is practicable but before the transfer or discharge .Notice of Transfer is provided to the resident .resident representative .as soon as practicable before the transfer .(LTC) ombudsman when practicable .monthly list of residents .includes all notice content requirements .

Based on observation, interview, and record review, the facility failed to ensure safe storage practice was followed in accordance with the professional standards of practice when a gallon of chocolate syrup with an open date of October 19, 2023, was found on top of the kitchen overhead counter, readily available for use. This failure had the potential to cause food-borne illnesses in a medically vulnerable population who consumed food in the facility. Findings: On May 12, 2025, at 12:12 p.m., during a brief kitchen tour with the Dietary Manager (DM), a gallon of chocolate syrup with an open date of October 19, 2023, was found on top of the kitchen overhead counter, readily available for use. In a concurrent interview with the DM, he stated the chocolate syrup should have been discarded one year after it was opened on October 19, 2023. He stated the chocolate syrup was only good for one year once opened. The DM stated the chocolate syrup should have been thrown away so the kitchen staff will not use it. He also stated expired food can cause stomach upset or stomach illnesses. On May 12, 2025, at 4:45 p.m., during a telephone interview with the Registered Dietician, she stated the facility should follow the guidelines for storing dry goods with regards to expiration dates and open dates. She stated there should be no expired food or food stored in the kitchen longer than the shelf like, whether it was opened or not. A review of the facility document titled, DRY GOODS STORAGE GUIDELINES, dated 2018, indicated, .FOOD ITEM .Chocolate Syrup .OPENED ON SHELF .6 (six) months .

Based on observation, interview and record review, the facility failed to ensure activities were being provided to 48 of 48 residents ( Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48) residing in the facility. This failure resulted in psychosocial harm for four residents (Resident 1, Resident 2, Resident 3, and Resident 12). Residents 1, 2, 3, and 12; verbalized being bored, frustrated, and felt no joy while at the facility. In addition, this failure to provide activities had the potential to cause psychosocial harm to 44 of 48 residents who were not being offered activities ( Residents 4, 5, 6, 7, 8, 9, 10, 11,13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48). On May 9, 2023, at 9:53 p.m., an Immediate Jeopardy (IJ-a crisis in which the health and safety of individuals are at risk) was identified and called in the presence of the Administrator (ADM) due to lack of activities and a qualified Activities Director. The facility failed to complete activity assessments for 48 residents for six months and update the care plans for 48 residents for a resident centered care plan concerning activity. On May 11, 2023, at 5:24 p.m., the facility submitted an acceptable removal plan which indicated: Immediate Action Plan Upon notice of the deficient practice, the facility immediately began to implement a plan to provide activity programs designed to meet the needs of each resident daily. To prevent recurrence of the deficient practice, the following immediate interventions will be initiated immediately on May 10, 2023. The facility reviewed its Activity Programs Policy and Procedure to ensure an activities program is available and geared to meet individual residents' needs to prevent psychosocial harm. The facility will ensure to address individual resident preferences during activity assessment. The facility will ensure that activities are scheduled 7 (seven) days a week. The facility immediately assigned a staff member to provide activities and to ensure the activities posted on the calendar are followed. The facility hired an activities assistant on 5/11/2023, to ensure activities are provided 7 (seven) days a week. The facility has posted an advertisement as of 5/6/2023, seeking a qualified Activities Director to fill the current partial vacancy of the position. The facility has hired an interim qualified Activities Director will oversee the Activities Program until the facility can hire a permanent qualified Activities Director. The facility's interim qualified Activities Director completed Activity Assessments for all residents residing in the facility on 5/11/2023. Facility will initiate monthly QAPI (Quality Assurance Program Improvement) on resident activity program, DON and Administrator will validate effectivity of QAPI program. Facility will submit QAPI protocols during the next QA committee meeting for approval and review. To ensure that the facility interventions are maintained, the following will be performed: Facility will review, monthly, QAPI program for monitoring of resident activity program. Management will re-evaluate effectivity of interventions in place and will perform updates as needed. On May 11, 2023, at 6:22 p.m., the immediate jeopardy was lifted in the presence of the ADM, after observation, interviews, and record reviews were conducted to ensure the removal plan was implemented. The facility was notified that an extended survey would be conducted due to substandard quality of care issue. Findings: On May 6, 2023, at 10:00 a.m.; during observation, the activity room was noted to be empty. No staff members were observed providing activities. On May 6, 2023, at 10:20 a.m., Resident 2 was interviewed. Resident 2 stated the facility has not offered him any activities for months, he stated there is, really nothing to do, it ' s so boring and frustrating to be stuck inside with nothing to do. On May 6, 2023, at 10:50 a.m., Resident 12 was interviewed. Resident 12 stated he was not going to activities because the facility did not have any. He stated he has nothing to do during the day, he stated, this is no way to exist. On May 6, 2023, at 11:15 am, Resident 13 was interviewed. Resident 13 stated no one from the facility checked on them except for mealtimes. Resident 13 stated it would be nice to do other activities instead of watching television in her room. On May 6, 2023, at 11:23 a.m., Resident 1 was interviewed. Resident 1 stated there were no staff providing activities, she stated the facility has nothing fun to do, she has no joy and would really like to move to another facility. On May 6, 2023, at 11:30 a.m., an interview with the Social Services Director (SSD 1) was conducted. SSD 1 stated she was originally hired as the Activity Director and shortly after being hired she transitioned to the SSD position. She stated the facility has not had an Activity Director for about eight months. She stated she is going to complete the Activity Director course in the future but currently she does not have the credentials that an Activity Director requires. On May 6, 2023, at 11:55 a.m., Certified Nursing Assistant (CNA) 5 was interviewed. CNA 5 stated there were no activities being provided. She stated she has worked in activities as an assistant at another facility and she knew it is important for the residents. CNA 5 further stated she would not be able to provide activities and do her CNA duties. On May 6, 2023, at 2:21 p.m., Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated there were no activities being provided at the facility on a routine basis. She stated the activity calendar was not followed. On May 9, 2023, at 2:30 p.m., the Director of Nursing (DON) was interviewed. The DON stated the facility did not have an Activity Director. She stated the activities on the calendar were not being offered. On May 6, 2023, at 3:15 p.m., Resident 3 was interviewed. Resident 3 stated he was never offered any activities, he stated he finds it hard to stay motivated. Resident 3 stated he was able to get around in his wheelchair, but he felt sorry for the residents who are stuck in their rooms. On May 6, 2023, at 3:30 p.m., Resident 4 was interviewed. Resident 4 stated there were no activities offered at the facility. A review of Residents 1, 2, 3, 4, 12, and 13 ' s records indicated no progress notes were documented related to activities, no activity evaluations were present, and no care plan had been initiated related to activity preferences. On May 6, 2023, at 7:18 p.m., the Administrator (ADM) was interviewed. The ADM stated there were no Activity Assistants or Activity Director currently hired at the facility. The activity assessments for the residents were not completed and the residents preferences have not been updated recently. A review of the facility policy and procedure titled, Activity Programs dated August 2006, indicated, .Activity programs designed to meet the needs of each resident are available on a daily basis .Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident ' s needs .Activities are scheduled 7 (seven) days a week and residents are given the opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs .

Based on observation, interview, and record review, the facility failed to ensure a system was in place in ensuring supervision was provided for 10 of 10 residents (Residents 1, 3, 4, 5, 6, 7, 8, 9,10, 11) during smoking activities. The facility disclosed being a non-smoking facility; however, had allowed residents to smoke cigarettes unsupervised while at the facility. The facility has no policy and procedure in place on how to manage residents smoking cigarettes. This failure of the facility resulted in Resident 3 sustaining burn on her nose while smoking without supervision. In addition, this failure could potentially jeopardize the health and safety of the other nine residents (Residents 1, 4, 5, 6, 7, 8, 9, 10, and 11) while smoking cigarettes. This resulted in an immediate jeopardy situation. On May 9, 2023, at 9:47 p.m., an Immediate Jeopardy (IJ-a crisis in which the health and safety of individuals are at risk) was identified and called in the presence of the Administrator (ADM) due to the facility failure of not having an updated policy and procedure addressing the facility process in managing residents smoking cigarettes, the facility was allowing 10 residents (Residents 1, 3, 4, 5, 6, 7, 8, 9, 10, and 11) to smoke without safety measures in place, and not providing supervision during smoking activities. On May 11, 2023, at 5:24 p.m., the facility submitted an acceptable removal plan which indicated: Immediate Action Plan Upon notice of the deficient practice, the facility immediately began in-servicing staff members regarding the facility smoking policy with emphasis on the facility's policy that all smoking sessions will be supervised by facility staff members. Additionally, staff was educated that all smoking will be conducted in designated smoking areas. In-services are expected to be completed by 5/11/2023. Employees who are off will be in-serviced before starting their next shift. Residents who smoke shall wear a smoking apron designated to retard combustion if they are found to be not safe (i.e., drop cigarettes or do not handle the ashes properly.) To prevent recurrence of the deficient practice, the following immediate interventions will be initiated immediately on May 9, 2023. The facility implemented a new smoking policy and procedure on 5/10/2023 to ensure safe smoking practices for the residents. The facility will ensure that residents are accurately assessed, and care plans developed and/or updated related to smoking. Resident smoking assessments were updated or completed on 5/10/2023. Staff was immediately assigned to monitor residents to ensure resident smoking is conducted in accordance with the policies and procedures of the facility at designated smoking times. Staff collected all smoking paraphernalia when the issue was identified. Staff assigned to monitor residents who smoke will collect all smoking paraphernalia after each designated smoking break. DON/Designee, and Administrator and designee started to in-service the facility staff on May 9, 2023, to discuss the facility's smoking policy with emphasis on the facility's policy that all smoking sessions will be supervised by facility staff members. Additionally, staff was educated that all smoking will be conducted in designated smoking areas. Facility will initiate monthly QAPI (Quality Assurance and Performance Improvement) on resident smoking and assessment, DON and Administrator will validate effectivity of QAPI program. Facility will submit QAPI protocols during the next QA committee meeting for approval and review. On May 11, 2023, at 6:22 p.m., the immediate jeopardy was lifted in the presence of the ADM, after observation, interview, and record reviews were conducted to ensure the removal plan was implemented. The facility was notified that an extended survey would be conducted due to substandard quality of care issue. Findings: On May 9, 2022, at 10:45 a.m., during an observation of the facility smoking area, two residents (Resident 1 and Resident 4) were noted to be smoking unsupervised. No smoking aprons were observed to be in use on the residents, and Resident 4 was observed retrieving a lighter from his pocket and lighting his cigarette. On May 9, 2023, at 11:23 a.m., during an observation and concurrent interview with Resident 3, she was observed outside in her wheelchair smoking a cigarette unsupervised. Resident 3 stated she burned her nose lighting a cigarette while she was smoking outside on May 2, 2023. She stated that would go out to smoke when she wanted to and kept her lighter with her. Resident 3 stated that she has her lighter and pulled it out of her pocket. A review of Resident 3's records indicated the resident was admitted to the facility on [DATE], with diagnoses that included Type 2 diabetes mellitus (disease in which the blood glucose, or blood sugar, levels are too high), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and chronic pain, A review of Resident 3's Smoking Safety Risk Assessment, dated August 10, 2021, indicated, .May independently be able to carry cigarettes, tobacco only, no matches/lighter . A review of Resident 3's Safe Smoking Assessment, dated August 10, 2021, indicated, The resident can light and smoke a cigarette or other smoking device while demonstrating a safe technique for putting out the matches or lighter and disposing of ash .IDT (Interdisciplinary Team) Determination, Safe Smoker . A review of Resident 3's care plan initiated on March 15, 2022, and revised on July 25, 2022, indicated .The resident is a smoker .The resident will not suffer injury from unsafe smoking practices .The resident will not smoke without supervision .The resident's cigarette will be kept in locked drawer. Resident will not have any lighters on her person . A review of Resident 3's Progress notes, written by Licensed Vocational Nurse (LVN) 1, on May 2, 2023, indicated, Resident has a burn on her nose, I asked resident what happened, resident stated over the weekend she burned herself with an electric lighter, trying to light a cigarette .Explained to resident that she is not to have a lighter or cigarettes on her person as our policy states there is smoking times and activities will go out with resident and they hold the cigarettes and lighter and she must obey the rules of our facility, resident stated she understands and will not happen again . A review of Resident 3's Change in Condition Evaluation (COC), written by LVN 1, dated May 2, 2023, indicated, Burn under the section titled Skin Status Evaluation and apply tao (Triple Antibiotic Ointment) bid (Twice a day) x 14 days, under the section titled Recommendations of Primary Clinicians. A review of Resident 3's record did not indicate a care plan was developed to address the incident when the resident sustained a burn injury on her nose. A review of Resident 3's Progress notes, written by the Social Services Director (SSD 2), on May 2, 2023, at 12:47 p.m., indicated, Went to resident's room to discuss the new smoking policy. Noticed a small mark on her nose and asked how she got it. She stated that she borrowed a lighter from a Nurse and had burned it while lighting her cigarette. Charge Nurse informed and our treatment Nurse came in to see Resident while this writer was still in the room. Inservice regarding our smoking policy was reviewed with Resident. A review of Resident 3's Medication Administration Record (MAR) for May 2023, indicated the resident received wound treatment for Burn; nose .cleanse with normal saline and pat dry . daily from May 2, 2023, to May 9, 2023. On May 9, 2023, at 11:15 a.m., during a concurrent observation and interview with LVN 1, a plastic tub was noted on top of the medication cart at the nursing station containing residents' cigarettes and lighters. LVN 1 stated, the tub had been out since she started her shift at 7:00 a.m., she stated the tub should not be out and accessible, it should have been locked away. A concurrent review of a posted sign at the nurse's station was conducted with LVN 1, the sign posted indicated, smoking is supervised by the activity assistant at the following times: 8:20 a.m., 10:00 a.m., 12:30 p.m., 2:00 p.m., 3:30 p.m., and by an available CNA (Certified Nursing Assistant) on duty at 6:00 p.m. LVN 1 stated, there is a guy who usually oversees the residents while they smoke, but she had not seen him today. She did not know who was supervising the residents while they smoke. On May 9, 2023, at 2:30 p.m., the Director of Nursing (DON) was interviewed. The DON stated if the facility has smoking aprons, they would be outside on the smoking patio. She stated the facility had always allowed residents to smoke since she started working at the facility. The DON stated she was hired at the facility in January 2023. On May 9, 2023, at 3:15 p.m., during an observation and concurrent interview with Resident 1, he was noted to be outside in his wheelchair on the smoking patio, he stated he keeps his cigarettes and lighter in his room so that he can go out to smoke whenever he wants to. A review of Resident 1's records indicated he was admitted to the facility on [DATE], with diagnoses that included history of pulmonary embolism (a blood clot that develops in a blood vessel in the body), pulmonary hypertension, (a condition of increased blood pressure in the arteries of the lungs). and hypertension, (when the pressure in your blood vessels is too high). A review of Resident 1's progress notes dated March 19, 2023, at 9:59 p.m., indicated, .resident (Resident 1) went to another residents room with cigarettes and a lighter, both shut the door and lit up and started smoking, room that [name of resident] was in had a O2 concentrator on .admin made aware. A review of Resident 1's Smoking Safety Risk Assessment, dated April 27, 2023, indicated incomplete assessment. A review of Resident 1's Safe Smoking Assessment, dated April 27, 2023, indicated incomplete assessment. A review of Resident 1's record indicated no documented care plan was develop related to Resident 1's smoking. On May 9, 2023, at 3:30 p.m., during an observation and concurrent interview with Resident 4, he was noted to be in his wheelchair outside on the smoking patio, he stated he kept his cigarettes and lighter in his room so that he could go out to smoke when he feels like it. A review of Resident 4's records indicated he was admitted to the facility on [DATE], with diagnoses that included congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 4's progress notes dated April 27, 2023, at 12:59 p.m., indicated, Resident continues to be noncompliant with smoking. He has been told many times if he is going to smoke it must be in the facility smoking area. He has been found more than once smoking in his room . A review of Resident 4's Smoking Safety Risk assessment dated [DATE], indicated, .Not capable of even supervised smoking secondary to severe impairment . A review of Resident 4's Safe Smoking assessment dated [DATE], indicated, .The resident cannot light and smoke a cigarette while demonstrating a safe technique for putting out matches or lighter and disposing of ash .IDT Determination .The resident is determined to be an unsafe smoker and is required to wear a protective vest/apron .The IDT determines the degree of supervision the resident needs while smoking: Constant . A review of Resident 4's progress notes dated May 3, 2023, at 1:04 p.m., indicated, Resident was caught smoking in his room by staff. All smoking paraphernalia was confiscated from him and locked up with the Charge Nurse . A review of Resident 4's plan of care indicated no documentation indicating a care plan was developed to address Resident 4's smoking. On May 9, 2023, at 3:35 p.m., during an observation and concurrent interview with Resident 8, she was noted to be alone, outside in her wheelchair smoking a cigarette. Resident 8 stated, she could wheel herself outside to smoke. A review of Resident 8's records indicated she was admitted to the facility on [DATE], with diagnoses that included Cellulitis, Kidney Dialysis, Anemia, Type 2 Diabetes Mellitus, Hypertension and Generalized Edema. A review of Resident 8's Safe Smoking Assessment, dated August 8, 2021, indicated the assessment was not completed. A review of Resident 8's Smoking Safety Risk Assessment, dated August 10, 2021, indicated the assessment was not completed. On May 9, 2023, at 3:30 p.m., during an observation and concurrent interview with Resident 11, he was noted to be outside smoking a cigarette on the smoking patio. Resident 11 stated, he would go out to smoke when he wanted to, and the staff were not always there to supervise. A review of Resident 11's records indicated he was admitted to the facility on [DATE], with diagnoses that included heart failure, and hypertension. A review of Resident 11's Safe Smoking assessment dated [DATE], indicated the assessment was not completed. A review of Resident 11's Smoking Safety Risk assessment dated [DATE], indicated the assessment was not completed. A review of Resident 11's care plan indicated no entry related to smoking. During a review of the plan of care for Resident 6, Resident 7, and Resident 9. There were no care plans noted related to smoking for Resident 6, Resident 7, and Resident 9. On May 9, 2023, at 7:18 p.m., during a concurrent interview and review of the undated facility smoking policy titled, Smoking Policy and Procedure, with the Administrator (ADM), he stated residents should be always supervised when they are smoking. He stated the facility has a fire extinguisher, smoking blankets, and smokeless ashtrays but he is not sure if they have any aprons. He further stated the cigarettes and lighters should be locked away when not in use. The ADM reviewed the facility smoking policy indicating the facility is a non-smoking facility for residents and he stated the policy was not current. The ADM stated he was aware of Resident 3's burn from smoking and stated Resident 3 should not have her lighter on her person. A review of the facility policy and procedure titled Smoking Policy and Procedure undated, indicated, This facility is a NON-SMOKING facility for residents and Residents MAY NOT carry any type of smoking materials .

Based on observations, interviews, and record reviews, the facility failed to maintain an environment that meets professional standards for food service safety and ensure the residents' food was prepared under sanitary conditions, when: 1. Unpasteurized eggs (have not been heat treated to eliminate bacteria), served to two(Residents 2 and 4) of 49 residents on oral diet , were not cooked to ensure all parts of the eggs were completely firm to eliminate the risk of Salmonella infection (bacterial disease that affects the intestinal tract. usually caused by eating raw or undercooked meat poultry or eggs and can be life-threatening in older adults where complications can be dangerous). This failure to cook unpasteurized eggs so that all parts of the eggs were completely firm when serving to residents had the potential to result in food-borne illness such as salmonella to these two residents who were part of the highly susceptible population of 49. 2. Multiple food items stored at the overhead kitchen counter were expired, with no expiration date indicated and one food item was not refrigerated.; 3. Multiple food items stored inside Refrigerators 1 and 2, were not labeled with opened dates, use-by dates or discard dates, and with item's name. ; 4. The kitchen stove-oven hood had an accumulation of a thick black substance inside the panel.; 5. The kitchen sink had no soap available ready for use. These failures had the potential to result in cross contamination and food-borne illness in a highly susceptible resident population of 49, who were on oral diet. On [DATE], at 4:06 p.m., the Administrator, the Director of Nursing (DON), the Administrator Designee, the Dietary Services Supervisor (DSS); and the Registered Dietitian (RD), were verbally notified that an immediate jeopardy situation (situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) existed regarding the failure to fully cook an unpasteurized egg yolk which was served to two residents during the breakfast meal. This failure to fully cook unpasteurized eggs, so that all parts of the eggs were completely firm when serving to residents, had the potential to result in serious harm to these two residents who were part of the highly susceptible population. On [DATE], at 5:07 p.m., the facility presented to the California Department of Public Health (CDPH) with an acceptable plan of action that indicated the following: All unpasteurized eggs in the facility have been removed and discarded. The facility will conduct 72-hour monitor of the two affected residents that had consumed the un-fully cooked pasteurized (sic) eggs to ensure there are no negative outcomes. Facility will only purchase pasteurized eggs to avoid risk of using unpasteurized eggs to ensure no reoccurrence. Dietary staff will check all deliveries to confirm compliance on a daily basis. Dietary staff has been in-serviced on the proper cooking process of eggs and have been educated on how to recognize and differentiate between pasteurized and unpasteurized eggs. Dietary staff will receive continued in-service and education regarding use of pasteurized eggs only. Dietary Supervisor, the Administrator, and the Registered Dietician (sic) will continue to monitor and check dietary supplies routinely to ensure compliance. On [DATE], at 1:46 p.m., the immediate jeopardy was removed, in the presence of the Administrator and the DON, after the facility implemented the plan of action. Findings: 1. On [DATE], at 10:15 a.m., during a concurrent tour of the facility kitchen and interview with the Dietary Services Supervisor (DSS), Refrigerator 1 was observed to contain a box of 16 fresh shell eggs. The eggs did not have a distinguishing mark to indicate whether the eggs were pasteurized (pasteurized eggs would have a marked with a red letter P on the shell). The box did not indicate whether the 16 unmarked eggs were pasteurized. The DSS verified the 16 fresh shell eggs was unmarked with a letter P on the shell. The DSS asked, What is pasteurized eggs? Upon further observation, the outside box (containing the 16 unmarked fresh shell eggs) indicated, SAFE HANDLING INSTRUCTIONS: To prevent from bacteria .cook eggs until yolks are firm and cook foods containing eggs thoroughly. On [DATE], at 7:25 a.m., during a concurrent kitchen observation and interview with Cook 1, eight cracked eggs were observed on top of the kitchen counter table. She stated there were four residents who requested sunny side up eggs (fried with the yolk up and is not flipped) for breakfast. Cook 1 confirmed the eight cracked eggs were unpasteurized, and she cooked sunny side up eggs. She stated the sunny side up eggs were served to four residents. On [DATE], at 7:32 a.m., during a concurrent observation and interview, Resident 2's tray had two fried eggs with runny yolks. Resident 2 stated that he got fried egg with runny yolks everyday. A review of the medical record, indicated Resident 2 was [AGE] years old, and was admitted to the facility on [DATE], with diagnoses which included heart failure, [CONDITION(S)] (high cholesterol), kidney failure, and chronic kidney disease (Longstanding disease of the kidneys leading to renal failure). A review of Resident 2's MDS (Minimum Data Set- a comprehensive assessment tool completed by the facility) indicated the resident had a BIMS score (Brief Interview for Mental Status score) of 15, indicating no cognitive (memory) problem. On [DATE], at 8:58 a.m., during a concurrent observation and interview with Resident 4 in his room, the resident's tray (Resident 4) included two fried eggs with runny yolks. Resident 2 stated that he got fried eggs with runny yolks every day. A review of the medical record, indicated Resident 4 was [AGE] years old, and was admitted to the facility on [DATE], with diagnoses which included disorder of the kidney and heart failure. A review of Resident 4's MDS indicated the resident had a BIMS score of 14, indicating no cognitive (memory) problem. On [DATE], at 4 p.m., during an interview with the Registered Dietician (RD), the RD stated she was unaware the facility was using unpasteurized eggs, and that the facility should be using pasteurized eggs. On [DATE], at 4:30 p.m., during review of the facility's food purchase invoices and concurrent interview with the DSS, the DSS verified that the last time shell eggs were delivered was on [DATE]. A review of the food purchase invoice, dated [DATE], indicated the shell eggs were not pasteurized. The DSS verified they were not pasteurized and stated these were the same shell eggs in Refrigerator 1, observed on [DATE]. Further review of the facility's food purchase invoices indicated a case (15 dozen = 180 eggs) of unpasteurized eggs were also delivered on the following dates: - [DATE]; - [DATE]; - [DATE]; - [DATE]; - [DATE]; and - [DATE]. Concurrently, the DSS verified this invoice and confirmed the eggs were not pasteurized. A review of the 2017 FDA Food Code, although foodborne illness can be severe or even fatal, milder cases are often not detected through routine surveillance. Eggs are still a major source of Salmonella infections, causing outbreaks when they are combined or undercooked, so special precautions need to be in place with those most susceptible to foodborne illness. The Food Code defines a highly susceptible population as persons who are more likely than other people in the general population to experience foodborne disease because they: 1. have compromised immune system .or are older adults; and 2. obtaining food at a facility that provides services such as custodial care, health care, or assisted living .hospital or nursing home . A review of a document titled, Food Facts, from the U.S. Food and Drug Administration (FDA), dated [DATE], indicated, .Fresh eggs, even those with clean, uncracked shells may contain bacteria called Salmonella (group of bacteria which is a common cause of food poisoning) that can cause food borne illness .The FDA requires that all cartons of shell eggs that have not been treated to destroy Salmonella - to carry the safe handling statement: Safe handling instructions, to prevent illness from bacteria, keep eggs refrigerated, cook yolks until yolks are firm and cook foods containing eggs thoroughly .Eggs that have been treated to destroy Salmonella- by in-shell pasteurization(eggs are heated in warm water bath using controlled time and temperature, to destroy any bacteria that may be present) .are not required to carry safe handling instructions .Preparing .Cook eggs until both the yolk and the white are firm. Scrambled eggs should not be runny .For recipes that call for eggs that are raw or undercooked when the dish is served, like Caesar salad dressing and homemade ice cream: - use either shell eggs that have been treated to destroy Salmonella, by pasteurization or another approved method, or pasteurized egg products . A review of information on Salmonella from the Centers for Disease Control and Prevention (CDC) guideline, titled, Salmonella and Eggs, last reviewed on February 16, 2021, indicated, .The inside of eggs that appear normal can contain a germ Salmonella that can make you sick, especially if you eat raw or lightly cooked eggs. Eggs are safe when you cook and handle them properly. How can I reduce my chance of getting a Salmonella infection .Cook eggs until both the yolk and white are firm .Make sure that foods that contain raw or lightly cooked eggs .are made only with pasteurized eggs (eggs rapidly heated and held at a minimum required temperature at a specified time,in order to reduce food-borne illness in dishes that are not cooked or that are only lightly cooked). A review of the facility policy and procedure titled, PROCEDURE FOR REFRIGERATED STORAGE, dated 2019, indicated, .Raw eggs shall be obtained pasteurized . 2. On [DATE], beginning at 9:45 a.m., to 11:30 a.m.,during the initial kitchen tour with Cook 2 and the Dietary Service Supervisor (DSS) the following were observed, at 9:45 a.m., at the overhead kitchen counter: - one chocolate syrup, with expiration date [DATE]; - one can low sodium beef flavored base, unable to distinguish the expiration date. The label indicated keep refrigerated. - three loaves of bread, with no open date; - one large plastic container 36 oz (ounce - unit of measurement) thickener, with expiration date of [DATE]; - one gallon of barbecue sauce, with no expiration date; and - one small can of chicken flavor base, with no expiration date. On [DATE], at 10:15 a.m., in an interview with the DSS, the DSS confirmed the food items have no expiration date or no discard date. The DSS stated, they should be discarded. 3. On [DATE], beginning at 10:15 a.m., to 11:30 a,m., during the initial kitchen tour with the DDS, the following were observed, at 10:20 a.m., a) Inside Refrigerator 1, the following food items were observed with no use-by date or discard date: - two liter of soup- has no discard date; - one one liter of olives- has no discard date; - two liters of blueberries- has no discard date; - two liters of plums- has no discard date; - two liters of jam- has no discard date; - one gallon of sweet pickles- has no discard date; - one gallon of pickle relish-opened on [DATE], but discard date was [DATE]; - three liters of gelatin- has no discard date; - one liter of pudding- has no discard date - two liters of pears-has no discard date; - 32 oz of sour cream- has no discard date; and - five lbs. (pounds) of garlic has no discard date. b) Inside Refrigerator 2, the following food items were observed, at 10:20 a.m., unlabeled (no open date, no prepared date, and no discard date): - eight cups of milk (three 8 oz cups, four 6 oz cups, one 4 oz cup); - three 4 oz cups of orange juice; - six 4 oz cups of strawberry juice; - three 4 oz cups of cranberry juice; - two 8 oz cups of strawberry juice; - three small bowl cup of apple sauce; - one pack of cilantro; - one plastic pitcher of cranberry juice; and - three pounds of fresh mushroom. During a concurrent interview, the DSS confirmed the items inside Refrigerators 1 and 2 were not labeled with the prepared date, opened date, use-by date or discard date. The DSS stated the items should have been labeled with the prepared date, opened date, use-by date or discard date. The facility's policy and procedure titled, LABELING AND DATING OF FOODS, dated 2020, was reviewed. The policy indicated, .Food delivered to facility needs to be marked with a received date .Newly opened food items will need to be closed and labeled with an open date and used by the date follows guidelines .All prepared foods need to be covered, labeled and dated . Produce is to be dated with received date .Leftovers will be covered, labeled and dated . 3. On [DATE], at 10:33 a.m., during kitchen observation with DSS, the kitchen stove-oven hood had an accumulation of a thick black substance inside the panel. In a concurrent interview with the DSS, she confirmed there was a thick black substance on the kitchen stove-oven hood. The DSS was asked when was the last time the oven hood was cleaned. The DSS stated she was not sure because the Administrator was the one who scheduled the cleaning for the facility's kitchen stove-oven hood by an outside cleaning company. The facility was not able to provide documentation indicating when and who was responsible in cleaning the facility kitchen stove-oven hood. 4. On [DATE], at 9:45 a.m., during kitchen observation and concurrent interview with Cook 2 the handwashing sink inside the kitchen had no soap. The DSS confirmed there was no soap at the kitchen sink, and she stated there should always be a soap in the kitchen sink. On [DATE], at 10:15 a.m., an observation and concurrent interview with the Dietary Services Supervisor (DSS), the handwashing sink inside the kitchen had no soap. The DSS confirmed there was no soap at the kitchen sink, and she stated there should always be a soap in the kitchen sink. A review of the 2017 US FDA (United States Food and Drug Administration) Food code, Food employees shall use the following cleaning procedure in the order stated to clean their hands .(1) Rinse under clean, running warm water; (2) Apply an amount of cleaning compound recommended by the cleaning compound manufacturer; (3) Rub together vigorously for at least 10 to 15 seconds while: (a) Paying particular attention to removing soil from underneath the fingernails during the cleaning procedure, and (b) Creating friction on the surfaces of the hands and arms .finger tips, and areas between the fingers; (4) Thoroughly rinse under clean, running warm water; and (5) Immediately follow the cleaning procedure with thorough drying .(without) re-contaminating their hands .

Based on observation, interview, and record review, the facility failed to provide on-going skin assessment, monitoring, and provide necessary interventions, for one of four residents' (Resident 30), reviewed for pressure ulcer, when the resident developed pressure injuries (Stage 1 on the right malleolus, Stage 2 on the right buttock, Stage 1 on the left upper buttock, Stage 3 on the left buttock and Stage 1 on the left posterior knee) and non-pressure injuries (open wound with yellowish dark brown discharge on the right foot 3rd, 4th, and 5th toes). On November 5, 2021, at 5:15 p.m., the Administrator, and the Director of Nursing (DON), were verbally notified of the immediate jeopardy situation (situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident), due to the facility's failure to assess, identify, and provide interventions for one resident's (Resident 30) pressure and non-pressure injuries. These failures resulted in a pressure injury (right heel) evolving from a Stage 2 to a Stage 3 pressure injury, while at the facility. In addition, these failures increased the risk for infection which could eventually lead to [CONDITION(S)] (blood poisoning), tissue necrosis, gangrene, and osteomylitis for Resident 30. On November 8, 2021, at 7:30 a.m., the facility presented an acceptable plan of action which included the following: a. the facility immediately assessed the patient and performed a head-to- toe assessment to identify other skin issues which includes pressure sores. b. The facility immediately notified the primary physician and wound physician of the skin condition and reported each site and received order for wound treatment. c. The resident was re-assessed for pain and needs for pain management. d. Registered dietitian re-evaluated the resident for nutritional needs. e. The DON, Licensed Vocational Nurse (LVN), and designee started to perform skin checks to all residents on November 5, 2021. f. Weekly skin sweep to be performed by the treatment nurse to identify future skin conditions. g. The DON/designee and the Administrator started to in-service the nursing staff on November 5, 2021, on wound protocol, skin checks and skin checks forms; h. CNAs (Certified Nursing Assistant) would complete daily skin check each shift starting November 5, 2021. On November 8, 2021, at 10:11 a.m., the immediate jeopardy was removed in the presence of DON, the Administrator, and the Administrator designee, after verification of implementation of the plan of action. The facility was notified that an extended survey would be conducted due to substandard quality of care issue. Findings: On November 1, 2021, at 11:35 a.m., an observation and a concurrent interview was conducted with Resident 30. The resident was observed lying on a flat regular mattress (mattress not designed to prevent and treat pressure wounds), was alert and verbally coherent. The resident stated he required moderate to extensive assistance in bed mobility and transfer. Resident 30 stated he had a skin problem on his buttocks. On November 5, 2021, a review of Resident 30's record, indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 30's MDS (Minimum Data Set, a comprehensive assessment tool), indicated the resident had a BIMS score (Brief Interview for Mental Status score) of 15, indicating no cognitive problem. A review of the progress notes dated September 3, 2021, indicated, .Skin .Pressure ulcer .Left malleolus Pressure ulcer Stage: Stage II .Right heel Pressure ulcer Stage: Stage II . A review of the Order Summary Report for the month of September 2021, indicated the following: a. August 25, 2021, TX (treatment): Cleanse Lt (left) lateral Malleolus (ankle)with NS (normal saline- mixture of salt and water), pat dry, apply barrier cream cover with dry dressing then wrap with kerlix, secure with tape for pressure ulcer, everyday shift for 31 days. b. August 25, 2021, TX: Cleanse Right Heel with NS, pat dry, apply barrier cream, cover with dry dressing then wrap in kerlix, secure with tape for Pressure ulcer, everyday shift for 31 days. c. September 1, 2021, TX: Cleanse RT (right) heel with NS, pat dry, apply Xeroform, wrap with Kerlix then secure with tape for Pressure ulcer, everyday shift for 21 days. A review of the MDS (Minimum Data Set- an assessment tool) dated September 17, 2021, Section M, titled, Determination of Pressure Ulcer/ Injury risk, indicated no unhealed pressure ulcers. (pressure injury on the right heel was documented with new treatment order on 9/1/2021). A review of the care plan for Pressure Ulcer on Left lateral Malleolus, developed on September 1, 2021, indicated interventions which included: monitor ulcers for signs of progression or declination, and provide wound care per treatment order. There was no Treatment Administration Record (TAR - form to document treatment) for August 1 to 31, 2021, to reflect the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the care plan for Pressure ulcer on Left upper buttock developed on October 13, 2021, indicated interventions which included: monitor ulcers for signs of progression or declination, and provide wound care per treatment order. A review of Resident 30's physician order, dated October 27, 2021, indicated, Cleanse Rt (right) Heel with NS, apply Medi Honey (medication to treat pressure injury), and non-adherent pad then cover with kerlix (bandage roll dressing) and secure with tape for Pressure Ulcer. everyday shift for 21 days. A review of Resident 30's progress report dated October 29, 2021, indicated, .Right heel Stage 2, left upper buttock Stage 1 . The progress note did not reflect any other pressure injuries. A review of TAR dated October 1 to 31, 2021, indicated that no treatment was completed for Resident 30's right heel and left upper buttock pressure injury. A review of the facility documents titled, SHOWER SKIN ASSESSMENT, and WEEKLY BODY CHECKLIST, dated June 15, 2021, to October 28, 2021, indicated no documentation the CNAs identified and reported to the licensed nurses, the following skin issues of Residents 30's: Site #2 - Right malleolus (ankle) pressure ulcer Stage 1. Site #3 - Right buttock pressure ulcer Stage 2. Site # 5 - Left buttock pressure ulcer Stage 3. Site # 6- Left posterior knee pressure ulcer Stage 1. Site ## 7- open wounds with yellowish dark brown discharge in between the 3rd, 4th, and 5th toes of the right foot. On November 5, 2021, at 10:15 a.m., the DON and Licensed Vocational Nurse (LVN) 2 were interviewed. LVN 2 and the DON were unable to provide a TAR for November 2021. The DON and LVN 2 confirmed no TAR sheet in the binder and in the medical record of Resident 30. In a concurrent interview, LVN 2 stated she was not currently (November 2021) providing wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On November 5, 2021, at 10:35 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated Resident 30 had an open skin area on the buttocks area. On November 5, 2021, at 10:50 a.m., the DON was interviewed. The DON stated, I did not know the resident (Resident 30) has a pressure ulcer (pressure injury). On November 5, 2021, at 10:55 a.m., the Medical Record Director (MRD) was interviewed. The MRD was asked for Resident 30's TAR for November 2021. The MRD was not able to locate November 2021 skin treatment sheet or TAR for Resident 30. On November 5, 2021, at 2 p.m., during skin assessment and inspection of Resident 30 with the DON and LVN 2, multiple pressure injuries and non-pressure injuries were identified. The following were observed during the body skin check: Site # 1 - Stage 3 pressure injury of the right heel measuring 3.5 cm x 1.5 cm x 0.3 cm (centimeter - unit of measurement) in depth. Site # 2 - Stage 1 pressure injury of the right malleolus (ankle) measuring 3 cm x 2 cm. Site # 3 - Stage 2 pressure injury of the right buttock measuring 1.5 cm x 1 cm x 0.1 cm in depth. Site # 4 - Stage 1 pressure injury of the left upper buttock measuring 15 cm x 20 cm. Site # 5- Stage 3 pressure injury of the left buttock (with yellow slough measuring 3 cm x 3/4 cm x 0.3 cm in depth. Site # 6 - Stage 1 pressure injury of left posterior knee pressure ulcer measuring 6 cm x 6 cm, with a 5 cm scratch mark on the center. Site # 7- open wounds with yellowish dark brown discharge in between the 3rd, 4th, and 5th toes of the right foot. Upon completion of Resident's 30's body assessment, the new pressure injuries (right malleolus, right buttock, left buttock with yellow slough, and the left posterior knee) and one old pressure injury (left upper buttock) did not have treatment orders. There was no treatment provided for the open wound with yellowish dark brown discharge in between the 3rd, 4th, and 5th toes of the right foot. On November 5, 2021, at 2:25 p.m., LVN 2 was interviewed. LVN 2 stated she was not aware Resident 30 had pressure injuries. LVN 2 stated she had never done any wound treatments for Resident 30. On November 5, 2021, at 2:35 p.m., the Administrator (ADM), the Administrator Designee (ADMD), and the DON were interviewed. The DON stated Resident 30 was high risk for skin breakdown. The DON stated the resident developed an in-house pressure injury (facility acquired, or facility develop pressure ulcer). On November 5, 2021, at 3:40 p.m., the DON was interviewed. The DON was asked if the licensed nurses had been providing wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, if the licensed nurses did not sign or initial the treatment sheets, it was not done. The DON further stated, if there is no documentation, then it was not done. There was no documented evidence of an on-going assessment and monitoring of resident' skin. There was no documented evidence a wound care treatment was provided for Resident 30's right malleolus, right buttock, left upper buttock, left buttock, left posterior knee; and the open wounds with yellowish dark brown discharge in between the 3rd, 4th, and 5th toes of the right foot. A review of the physician orders indicated the following: -For September 2021. - There were no physician treatment orders for wound on the right malleolus (ankle) pressure ulcer Stage 1, right buttock pressure ulcer Stage 2, right foot: 2 sites were infected, left buttock pressure ulcer Stage 3, and left posterior knee pressure ulcer Stage 1, and the open wounds on the right foot. For October 2021. - There were no physician treatment orders for wound on right malleolus (ankle) pressure ulcer Stage 1, right buttock pressure ulcer Stage 2, right foot: 2 sites were infected, left buttock pressure ulcer Stage 3, left posterior knee pressure ulcer Stage 1, and the open wounds on the right foot. For November 1 to 5, 2021. - There were no physician treatment orders for pressure injuries on the right malleolus (ankle) pressure ulcer Stage 1, right buttock pressure ulcer Stage 2, right foot: 2 sites were infected, left buttock pressure ulcer Stage 3, left posterior knee pressure ulcer Stage 1, and the open wounds on the right foot. A review of the Nurses Progress Notes, beginning August 8, 2021, to November 4, 2021, indicated no documented evidence the facility consistently assessed, monitored wound status, and provided the necessary care and treatment on the following skin problems: Site #2 - Stage 1 Right malleolus (ankle) pressure injury. Site #3 - Stage 2- Right buttock pressure injury. Site # 4 - Stage 1 pressure injury of the left upper buttock. Site # 5 - Stage 3-Left buttock pressure injuries. Site # 6 - Stage 1-left posterior knee pressure injuries. Site # 7- the open wounds on the right foot. On November 8, 2021, at 11:17 a.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 stated she was not aware Resident 30 had a pressure injury. LVN 3 stated, nothing was reported to me. There was no documentation the facility's IDT (Interdisciplinary Team - a group of staff meeting and working together for the benefit of the resident) meet for the prevention, care, treatment, services and management for Resident's 30 pressure ulcer. The facility policy and procedure titled, Prevention of Pressure Ulcers, dated October 2010, was reviewed. The policy indicated the following: General Guidelines .The facility should have a system/procedure to assure assessments are timely, and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed . Interventions and Preventive Measures .Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown .Immediately report any signs of developing pressure ulcer to the supervisor .The care process should include effort to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate .

Based on observation, interview and record review, the facility failed to ensure resident was free from neglect, when on-going skin assessment, monitoring and necessary interventions were not provided for one of four residents' (Resident 30) pressure (Stage 1 on the right malleolus, Stage 2 on the right buttock, Stage 1 on the left upper buttock, Stage 3 on the left buttock and Stage 1 on the left posterior knee and non-pressure injuries (open wound with yellowish dark brown discharge on the right foot 3rd, 4th, and 5th toes and dry scab on the left anterior lower knee). These failures resulted in a pressure injury (right heel) evolving from a Stage 2 to a Stage 3 pressure injury, while at the facility. In addition, these failures increased the risk for infection which could eventually lead to [CONDITION(S)] (blood poisoning), tissue necrosis, gangrene, and osteomylitis for Resident 30. Findings: On November 1, 2021, at 11:35 a.m., an observation and a concurrent interview was conducted with Resident 30. The resident was observed lying on a flat regular mattress (mattress not designed to prevent and treat pressure wounds), was alert and verbally coherent. The resident stated he required moderate to extensive assistance in bed mobility and transfer. Resident 30 stated he had a skin problem on his buttocks. On November 5, 2021, a review of Resident 30's record, indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 30's MDS (Minimum Data Set, a comprehensive assessment tool), indicated the resident had a BIMS score (Brief Interview for Mental Status score) of 15, indicating no cognitive problem. A review of the progress notes dated September 3, 2021, indicated, .Skin .Pressure ulcer .Left malleolus Pressure ulcer Stage: Stage II .Right heel Pressure ulcer Stage: Stage II . A review of the Order Summary Report for the month of September 2021, indicated the following: a. August 25, 2021, TX (treatment): Cleanse Lt (left) lateral Malleolus (ankle)with NS (normal saline- mixture of salt and water), pat dry, apply barrier cream cover with dry dressing then wrap with kerlix, secure with tape for pressure ulcer, everyday shift for 31 days. b. August 25, 2021, TX: Cleanse Right Heel with NS, pat dry, apply barrier cream, cover with dry dressing then wrap in kerlix, secure with tape for Pressure ulcer, everyday shift for 31 days. c. September 1, 2021, TX: Cleanse RT (right) heel with NS, pat dry, apply Xeroform, wrap with Kerlix then secure with tape for Pressure ulcer, everyday shift for 21 days. A review of the MDS (Minimum Data Set- an assessment tool) dated September 17, 2021, Section M, titled, Determination of Pressure Ulcer/ Injury risk, indicated no unhealed pressure ulcers. (pressure injury on the right heel was documented with new treatment order on 9/1/2021). A review of the care plan for Pressure Ulcer on Left lateral Malleolus, developed on September 1, 2021, indicated interventions which included: monitor ulcers for signs of progression or declination, and provide wound care per treatment order. There was no Treatment Adminitration Record (TAR - forms to document treament) for August 1 to 31, 2021, to reflect the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the care plan for Pressure ulcer on Left upper buttock developed on October 13, 2021, indicated interventions which included: monitor ulcers for signs of progression or declination, and provide wound care per treatment order. A review of Resident 30's physician order, dated October 27, 2021, indicated, Cleanse Rt (right) Heel with NS, apply Medi Honey (medication to treat pressure injury), and non-adherent pad then cover with kerlix (bandage roll dressing) and secure with tape for Pressure Ulcer. everyday shift for 21 days. A review of Resident 30's progress report dated October 29, 2021, indicated, .Right heel Stage 2, left upper buttock Stage 1 . The progress note did not reflect any other pressure injuries. A review of TAR dated October 1 to 31, 2021, indicated that no treatment was completed for Resident 30's right heel and left upper buttock pressure injury. A review of the facility documents titled, SHOWER SKIN ASSESSMENT, and WEEKLY BODY CHECKLIST, dated June 15, 2021, to October 28, 2021, indicated no documentation the CNAs identified and reported to the licensed nurses, the following skin issues of Residents 30's: Site #2 - Right malleolus (ankle) pressure ulcer Stage 1. Site #3 - Right buttock pressure ulcer Stage 2. Site # 5 - Left buttock pressure ulcer Stage 3. Site # 6- Left posterior knee pressure ulcer Stage 1. Site # 7- open wounds with yellowish dark brown discharge in between the 3rd, 4th, and 5th toes of the right foot. On November 5, 2021, at 10:15 a.m., the DON and Licensed Vocational Nurse (LVN) 2 were interviewed. LVN 2 and the DON were unable to provide a TAR for November 2021. The DON and LVN 2 confirmed no TAR sheet in the binder and in the medical record of Resident 30. In a concurrent interview, LVN 2 stated she was not currently (November 2021) providing wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On November 5, 2021, at 10:35 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated Resident 30 had an open skin area on the buttocks area. On November 5, 2021, at 10:50 a.m., the DON was interviewed. The DON stated, I did not know the resident (Resident 30) has a pressure ulcer (pressure injury). On November 5, 2021, at 10:55 a.m., the Medical Record Director (MRD) was interviewed. The MRD was asked for Resident 30's TAR for November 2021. The MRD was not able to locate November 2021 skin treatment sheet or TAR for Resident 30. On November 5, 2021, at 2 p.m., during skin assessment and inspection of Resident 30 with the DON and LVN 2, multiple pressure injuries and non-pressure injuries were identified. The following were observed during the body skin check: Site # 1 - Stage 3 pressure injury of the right heel measuring 3.5 cm x 1.5 cm x 0.3 cm (centimeter - unit of measurement) in depth. Site # 2 - Stage 1 pressure injury of the right malleolus (ankle) measuring 3 cm x 2 cm. Site # 3 - Stage 2 pressure injury of the right buttock measuring 1.5 cm x 1 cm x 0.1 cm in depth. Site # 4 - Stage 1 pressure injury of the left upper buttock measuring 15 cm x 20 cm. Site # 5- Stage 3 pressure injury of the left buttock (with yellow slough measuring 3 cm x 3/4 cm x 0.3 cm in depth. Site # 6 - Stage 1 pressure injury of left posterior knee pressure ulcer measuring 6 cm x 6 cm, with a 5 cm scratch mark on the center. Site # 7- open wounds with yellowish dark brown discharge in between the 3rd, 4th, and 5th toes of the right foot. Upon completion of Resident's 30's body assessment, four new pressure injuries (right malleolus, right buttock, left buttock with yellow slough, and the left posterior knee) and one old pressure injury (left upper buttock) did not have treatment orders. There was no treatment provided for the open wound with yellowish dark brown discharge in between the 3rd, 4th, and 5th toes of the right foot. On November 5, 2021, at 2:25 p.m., LVN 2 was interviewed. LVN 2 stated she was not aware Resident 30 had pressure injuries. LVN 2 stated she had never done any wound treatments for Resident 30. On November 5, 2021, at 2:35 p.m., the Administrator (ADM), the Administrator Designee (AD), and the DON were interviewed. The DON stated Resident 30 was high risk for skin breakdown. The DON stated the resident developed an in-house pressure injury (facility acquired, or facility develop pressure ulcer). On November 5, 2021, at 3:40 p.m., the DON was interviewed. The DON was asked if the licensed nurses had been providing wound care treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, if the licensed nurses did not sign or initial the treatment sheets, it was not done. The DON further stated, if there is no documentation, then it was not done. There was no documented evidence of an on-going assessment and monitoring of resident' skin. There was no documented evidence a wound care treatment was provided for Resident 30's right malleolus, right buttock, left upper buttock, left buttock, left posterior knee; and the open wounds with yellowish dark brown discharge in between the 3rd, 4th, and 5th toes of the right foot. A review of the physician orders indicated the following: -For September 2021. - There were no physician treatment orders for wound on the right malleolus (ankle) pressure ulcer Stage 1, right buttock pressure ulcer Stage 2, right foot: 2 sites were infected, left buttock pressure ulcer Stage 3, and left posterior knee pressure ulcer Stage 1, and the open wounds on the right foot. For October 2021. - There were no physician treatment orders for wound on right malleolus (ankle) pressure ulcer Stage 1, right buttock pressure ulcer Stage 2, right foot: 2 sites were infected, left buttock pressure ulcer Stage 3, left posterior knee pressure ulcer Stage 1, and the open wounds on the right foot. For November 1 to 5, 2021. - There were no physician treatment orders for pressure injuries on the right malleolus (ankle) pressure ulcer Stage 1, right buttock pressure ulcer Stage 2, right foot: 2 sites were infected, left buttock pressure ulcer Stage 3, left posterior knee pressure ulcer Stage 1, and the open wounds on the right foot. A review of the Nurses Progress Notes, beginning August 8, 2021, to November 4, 2021, indicated no documented evidence the facility consistently assessed, monitored wound status, and provided the necessary care and treatment on the following skin problems: Site #2 - Stage 1 Right malleolus (ankle) pressure injury. Site #3 - Stage 2- Right buttock pressure injury. Site # 4 - Stage 1 pressure injury of the left upper buttock. Site # 5 - Stage 3-Left buttock pressure injuries. Site # 6 - Stage 1-left posterior knee pressure injuries. Site # 7- the open wounds on the right foot. On November 8, 2021, at 11:17 a.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 stated she was not aware Resident 30 had a pressure injury. LVN 3 stated, nothing was reported to me. There was no documentation the facility's IDT (Interdisciplinary Team - a group of staff meeting and working together for the benefit of the resident) meet for the prevention, care, treatment, services and management for Resident's 30 pressure ulcer. The facility policy and procedure titled, Prevention of Pressure Ulcers, dated October 2010, was reviewed. The policy indicated the following: General Guidelines .The facility should have a system/procedure to assure assessments are timely, and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed . Interventions and Preventive Measures .Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown .Immediately report any signs of developing pressure ulcer to the supervisor .The care process should include effort to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate . A review of the policy of the procedure titled, Policy and Procedure for Reporting Abuse, last reviewed on October 21, 2020, indicated, . I. Policy: It is the policy of this facility that every resident be free of all forms of abuse .Deprivation by a custodian of good or services tht are necessary to avoid physical harm or mental suffering .Neglect includes, but is not limited to, all of the following: 1. Failure to assist in personal hygiene, or in the provision of food, clothing or shelter. 2. Failure to provide medical care for physical and mental health needs . A review of the facility procedure titled, Abuse Prohibition and Prevention Policy and Procedure, last reviewed on October 21, 2020, indicated, .The facility prohibits and prevents abuse, neglect .Prevention .5. The facility has the structure and process to provide the needed care and services to all services residents, which includes, but is not limited to the provision of a facility assessment to determine what resources are necessary to care for its residents competently .