Every finding on record at Meadowood a Health and Rehabilitation Center

Based on observations, interviews, and record review the facility failed to provide food preparation and storage, as well as maintain kitchen equipment in accordance with professional standards for food safety for the 67 residents who ate facility prepared meals when: 1. One (1) box of carrots in the kitchen freezer was found without an open date;2. One (1) tote of thickener powder was found expired;3. Four (4) non-stick pans were discovered with significant scratches and areas where the non-stick coating was missing and;4. A blender stirring rod was found with deep gouges and broken with a piece of plastic missing. These failures had the potential to put residents at risk for foodborne illnesses and hazards. Findings: 1. During a concurrent observation and interview on 6/23/26, during the initial kitchen tour at 9:16 a.m., with the CDM (Certified Dietary Manager) in the kitchen freezer, one (1) box of carrots was found without an open date. The CDM confirmed that the box should have had an orange label on it with an open date. During an interview on 6/26/26 at 8:57 a.m., the CDM stated that any food items needed to be labeled properly and should have an open date. According to the CDM, once a product is opened and exposed to air, it begins to deteriorate. The CDM stated that the best practice is to write an open date whenever a product is opened. The CDM additionally stated that the absence of an open date presents safety concerns for residents, as food may be used beyond its recommended period, potentially increasing the risk of foodborne illnesses. A review of the facility's Policy and procedure (P&P) titled, PRODUCTION, PURCHASING, STORAGE, revised 1/26, the P&P indicated, .Cover, label and date unused portions and open packages. Use the Medvantage/Freshdate labeling system or complete all sections on an orange label. Products are good through the close of business on the date noted on the label.Date and rotate items; first in, first out (FIFO). 2. During a concurrent observation and interview on 6/23/26, during the initial kitchen tour at 9:22 a.m., with the CDM in the kitchen, one (1) tote of thickener powder was found with an expiration date of 6/18/26. The CDM confirmed that the thickener powder should have been discarded after its expiration date. During an interview on 6/26/26 at 9:07 a.m., the CDM stated the thickener powder should have been thrown away when it expired. The CDM stated that an expired thickener powder would not thicken the food properly and could put the residents at risk of aspiration. A review of the facility's P&P titled, PRODUCTION, PURCHASING, STORAGE, revised 1/26, the P&P indicated, .Foods past the use by, sell-by, best -by, or enjoy by date should be discarded.Discard food past the use-by or expiration date. 3. During a concurrent observation and interview on 6/23/26, during the initial kitchen tour at 9:27 a.m., with the CDM in the kitchen, four (4) non-stick fry pans were found with signs of over usage (e.g. scratched, discolored, dented and coating worn off cooking surface). The CDM confirmed the fry pans showed signs of over usage and should have been replaced. During an interview on 6/26/26 at 9:15 a.m., the CDM stated that scratched fry pans could lead to cross-contamination and should have been replaced. The CDM explained that kitchen staff were utilizing metal spatulas with non-stick pans, rather than the designated high-temperature plastic spatulas intended for non-stick surfaces. The CDM said this put the residents at risk as Teflon flakes could have come off and go in the food and make it a physical hazard. The CDM stated it was very important to use proper equipment for safely cooking and preparing the food. A review of the United States (US) Food and Drug Administration (FDA) 2022 Food Code, section 4-101.18, titled Nonstick Coatings, Use Limitation, indicated, .Multiuse KITCHENWARE such as frying pans, griddles, sauce pans, cookie sheets, and waffle bakers that have a perfluorocarbon resin coating shall be used with nonscoring or nonscratching UTENSILS and cleaning aids. A review of the US FDA 2022 Food Code, section 4-202.11, titled Food Contact Services, indicated, .Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. 4. During a concurrent observation and interview on 6/23/26, during the initial kitchen tour at 9:30 a.m., with the CDM in the kitchen, a blender food stirring rod was found to have been extensively used when it was found with deep gouges and a missing piece of plastic. During an interview on 6/26/26 at 9:25 a.m., the CDM stated the blender rod was overly used and should have been replaced. The CDM stated that failing to promptly replace the food stirring rod exposed residents to potential harm, as fragments of plastic could have contaminated the food and posed a physical risk. The CDM further stated that it was important to keep the equipment in good condition to prevent any hazards to the residents. A review of the US FDA 2022 Food Code, section 4-202.11, titled Food Contact Services, indicated, .Surfaces which have imperfections such as cracks, chips, or pits allow microorganisms to attach and form biofilms. Once established, these biofilms can release pathogens to food. Biofilms are highly resistant to cleaning and sanitizing efforts. A review of the US FDA 2022 Food Code, Annex 7, titled Good Retail Practices (GRPs), indicated, .Good Retail Practices (GRPs) are systems to control basic operational and sanitation conditions within a facility, and if not controlled, they could be contributing factors to foodborne illness by introducing hazards (biological, chemical and physical), into the end product, either directly or indirectly. For example, equipment in disrepair, such as a cutting board with deep grooves/cuts, makes effective cleaning difficult or impossible, and thereby could introduce a bacterial hazard onto food that comes into contact with the board.

Based on observation, interview, and record review, the facility failed to follow infection control practices for a census of 67 when:1. Staff did not wear an isolation gown (protective clothing to prevent transfer of infectious materials) and gloves before entering a designated isolation room (for exposed or suspected residents with infection) of Resident 93;2. Staff did not perform hand hygiene after blood pressure check and proceeded to prepare medications for Resident 42;3. Staff picked up a tablet of aspirin with her bare hands during medication preparation for Resident 65;4. Two pill cutters were found with white pill residues during medication cart inspection.These deficient practices created a potential for cross -contamination and transmission of infections. Findings: 1. A review of Resident 93's clinical record titled, Resident Face Sheet, indicated Resident 93 was admitted to the facility in 2026, with diagnoses of, but not limited to enterocolitis (inflammation of small and large intestine) due to Clostridium difficile (c-diff- a disease-causing bacterium that infects the large intestine causing infection and watery diarrhea). During an observation on 6/25/26, at 4:27 p.m., a room in the sequoia wing (residents' space in the facility) hallway 3 was labeled with contact precaution sign (to alert those entering the room regarding a possible infection and what type of personal protective equipment (PPE) was required to help stop the spread of germs from one person to another) was posted at the door outside Resident 93's room. The Resident Assessment Coordinator (RAC) was observed without PPE sitting on Resident 93's bed and touched Resident 93 who was under the Contact Isolation Precautions. During a concurrent observation and interview on 6/25/26 at 4:25 p.m., the Treatment Nurse (TN) confirmed that Resident 93 was on contact isolation precautions. The TN also confirmed that RAC was sitting on Resident 93's bed without wearing PPE. When asked TN about the risk of not following contact isolation precautions, the TN explained that the RAC could become contaminated and potentially spread infection throughout the facility. During an interview with the RAC on 6/25/26, at 4:30 p.m., the RAC confirmed that she was sitting on Resident 93's bed and she was not wearing gown and gloves. The RAC also confirmed that Resident 93 was on contact isolation precautions. During an interview on 6/26/26 at 2:46 p.m., with the Infection Preventionist (IP), the IP stated that staff were expected to wear isolation gowns and gloves prior to entering any contact isolation room. The IP explained that the RAC must sanitize her hands and don (to put on) the required gown and gloves before entering Resident 93's room. The IP stated that staff must avoid sitting on residents' beds or touching any personal belongings or residents with bare hands while in a contact isolation room. The IP explained that it was important for facility staff to follow contact isolation precautions to protect everyone in the facility and not following these precautions could lead to staff getting contaminated and spreading infection to residents. During an interview on 06/25/2026 at 4:37 p.m., the Director of Nursing (DON) confirmed that Resident 93 had tested positive for Clostridium difficile and was placed under contact isolation precautions. The DON explained that before entering Resident 93's room, all staff members were required to wear gloves and gowns. The DON stated that failing to follow these precautions increased the risk of spreading infection to other residents and put both staff and residents at risk. A review of the facility's policy and procedure (P&P) titled, Clostridium Difficile), revised 10/21/22, indicated, .To prevent transmission of Clostridium difficile to .Gloves and gowns will be worn.when.having contact with the resident's environment . 2. During a concurrent observation and interview on 6/24/26 at 8:11 AM with Licensed Nurse (LN) 1 and LN 2, LN 1 was observed performing a blood pressure check for Resident 42 as part of medication pass. LN 1 obtained Resident 42's blood pressure and then immediately proceeded to prepare medications for the resident without performing hand hygiene. LN 2 was also present during the observation. When interviewed immediately following the observation, LN 1 confirmed she did not perform hand hygiene after checking the resident's blood pressure before preparing medications. According to LN 1 this practice created the potential for transmission of germs from the resident's environment or equipment to the medications. During a review of the facility's policy titled, HAND HYGIENE PROGRAM revised on 6/6/20, indicated, .Hand Hygiene of approximately 20 seconds must be performed under the following conditions. Before preparing or handling medications. 3. During a concurrent observation and interview on 6/24/26 at 8:41 AM with LN 1 and LN 2, LN 1 was observed preparing medications without wearing gloves for Resident 65. As LN 1 was preparing aspirin, she poured the aspirin tablets into the bottle cap and then picked up a tablet with her bare hands. When interviewed immediately following the observation, LN 1 stated she should have used gloves to prevent risk of infection. During an interview on 6/24/26 at 4:32 PM with LN 2, LN 2 reported that the bottle of aspirin used that morning, which LN 1 had touched with her bare hands while preparing medications for Resident 65, was discarded. During an interview on 6/24/26 at 5:25 PM with the Director of Nursing (DON), the DON stated that the facility had provided an in-service to staff regarding wearing gloves when preparing medications. During a review of the facility's policy and procedures titled, SPECIFIC MEDICATION ADMINISTRATION PROCEDURES – IIB2: ORAL MEDICATION ADMINISTRATION revised 1/2018, indicated, .Procedures.wash hands when beginning a med pass, or when contact with resident is expected or has occurred.pour or push the correct number of tablets or capsules into the souffle cup, taking care to avoid touching the tablet or capsule, unless wearing gloves. 4. During a concurrent observation and interview on 6/24/26 at 11:48 AM with the Infection Preventionist (IP), during inspection of the Redwood and Sequoia medication carts, a pill cutter on the Redwood medication cart was observed with visible pill dusts on the cutting surface and inside compartments. A pill cutter on the Sequoia medication cart was also observed with visible white residue on the cutting surface and inside compartments. The IP stated that pill cutters should be cleaned after each use and that residual medication on a pill cutter poses a risk for medication cross contamination, which may result in medication interactions and allergic reactions. During an interview on 6/25/26 at 10:16AM with LN 2, LN 2 stated that a pill cutter that was not cleaned after use poses a risk for cross-contamination between medications and may result in allergic reactions if medication residue is transferred to another resident's medication. During an interview on 6/26/26 at 10:36AM with the DON, the DON stated that pill cutters should be cleaned after each use. The DON acknowledged that the observed pill cutters did not meet the facility's expectations for infection prevention practices because medication residue could contribute to cross-contamination and potential allergic reactions. During a review of the facility's policy and procedures titled, PREPARATION AND GENERAL GUIDELINES – IIA2: MEDICATION ADMINISTRATION-GENERAL GUIDELINES revised on 12/2019, indicated, .the splitter blade and surface contacting tablet are cleaned before and after each use.

Based on observation, interview and record review, the facility failed to ensure medications, medication-related supplies, and controlled substances were stored, labeled, and maintained in accordance with manufacturer instructions and facility policy for a census of 67 residents when:1. Three sterile packing strips were maintained in opened containers that were not labeled with the date and time opened;2. Multi-resident use of opened 100 mL Normal Saline (NS, salt water) bottles occurred despite the manufacturer's label/instruction, DO NOT REUSE;3. The vault used to store controlled substances awaiting destruction was not permanently affixed to the wall or floor.These failures had the potential to increase the risk of contamination and infection, contribute to resident identification errors during the administration of resident-specific nutritional supplements, and compromise the security of controlled substances awaiting destruction. FINDINGS:1. During a concurrent observation and interview on 6/24/26 at 10:11 AM with the Treatment Nurse (TN), an inspection of the treatment cart located in the Sequoia hallway was conducted. Three opened bottles of sterile packing strips were observed inside the treatment cart. None of the bottles were labeled with the date or time they had been opened. The TN stated that the sterile packing strips are used by admission nurses and that she did not know why the opened bottles were inside the treatment cart. The TN further stated that she would discard the bottles due to the risk of infection. During a follow-up interview on 6/25/26 at 4:35 PM with the IP, the IP stated that the facility does not use sterile packing strips frequently because they are only used when a resident has a tunneled wound or a small wound requiring packing. The IP further stated that the opened, undated bottles of sterile packing strips were not maintained in accordance with the facility's policy and posed a risk for cross-contamination and infection.A review of the facility's policy titled, Wound Dressings revised on 1/23/25, indicated, .All wound dressings will be handled in a safe and sanitary manner.to avoid contamination.A review of the facility's policy and procedure titled, PREPARATION AND GENERAL GUIDELINES - IIA1: EQUIPMENT AND SUPPLIES FOR ADMINISTERING MEDICATIONS revised on 1/2018 revealed that the facility must maintain supplies for proper storage, preparation, and administration of medications to residents, including .labels for date opened/date expires, discontinued and other applicable procedures. 2. During a concurrent observation and interview on 6/24/26 at 10:29 AM with Licensed Nurse (LN) 10, an inspection of the treatment cart located in the Redwood hallway was conducted. An opened bottle of Normal Saline (NS, saltwater) was observed inside the treatment cart. The top of the bottle cap was labeled with the date 6/24/26. LN 10 stated that she uses the opened NS bottle during her shift and that the bottle is not taken into any resident rooms. During an interview on 6/24/26 at 11:48 AM with the Infection Preventionist (IP), the IP stated an opened bottle of NS that was labeled with the date and time it was opened may be used for up to 24 hours as per the facility's policy. During an interview on 6/25/26 at 10:16 AM with LN 2, LN 2 stated that when she opens a small bottle of NS, she reused it for up to 24 hours before discarding it. LN 2 was shown the manufacturer's label on the front of the NS bottle, which indicated, DO NOT REUSE. LN 2 stated that the manufacturer's instruction was likely intended to prevent the risk of infection. During an interview on 6/25/26 at 3:11 PM with LN 4, LN 4 stated that NS is used for treatments and that, most of the time, one bottle is used throughout the duration of the shift. LN 4 further stated that the same bottle was used for multiple residents and, if not emptied, may also be used by the next shift. LN 4 was shown the manufacturer's label on the NS bottle, which indicated DO NOT REUSE. LN 4 stated that she did not believe there was a risk because staff label the bottle with the date it was opened, saturate a cotton with NS before entering a resident's room, and do not take the opened bottle into the resident rooms as part of standard precautions. During a follow up interview on 6/25/26 at 4:28 PM with LN 4, LN 4 stated that after speaking with the IP, staff were informed that the facility would begin using a NS ampules instead of the current 100 ml NS bottles because the 100 ml bottles are intended for single use. LN 4 further stated that the manufacturer's label, DO NOT REUSE, means that once the bottle is opened, it should not be used again due to the risk of contamination and infection. During a follow up interview on 6/25/26 at 4:35 PM with the IP, the IP stated that the staff had been educated that NS bottles were not to be reused in accordance with the manufacturer's label. The IP acknowledged that although the facility's policy allowed opened NS bottles with date and time to be used for up to 24 hours, the facility would instead follow the manufacturer's instruction, DO NOT REUSE, meaning the bottle is intended for one-time use only because of the potential risk of contamination. The IP further stated that the facility would begin purchasing NS ampules. During an interview on 6/26/26 at 10:36 AM with the Director of Nursing (DON), the DON stated that the facility was changing from 100 ml NS bottles to smaller NS vials. The DON further stated that the manufacturer's label, DO NOT REUSE, means the bottle is intended for one-time use only and must be discarded after opening. During a review of the facility's policy and procedure titled, PREPARATION AND GENERAL GUIDELINES - IIA8: IRRIGATION SOLUTIONS revised ON 1/2018, indicated, .Irrigation solutions, whether provided by the pharmacy for an individual resident or available as facility house supply may be stored until the manufacturer's expiration date until opened. Opening the container triggers a new expiration date. The use period after opening is usually found on the manufacturer's label. The nurse opening the container labels the container with the date and time immediately upon opening. 3. During a concurrent observation and interview on 6/24/26 at 1:35 PM with the DON in the DON's office, a SentrySafe vault identified by the DON as the storage location for narcotics awaiting destruction was observed. When asked whether the vault was permanently affixed to the wall or floor, the DON stated she did not know. During interview, the DON telephoned the facility Administrator, who confirmed that the vault was not permanently affixed to the wall or floor. During a follow up interview on 6/26/26 at 10:36 AM with the DON, the DON stated that she was not aware the vault was required to be permanently affixed. The DON stated that the facility's Maintenance Director would permanently affix the vault to the floor as soon as possible. The DON further stated that permanently affixed meant the vault could not be picked up and removed because it was bolted to the floor.During a review of the facility's policy and procedures titled, MEDICATION STORAGE IN THE FACILITY - ID2: CONTROLLED SUBSTANCE STORAGE revised on 1/2018 indicated, .Schedule [II-V] medications and other medications subject to abuse or diversion are stored in a permanently affixed, [double-locked] compartment separate from all other medications.

Based on observation, interview and record review, the facility failed to ensure that timely medication reordering and adequate medication supply management to ensure medications were available and administered as ordered for 2 of 67 residents (Resident 65 and 8) when:A. Resident 65 did not receive the ordered Lidocaine patch on 6/24/26 due to the medication being unavailable. The resident experienced a pain level of 5 on a scale of 1-10 on her right hip the following day.B. Resident 8 did not receive two of the three ordered doses of Calcium Acetate due to the medication being unavailable. Resident 8 receives dialysis for whom consistent administration of Calcium Acetate is necessary to maintain therapeutic levels.These failures resulted in Resident 65 experiencing pain and placed Resident 8 at risk for reduced medication effectiveness due to missed doses. FINDINGS:A. During a concurrent observation and interview on 06/24/2026 at 8:41 AM with Licensed Nurse (LN) 1 and LN 2 in the Sequoia Hallway during medication pass, LN 1 reported that the Lidocaine patch (a sticky patch containing medicine that is placed on skin to numb pain in that area) for Resident 65 was unavailable. LN 2 stated that Resident 65 had been informed the Lidocaine patch would be re-ordered and noted that the resident was understanding and denied pain at the time of observation.During an interview on 06/24/2026 at 4:32 PM with LN 2, LN 2 reported that the lidocaine patch had not yet been received from the pharmacy.During a concurrent interview and record review on 6/26/26 at 9:14 AM with LN 7, LN 7 stated that when medications are supplied in bubble packs, a blue/last column indicates it is time to re-order the medication. However, when a medication is supplied in a different form, (for example, a patch or a bottle), it is at the nurse's discretion to check the contents and reorder when the supply is getting low. LN 7 reviewed the electronic medication administration record (eMAR, system used in the facility) for Resident 65 and confirmed the Lidocaine patch was not administered on 6/24/26 because the patch was unavailable. LN 7 further stated that the Lidocaine patch was delivered on 6/24/26 at 8:55 PM and that Resident 65 had a pain level of 5 on a scale of 1-10 on her right hip when the Lidocaine patch was administered at 8:32 AM on 6/25/26. No PRN (as needed) medication was administered. LN 7 stated the Lidocaine patch was not re-ordered on time, possibly because it was overlooked when the nurses were busy or the nurse forgot. B. During a concurrent observation and interview on 06/24/2026 at 8:48 AM with Licensed Nurse (LN) 1 and LN 2 in the Sequoia Hallway during medication pass, LN 1 reported that the Calcium Acetate of Resident 8 was unavailable. LN 2 stated that they would inform the physician. During a concurrent interview and record review on 6/26/26 at 9:14 AM with LN 7, LN 7 stated that Resident 8 did not receive two out of three ordered doses of the Calcium Acetate as documented in the eMAR. The reason documented was that the medication had to be re-ordered. LN 7 furthered stated that missing Calcium Acetate for a dialysis resident such as Resident 8 may reduce the medication effectiveness or therapeutic dose.During an interview with the Director of Nursing (DON) on 6/26/26 at 10:36 AM, the DON stated that the unavailability of medications during medication pass did not meet her expectations because licensed nurses need to track residents' medication supply and re-order in a timely manner so as not to delay treatments.During a review of the facility's policy and procedure titled, SPECIFIC MEDICATION ADMINISTRATION PROCEDURES - IIB2: ORAL MEDICATION ADMINISTRATION revised on 1/2018, indicated, .To administer oral medications in a safe, accurate and effective manner. B. Review and confirm medication orders for each individual residents on the medication Administration Record PRIOR to administering medications to each resident.A review of the facility's policy and procedure titled, PREPARATION AND GENERAL GUIDELINES - IIA1: EQUIPMENT AND SUPPLIES FOR ADMINISTERING MEDICATIONS revised on 1/2018, indicated, .The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents.D. the charge nurse is notified if supplies are inadequate.The charge nurse reports.supply deficiencies to the director of nursing.A review of the facility's policy and procedure titled, PREPARATION AND GENERAL GUIDELINES - IIA2: MEDICATION ADMINISTRATION-GENERAL GUIDELINES revised on 12/2019, indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices.The facility has sufficient staff and a medication distribution system to ensure safe medications without unnecessary interruptions.

Based on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for 1 of 2 sampled residents (Resident 1), using a Continuous Positive Airway Pressure machine (CPAP- a machine that helps a person breathe by gently blowing air through a mask while sleeping), when Resident 1's CPAP pressure settings (the doctor-ordered air pressure level for the CPAP) were not included in the physician's order.This failure had the potential to result in inconsistent implementation of CPAP therapy, improper setup and administration of the CPAP device, ineffective treatment of 1's respiratory condition, delayed recognition of respiratory needs, and an increased risk for respiratory compromise for Resident 1.Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with a diagnosis of, but not limited to acute respiratory failure with hypoxia (a sudden, serious breathing problem that causes low oxygen levels in the body), chronic obstructive pulmonary disease (COPD - progressive lung condition that makes it hard to breathe because airflow into and out of the lungs get blocked) with acute exacerbation (a long-term lung diseases that suddenly became worse), pneumonia (an infection in the lungs), and obstructive sleep apnea (a condition where the airway becomes blocked during sleep, causing breathing to stop and start).Review of Resident 1's General Order, dated 6/4/26, indicated, .Order Description: CPAP ON QHS [at bedtime].Frequency: At bedtime.During a review of Resident 1's clinical record titled, Care Plan, in the section titled, Problem, date revised 6/23/26, indicated, .Resident has ineffective airway clearance using CPAP QHS . Further review of the document under the section titled, Goal, indicated, .Resident will have adequate ventilation [breathing well enough to get enough air into and out of the lungs] and tissue oxygenation [getting enough oxygen to the body's tissues and organs] . Review of the document under the section titled, Approach, indicated, .CPAP AS PER ORDER.During a concurrent observation and interview on 6/23/26, at 3:44 PM, with Resident 1 in her room, Resident 1 was observed lying in bed with the head of the bed elevated. A CPAP machine was noted on top of the bedside drawer located on the right side of Resident 1's bed. The CPAP device was connected to a corrugated air tubing (a flexible ribbed tube that carries air from a machine to a person) leading to a humidifier chamber (a small water container that adds moisture to the air from the breathing machine). The CPAP tubing remained attached to the device and extended across the surface of the bedside drawer. Resident 1 stated that she recently had pneumonia and used the CPAP machine every night while sleeping. Resident 1 further stated, I don't know about its setup. You should ask the nurses, they're supposed to know about that. During a concurrent interview and record review on 6/23/26, at 4:01 PM, with Licensed Nurse (LN) 4, Resident 1's electronic health record (EHR) was reviewed. LN 4 confirmed that the physician order for Resident 1's CPAP machine was incomplete, as it only indicated, CPAP at bedtime and did not include the prescribed pressure settings or other specific parameters necessary for the safe implementation of CPAP therapy. LN 4 stated that the physician order should have also included the clinical indication for CPAP use, pressure settings, instructions for the application and removal of the device, and directions for the cleaning, maintenance, and replacement of the CPAP equipment, including the mask, tubing, and humidifier chamber. LN 4 further stated that complete physician orders were important to provide clear guidance to nursing staff, promote consistent implementation of respiratory care, ensure proper maintenance of the equipment, and maintain Resident 1's safety and comfort. LN 4 stated that with the current order stating only CPAP at bedtime, it was unclear who was responsible for removing the CPAP device after use or whether additional respiratory care instructions had been prescribed by the physician.During an interview on 6/26/26, at 8:15 AM, with LN 5, LN 5 stated that she was aware the evening shift routinely applied the CPAP at bedtime; however, she did not know the prescribed pressure settings or other device parameters. During an interview on 6/26/26, at 9:37 AM, with the Director of Nursing (DON), the DON stated that physician orders needed to be complete, clear, and specific to ensure licensed nursing staff provided respiratory care consistent with the physician's prescribed treatment plan and accepted standards of nursing practice. The DON further stated that if a physician's order was incomplete, unclear, or lacked essential treatment parameters, such as the prescribed CPAP settings, the licensed nurse was expected to promptly contact the physician to obtain clarification and a complete physician order before implementing the treatment. The DON explained that complete physician orders provided clear clinical direction, promote consistency among nursing staff, reduce the risk of misinterpretation, and help ensure safe and effective resident care. The DON stated that Resident 1 should have had a complete physician order that included the prescribed CPAP pressure settings and any additional instructions necessary for the safe implementation of CPAP therapy. Review of a facility provided manufacturer's instructions for use titled, [Name of Company/Brand] CPAP System, dated 2001, indicated, .At low CPAP pressures, some exhaled gas (CO2 - carbon dioxide, a waste gas that the body breathes out) may remain in the mask and be rebreathed.Do not use the device if the room temperature is warmer than 95 degrees Fahrenheit.this could cause irritation to your airway.Contact your doctor if symptoms of sleep apnea recur.If you notice any unexplained changes in the performance of this device, if it is making unusual or harsh sounds, if it has been dropped or mishandled, if the enclosure is broken, or if water has entered the unit, discontinue use and contact your provider.First time Setup.DO NOT use.until an appropriate professional adjusts the settings.

Based on observation, interview, and record review, the facility failed to ensure interventions for pressure ulcer (a sore on the skin caused by staying in one position for too long) prevention and treatment were consistent with professional standards of practice for 1 of 23 sampled residents (Resident 94) using a low air loss mattress (LAL - a special mattress that helps prevent and treat bed sores by blowing gentle air through the mattress), when Resident 94's LAL mattress was not set accurately according to the resident's current weight. This failure had the potential to result in inadequate pressure redistribution (reducing and spreading pressure on the skin to help prevent bedsores), increased pressure over bony prominences (parts of the body where the bones are close to the skin), impaired wound healing, development of new pressure injuries, worsening of existing pressure ulcers, pain, skin breakdown, and risk of infection for Resident 94.Findings:Review of Resident 94's admission RECORD, indicated Resident 94 was admitted to the facility with a diagnosis of, but not limited to age-related physical debility (physical weakness caused by aging), need for assistance with personal care, and abnormalities of gait and mobility (problems with walking and moving).Review of Resident 94's General Order, dated 6/18/26, indicated, .Order Description: LOW AIR LOSS MATTRESS.Frequency: Continuous.A review of Resident 94's clinical record titled, Care Plan, in the section titled, Problem, dated 6/17/26, indicated, .At Risk for Impaired Skin Integrity r/t [related to] Fragile Skin. Further review of the document under the section titled, Goal, indicated, Will Have No New Impaired Skin Integrity Daily x [times] 3 months. Review of the document under the section titled, Approach, indicated, PRESSURE REDUCING MATTRESS.During a concurrent observation and interview on 6/23/26, at 11:04 AM, with Resident 94 in her room, Resident 94 was observed lying on a LAL mattress. The LAL mattress control unit (the control box that operates a low air loss mattress) was observed to be powered on and functioning. The weight/pressure setting indicator was illuminated (lit up or turned on) at the 180-pound setting. Resident 94 stated that she felt uncomfortable while lying in bed. Resident 94 further stated that she did not know what type of mattress she was using and was unable to state the purpose of the special mattress or why it had been provided. During a concurrent observation, interview and record review on 6/23/26, at 11:14 AM, with Licensed Nurse (LN) 3, in Resident 94's room, Resident 94's electronic health record (EHR) was reviewed. LN 3 confirmed that Resident 94 had a physician's order for a LAL mattress. LN 3 stated that Resident 94 was admitted to the facility on [DATE] and, to her understanding, had been using the LAL mattress since admission. LN 3 further stated that the pressure setting needed to be based on the resident's current body weight. LN 3 stated that Resident 94's most recent documented weight in the EHR was 106.5 pounds, obtained on 6/23/26. LN 3 confirmed Resident 94's LAL mattress was set at 180 pounds. LN 3 further confirmed that the setting did not correspond with the resident's current weight of 106.5 pounds. LN 3 stated that the pressure setting needed to be adjusted accordingly. LN 3 explained that if the mattress was not programmed to the appropriate setting, the pressure redistribution provided by the specialty mattress could be compromised, potentially reducing its therapeutic effectiveness. LN 3 stated that the assigned cart nurses were responsible for ensuring that the resident's specialty mattress was programmed to the correct setting and functioning as ordered. LN 3 further stated that the physician's order should clearly include the clinical indication for the LAL mattress, the prescribed pressure/weight setting, and nursing instructions for ongoing monitoring, including verification of the mattress settings and proper placement each shift. LN 3 explained that without these specific instructions, the order remained a general physician order that would not populate on the electronic Medication Administration Record (eMAR - an electronic chart that tracks what medicines a person receives)) for routine nursing follow-up and documentation.During an interview on 6/24/26, at 3:56 PM, with Licensed Nurse (LN) 2, LN 2 stated that nursing staff generally relied on alarm or beep sounds from the LAL mattress control unit to identify whether there was a problem with the mattress. LN 2 further stated that there were no specific physician's orders or eMAR tasks directing nursing staff to routinely assess or document the mattress placement, functionality, pressure/weight settings, or overall operation during resident care. LN 2 stated that when staff identified a problem with the mattress, they typically referred the issue to the Maintenance Department for evaluation and repair. During an interview on 6/26/26, at 2:24 PM, with the Director of Maintenance (DM), the DM stated that the Maintenance Department was responsible for delivering, installing, and setting up the LAL mattress in a resident's room after receiving a request from the nursing department. The DM further stated that obtaining the resident's current weight was an essential part of the initial setup process because the mattress pressure/weight setting should be adjusted according to the resident's body weight. The DM explained that selecting the correct pressure setting was important to ensure the mattress was neither too soft nor too firm. The DM stated that an appropriate pressure setting based on the resident's current weight promoted effective pressure redistribution, enhances resident comfort, and supports wound healing. The DM further stated that once the LAL mattress had been installed and programmed, the nursing staff were responsible for the ongoing daily monitoring of the mattress, including verifying that the appropriate settings remained in place and that the equipment continued to function properly during resident care. The DM stated that it was important for staff to follow the manufacturer's instructions for use when operating and maintaining the LAL mattress. During a concurrent interview with record review on 6/26/26, at 9:05 AM, with the Director of Nursing (DON), Resident 94's EHR was reviewed. The DON confirmed that Resident 94 had multiple skin impairments, including a Stage 3 pressure injury (a deep bedsore with damage below the skin) to the left buttock, an unstageable pressure injury (a severe bedsore that is too covered to tell how deep it is) to the right buttock/sacral area (the lower back near the tailbone, between the hips), a popped blister to the left posterior (back) lower extremity, and redness to the left shin (the front part of the leg). The DON further confirmed that Resident 94 had a Braden Scale (a tool that measures a person's risk of getting bedsores) score of 10, indicating Resident 94 was at high risk for pressure injury development and deterioration, and therefore required a LAL mattress as part of Resident 94's pressure injury prevention and treatment plan. The DON stated that the pressure/weight setting of the LAL mattress needed to be based on the resident's current body weight to provide appropriate therapeutic pressure redistribution and maximize the effectiveness of the specialty support surface. The DON acknowledged the importance of ensuring that the mattress was programmed correctly to support wound healing, reduce pressure over bony prominences, and help prevent further skin breakdown. Review of a facility provided manufacturer's instructions for use titled, .[Name of Company/Brand] Alternating Pressure Redistribution System, indicated, .Please Read The Manual Before Use.Intended Use: This product is intended to help and reduce the incidence of pressure ulcers while optimizing patient comfort.This product can only be operated by personnel who are qualified to perform general nursing procedures and have received adequate training in knowledge of prevention and treatment of pressure ulcer.Pressure Adjust Levels: Pressure adjust levels controls the air pressure output.Higher-pressure output will support the heavier weight patient.Operation.According to the weight and height of the patient, adjust the pressure setting.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 2 sampled residents (Resident 6) using a Continuous Glucose Monitor (CGM - a device that continuously checks a person's blood sugar levels throughout the day and night), when:1. Resident 6 did not have a complete physician order for the use of a CGM;2. There was no process to verify the quality control (a process to make sure something works correctly) and accuracy (being correct) of the device, and;3. There was no documentation to ensure the nursing staff demonstrated competency (having the knowledge and skills to do a job correctly and safely) in the use and management of the CGM.This deficient practice had the potential to result in inaccurate blood glucose readings, inappropriate clinical decision-making, delayed identification of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar), and/or medication errors including inappropriate insulin (a medicine that helps control blood sugar) administration.Findings:Review of Resident 6's admission RECORD, indicated Resident 6 was admitted to the facility with a diagnosis of, but not limited to diabetes mellitus (DM - a condition where the body cannot control blood sugar levels).Review of Resident 6's Medication Order, dated 10/24/24, indicated, . Order Description: Semglee (insulin glargine [a long-acting insulin medicine used to control blood sugar]) at bedtime. Further review of Resident 6's Medication Order, dated 10/22/24, indicated, .Order Description: Novolin R (insulin regular human [a fast-acting insulin medicine used to lower high blood sugar]).per Sliding scale [the amount of medicine depends on the person's blood sugar level].Frequency: before meals and at bedtime.Special Instructions: for DM - if BG [blood glucose] less than 70 mg/dl [unit of measurement] and alert, hold insulin.if BG less than 70 mg/dl and unresponsive initiate hypoglycemia injection and notify MD [Medical Doctor], and notify MD if BS [blood sugar] greater than 449.Review of Resident 6's General Order, dated 3/3/25, indicated, .Order Description: change out the [Brand Name Continuous Glucose Monitor - a device that continuously checks a person's blood sugar levels throughout the day and night].Frequency: As Needed.Review of Resident 6's facility provided hospital document titled, [Name of Hospital] Order Details, dated 6/7/23, indicated, .Order Questions.Does the member have a diagnosis of Diabetes Mellitus? Yes.Is the member insulin treated? Yes.Which do you want to order? [Brand Name Continuous Glucose Monitor - a device that continuously checks a person's blood sugar levels throughout the day and night).Review of Resident 6's clinical record titled, Care Plan, in the section titled Problem, dated 10/23/24, indicated, Resident at risk for complications such as hypo/hyperglycemia related to diagnosis of diabetes mellitus. Further review of the document under the section titled, Goal, indicated, Resident will have absence of signs or symptoms of hypo/hyperglycemia. Review of the document under the section titled, Approach, indicated, .administer medications as ordered.monitor blood glucose as ordered.monitor for signs of hyperglycemia.monitor for signs of hypoglycemia.monitor resident during peak action time for diabetic medication(s).During a concurrent observation and interview on 6/24/26, at 9:44 AM, with Resident 6 in her room, Resident 6 was observed lying in bed. A CGM sensor was observed securely attached to the posterior (back) of Resident 6's left arm. Resident 6 stated she had diabetes mellitus and had been using a CGM sensor for approximately two years. Resident 6 explained that she preferred the CGM because it eliminated the need for frequent finger-stick (a small finger prick to check blood sugar) blood glucose testing. Resident 6 stated that (Name of Hospital) supplied the CGM sensors and related supplies, and that since her admission to the facility, the supplies had continued to be delivered to the facility. Resident 6 further stated the nursing staff replaced the sensor approximately every 14 days. Resident 6 stated she had not observed the nursing staff performing finger-stick blood glucose testing to verify the quality, accuracy, or reliability of the CGM readings. Resident 6 further stated that based on her observations, the nursing staff relied on the glucose readings displayed by the CGM receiver when determining her blood glucose level and administering insulin. Resident 6 stated she was unsure whether the nursing staff had reviewed the manufacturer's instructional pamphlet accompanying the CGM sensor. Resident 6 further stated that, according to her physician, the manufacturer's instructions contained important information regarding the proper use, operation, and performance of the device. Resident 6 stated that obtaining accurate blood glucose readings was important because her blood glucose levels fluctuated and inaccurate readings could affect the amount of insulin administered.During a concurrent interview and record review on 6/24/26, at 10:10 AM, with the Resident Assessment Coordinator (RAC), Resident 6's electronic health record (EHR) was reviewed. The RAC stated that the facility's in-house glucometer underwent routine quality control checks (tests to make sure equipment or devices are working correctly) by the night shift licensed nurses. The RAC explained that performing quality control testing was important to ensure the glucometer provided accurate blood glucose readings, as inaccurate results could lead to administration of an incorrect insulin dose and place the resident at risk for hypoglycemia or hyperglycemia. The RAC confirmed there was no physician's order authorizing the use of the CGM. The RAC further confirmed there was no physician's order directing nursing staff to use the CGM glucose readings as the basis for insulin administration, and no physician's order or facility protocol identifying when or how to verify the quality, accuracy, or reliability of the CGM readings, such as comparison with finger-stick blood glucose testing. The RAC stated that it was important to obtain a physician's order addressing the use of the CGM because the order would provide clear clinical direction for nursing staff regarding its use, monitoring requirements, and insulin administration. The RAC further stated that licensed nurses were responsible for notifying the physician of significant clinical findings, obtaining appropriate physician orders, and ensuring those orders were accurately implemented and documented. The RAC stated that complete and specific physician orders promoted consistent nursing practice and were essential to ensuring Resident 6's safety and appropriate diabetes management.During a concurrent interview and record review on 6/25/26, at 9:56 AM, with Licensed Nurse (LN) 4, LN 4, Resident 6's EHR was reviewed. LN 4 confirmed that Resident 6 had physician orders for both short-acting and long-acting insulin. LN 4 further confirmed that Resident 6 currently had a CGM sensor attached to her left arm. LN 4 stated that nursing staff monitored Resident 6's blood glucose levels four times daily by using the glucose readings obtained from the CGM and used those readings as the basis for insulin administration. Upon further review of the EHR, LN 4 confirmed there was no physician's order authorizing the use of the CGM glucose readings for blood glucose monitoring or directing nursing staff to use those readings to determine insulin administration. LN 4 stated that the physician should have been notified to obtain clarification and appropriate physician orders regarding the use of the CGM. LN 4 stated that, based on the prompt displayed on the CGM monitor, the sensor remained in place for approximately 14 days before replacement. LN 4 further stated there was an order dated 3/3/25, to Change out [Brand Name CGM] sensor as needed. LN 4 stated that the order was not sufficiently specific because the sensor was routinely replaced every 14 days rather than on an as needed basis. LN 4 further stated physician orders needed to be clear, complete, and specific to provide consistent direction for all licensed nurses and to ensure uniform implementation of care. LN 4 confirmed that there was no specific physician order identifying the frequency for sensor replacement, parameters for use of the CGM, or instructions for verifying the accuracy of the CGM readings. LN 4 stated that she could not recall receiving an in-service or competency training regarding the use and management of the CGM device. During an interview on 6/26/26, at 8 AM, with LN 5, LN 5 stated that she had never received an in-service or competency-based education regarding the manufacturer's instructions for the use and management of the [Brand Name] CGM. LN 5 further stated that she was aware a manufacturer's instructional pamphlet typically accompanied each sensor device; however, she was not familiar with the specific contents or recommendations outlined in the manufacturer's instructions. LN 5 stated that she had not reviewed the manufacturer's guidance and was unaware of the detailed instructions regarding the proper use, operation, monitoring, or recommendations for ensuring the accuracy and reliability of the CGM readings.During an interview on 6/25/26, at 4:32 PM, with the Director of Staff Development (DSD), the DSD stated that a review of the facility's education and training records revealed no documentation showing that licensed nurses had received an in-service or competency-based education specific to the use and management of the Libre CGM. The DSD further stated that education regarding the proper use of the [Brand Name] CGM was necessary to ensure licensed nurses understood the device's intended use, physician order requirements, manufacturer recommendations, methods for verifying the accuracy and reliability of glucose readings, and the appropriate use of CGM results for clinical decision-making, including insulin administration. The DSD further stated that providing education and validating staff competency would help ensure nurses consistently followed appropriate procedures and promote safe, accurate, and effective care for Resident 6.During an interview on 6/26/26, at 8:58 AM, with the Director of Nursing (DON), the DON stated that it was essential for physician orders to be complete, clear, and specific to ensure nursing staff provided care consistent with the physician's treatment plan. The DON further stated that her expectation was that if a physician's order was incomplete, unclear, or lacked specific instructions, the licensed nurse would contact the physician to obtain clarification and secure a complete physician's order before implementing the treatment. The DON explained that clear physician orders provided consistent clinical direction for all licensed nurses and promote safe and appropriate resident care. The DON further stated that Resident 6 should have had a complete physician's order specifically addressing the use of the [Brand Name] CGM, including clear directions regarding its use for blood glucose monitoring, insulin administration, and other necessary clinical parameters. The DON stated that the facility did not have a policy or procedure specifically addressing the use and management of CGM devices. The DON further stated that education and competency validation were important to ensure licensed nurses understood the manufacturer's recommendations, followed consistent nursing practices, and safely implemented physician orders. Review of a facility provided manufacturer's instructions titled, [Brand Name] Glucose Monitoring System, dated 3/19/25, indicated, .Important Safety Information.Before using the App [application], please review the complete product information.Be safe and follow the instructions properly. Using the System incorrectly could cause you to miss a severe low or high glucose event and/or make a harmful treatment decision.Talk to your health care professional about how to use your Sensor.During the first 12 hours of Sensor wear symbol [blood drop with magnifying glass icon] will display and you cannot use the Sensor values to make treatment decisions during this time. Confirm Sensor glucose readings with a blood glucose test before making treatment decisions during the first 12 hours of Sensor wear when you see the symbol . Warnings: Don't ignore low or high glucose symptoms. Use your blood glucose meter to make treatment decisions . Choking hazard: The system has a small parts that may be dangerous.Cautions - Overall System.What to know before using the system.Who should not use the system.When is Sensor glucose different from blood glucose.Cautions - Sensor Use.What to know before you apply the Sensor.What to know about wearing a Sensor.How to store the Sensor Kit.When to remove the Sensor.When not to use the Sensor.Using Your Glucose Reading to Make a Treatment Decision. IMPORTANT: Don't take a correction dose within 2 hours of your meal dose. This may result in insulin stacking [taking insulin too close together before the previous dose has finished working] and low glucose.WARNING.Your System can replace blood glucose testing except.Do a blood glucose test if you think your glucose readings are not correct or do not match how you feel.Do a blood glucose test when you see the symbol [blood drop with magnifying glass icon] during the first 12 hours of wearing a Sensor or the Sensor glucose reading does not include a current glucose number.

Based on interview and record review, the facility failed to protect one of three sampled resident's (Resident 2's) right to be free from neglect (failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress) when, Certified Nursing Assistant (CNA) 2 placed tape over the reset button on the call light panel in Resident 2's room, which prevented the call light from working on 3/11/26.This failure had the potential to decrease Resident 2's safety and psychosocial well-being.Findings:A review of Resident 2's admission Record, indicated that Resident 2 was admitted to the facility in 2026 with diagnoses which included dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Urinary Tract Infection (UTI, a condition in which germs invade and grow in the urinary tract), difficulty in walking, and legal blindness (severe vision loss).A review of Resident 2's Minimum Data Set (MDS; and assessment tool), dated 3/5/26 indicated, Resident 2's Brief Interview for Mental Status (BIMS; used to evaluate a resident's memory, orientation, and ability to process information) score was a 10 (scoring ranges from 00 to 15, with a score of 10 indicating moderately impaired cognition). Resident 2's Section GG [evaluates a resident's functional abilities and goals in self-care and mobility] of the MDS indicated, Resident 2 used a wheelchair, with a need for substantial assistance (helper provides more than half the effort) for toileting/hygiene/shower/bathing/lower body dressing/footwear, partial assistance (helper provides less than half the effort) with upper body dressing/eating, substantial assistance with sit to stand/chair to bed transfer/toilet transfer, partial assistance with walking, and substantial assistance with the use of the wheelchair.A review of Resident 2's impaired vision care plan, start date 3/11/26, in the section titled Problem, indicated, .Resident has severely impaired vision R/T [related to] blindness to both eyes. In the section titled Approach, indicated, .Keep call light in reach at all times.Remind resident to call and wait for help with all transfers.A review of Resident 2's fall risk care plan, start date 3/1/26, in the section titled Problems, indicated, POTENTIAL FOR FALLS AND INJURY DUE TO: unsteady gait and weakness, BLINDNESS,HX [history (sic)] OF FALLS. In the section titled Approach, indicated, .Approach Start Date: 03/01/2026.ASSIST WITH TOILETING NEEDS.Approach Start Date: 03/01/2026.CALL LIGHT WITHIN REACH AND ANSWERED PROMPTLY. Approach Start Date: 03/01/2026.ENSURE RESIDENT UNDERSTANDS HOW TO USE CALL LIGHT. DEMONSTRATE USE AND HAVE RESIDENT COMPELTE RETURN DEMONSTRATION.A review of Resident 2's Activities of Daily Living (ADL's) care plan, start date 3/1/26, in the section titled Problem, indicated, .ADLs Functional Status/Rehabilitation Potential SELF CARE DEFCIT MANIFESTED BY IMPAIRED: BED MOBILITY, TRANSFER [movement from one surface to another], LOCOMOTION [moving from one place to another], DRESSING, EATING, TOILET USE, PERSONAL HYGEINE, BATHING.A review of Resident 2's Progress Notes, indicated, .03/11/2026 20:07.MAINTENANCE LEAD WAS GOING TO RESIDENT ROOM THINKING HE WAS GOING TO FIX A CALL LIGHT MALFUNCTION. WHEN ENTERING THE RESIDENT ROOM, MAINTENANCE LEAD NOTICED THAT IT WAS NOT A MALFUNCTION AND THAT THERE WAS TAPE ONTOP [sp] OF THE CALL LIGHT HOLDING IT DOWN SO THAT IT WAS NOT FUNCTIONAL FOR THE PATIENT [Resident 2] TO CALL FOR ASSISTANCE. MAINTENANCE LEAD IMMEDIATELY NOTIFIED ADMINISTRATOR. ADMINISTRATOR NOTIFIED DON [Director of Nursing] WHOM [sp] NOTIFIED MD [Medical Doctor], RP [Responsible Party, the person designated to direct the care of a loved one admitted into a nursing facility] AND.PD [Police Department]. STAFF MEMBER WAS TAKEN OFF THE FLOOR FOR FURTHER INVESTIGATION. AT THIS TIME, CONSTANT ROOM CHECKS MADE TO THE RESIDENT. CALL LIGHT IS FUNCTIONAL AND WITHIN REACH. ALL NEEDS MET BY STAFF.During an interview with Resident 2 in his room on 5/20/26 at 12:10 p.m., Resident 2 was well-groomed and well-dressed, lying on his bed with the call light within reach. Resident 2 stated that he felt safe at the facility. Resident 2 stated that the staff treated him with dignity and respect. Resident 2 stated that he did not remember when the call light was not working so that he could not use it. Resident 2 stated that the staff responded when he called for help.During an interview with the Maintenance Lead (ML) on 5/20/26 at 1:43 p.m., the ML stated that he saw Resident 2 earlier that day and spoke with him. The ML stated that he told Resident 2 that he would stop by his room to check on him later that day. The ML stated that on the date of the incident, he walked into Resident 2's room and Resident 2 was actively pressing his call light. The ML stated that Resident 2 stated to him that he did not think that his call light was working. The ML stated that Resident 2 was in his bed lying on his back and repeatedly pressing the call light. The ML stated that he looked at the panel for the call light above Resident 2's bed and saw that the reset button for the call light was taped. The ML stated that he told Resident 2 that he would be right back and walked toward the room door to go find a nurse. The ML stated that when he walked out of the door, Certified Nursing Assistant (CNA) 2 came into the room and he followed CNA 2 back into the room, pointed at the call light reset button and said to CNA 2, You can't do that! The ML stated that CNA 2 answered, What? went to the reset panel for the call light and began to pull the tape off the reset button, so he took a picture with his cell phone and went to the Administrator (ADM) to report the incident. The ML stated that Resident 2 was blind and could not see that the light was not on at the call light panel in his room or that the reset button had been taped.During an interview by phone with CNA 2 on 5/21/26 at 10:31 a.m., CNA 2 confirmed that she was assigned to care for Resident 2 on the day of the incident. CNA 2 stated that after she finished assisting Resident 2 with his lunch that day, she told Resident 2 that she was going to assist the resident across the hall back to bed. CNA 2 stated that when she returned to Resident 2's room, she assisted Resident 2 back to bed. CNA 2 stated that on the day of the incident Resident 2 had pressed his call light frequently. CNA 2 stated that she was standing in the doorway when the ML went into Resident 2's room. CNA 2 stated that after the ML went into Resident 2's room, she went into Resident 2's room, and Resident 2 told the ML that his call light was not working. CNA 2 stated that she did not see the tape on the reset button until the ML pointed it out to her. CNA 2 stated that the ML was mad and asked her if she put the tape on the reset button, and CNA 2 stated that she told the ML that she did not do it. CNA 2 stated that when she began to remove the tape, the ML took a picture of the reset button on the call light panel in Resident 2's room with his cellphone and went to the ADM's office. CNA 2 denied putting tape on the reset button on the call light panel in Resident 2's room and stated that she did not know who put the tape on the reset button in Resident 2's room. CNA 2 stated that she went to the nurses' station and told the charge nurse that the reset button in Resident 2's room was taped but that she did not know who did it. CNA 2 stated that the ADM called her to the office later and told her that she had to go home because they had to investigate the incident. CNA 2 stated that the ADM called a few days later and told her that she was terminated. CNA 2 stated that she did not do anything wrong.During an interview with Licensed Nurse (LN) 1 on 5/21/26 at 11:42 a.m., LN 1 stated that she knew Resident 2. LN 1 stated that Resident 2 was on the other unit when the taped call light reset button incident occurred and was moved to his current room after the incident. LN 1 stated that if she walked into a room where the call light reset button was taped, she would ask the resident if he or she were okay, report it to the ADM, and start an abuse report form.During an interview with CNA 1 on 5/21/26 at 11:50 a.m., CNA 1 stated that the tape should not be on the call light reset button. CNA 1 stated that putting tape on the call light reset button was a form of neglect.During an interview with LN 2 on 5/21/26 at 11:54 a.m., LN 2 stated that if she entered a resident's room and the call light reset button was taped, she would call to report it to the ADM and file the abuse form because it would be considered abuse. During an interview with the Director of Nursing (DON) on 5/21/26 at 12:58 p.m., the DON stated that her expectation was that staff, including the CNA's and LN's, answer the residents' call lights as soon as possible. The DON stated that the risk of not answering the residents' call lights timely was that the resident could be in pain and need pain medication, the resident could need to go to the bathroom or could be incontinent (involuntary loss of urine of feces). The DON stated that the residents used their call lights as a way of communicating their needs with the staff. The DON stated that she was aware of the incident involving Resident 2's call light reset button being taped so that Resident 2's call light was not working. The DON stated that since the call light was not functioning due to the tape, Resident 2 could not use it to call for assistance, and that was a form of abuse. The DON stated the facility suspended CNA 2 who was caring for Resident 2 on the day of the incident, the facility investigated the incident, and the facility later fired CNA 2.During an interview with the ADM and the DON on 5/21/26 at 3 p.m., the ADM stated that immediately after the incident of the taped call light was reported, an investigation into the incident was started. The ADM stated that CNA 2, who was caring for Resident 2 at the time of the incident was immediately suspended and left the premises for Resident 2's safety. The ADM stated that CNA 2 admitted that she taped the reset button on the call light panel in Resident 2's room and had left the resident unattended for about five minutes. The ADM stated that CNA 2 was terminated.A review of a facility policy and procedure (P&P) titled, Elder and Dependent Adult Suspected Abuse & Reporting, revised 11/21, the P&P indicated, .Policy Statement.Residents have the right to be free from abuse, neglect.Mandated reporters shall report any such incidents by staff, visitors, or residents.Policy Interpretation and Implementation.Neglect.Failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.A review of a facility document titled, Code of Conduct, revised 12/16, the Code of Conduct, indicated, .Resident Rights.Skilled Nursing.Residents receiving healthcare and other services have clearly defined rights. To honor these, we must.Protect every resident from.neglect.Abuse and Neglect.We will not tolerate any type of resident abuse or neglect.This standard applies to all residents at all times.Abuse and neglect must be reported immediately.in accord [sp] with the mandatory reporting requirements.A review of an undated facility document titled, Certified Nurse Assistant CNA, the document indicated, .Position Summary.the CNA job entails all facets of resident care and support including but not limited to daily life enrichment tasks such as providing direct personal care.Essential Functions.2. Provide ongoing routine checks and ongoing night checks including timely response and answering pull cord (call light) .16. Ensures the safety, health and welfare of. residents at all times.19. Adheres to company policies and.Code of Conduct.

Based on interview and record review, the facility failed to ensure that one of three sampled resident's (Resident 3) call lights was functioning properly when Resident 3's call light did not light up outside his bedroom doorway when the call light button was pressed.This failure resulted in Resident 3 experiencing an episode incontinence and put Resident 3 at risk of fall or injury.A review of Resident 3's admission RECORD, indicated Resident 3 was admitted to the facility in 2025, with diagnoses which included Pneumonia (a lung infection) and lack of coordination.During an interview on 8/14/25, at 10:09 AM, with Family Member (FM)1, FM 1 stated Resident 3's call light was not working from Saturday 8/2/25 through Tuesday 8/5/25. FM 1 further stated Resident 3 pressed his call light but the light above the door did not light up. FM 1 stated there was an incident where Resident 3 was incontinent (not able to hold urine) of urine and no one responded to his call light for assistance to the bathroom. FM 1 stated Resident 3 was unable to get up to go to the bathroom.A review of Resident 3's clinical document titled, Care Plan, dated 7/24/25, indicated, .Problem.Potential for falls and injury due to unsteady gait.Approach.CALL LIGHT WITHIN REACH AND ANSWERED PROMPTLY.ENSURE RESIDENT UNDERSTANDS HOW TO USE CALL LIGHT.During an interview on 8/14/25, at 1:08 PM, with Certified Nurse Assistant (CNA) 1, CNA 1 stated when a call light was broken the staff wrote an entry in the maintenance log. CNA 1 further stated if the call light broke on a weekend, maintenance waited until Monday to fix it. CNA 1 stated she was unaware of other options for the residents when the call light was not working. During a telephone interview on 8/15/25, at 10:28 AM, with Licensed Nurse (LN) 3, LN 3 stated when a call light was not working, she would check with maintenance. LN 3 further stated she was not sure if the facility had spare call lights or hand bells to provide for the residents when the call lights did not work.A review of a facility document titled, Maintenance Log, indicated, .8/2.Item Location.[Resident 3's room]. Call Light Broken.8-4.Fixed. and .8/5.Item Location. [Resident 3's room].Call Light Broke.8-5.Fixed .During an interview on 8/14/25, at 2:24 PM, with the Administrator (ADM), the ADM confirmed the call light had not been illuminating outside Resident 3's doorway. The ADM stated when Resident 3 pressed his call light, the panel by the nurse's station lit up. The ADM further stated Resident 3 was not provided a hand bell because the light was working at the panel even though it was not working outside Resident 3's room. During a telephone interview on 8/15/25, at 1:15 PM, with the Director of Maintenance (DOM), the DOM confirmed the call light outside room Resident 3's room had been broken. The DOM stated that the light would only show up at the panel near the nurse's station and not outside Resident 3's room. The DOM further stated when a call light was broken the staff placed an order in the electronic maintenance request system. The DOM stated the maintenance department received a work order for Resident 3's call light on 8/3/25 and the light bulb was replaced on 8/4/25. The DOM stated the wrong bulb was used on 8/4/25 and it overheated and popped. The DOM further stated the correct bulb was placed on 8/5/25.A review of a facility policy titled, Call Light System, dated 3/5/02, indicated, .Each resident will be provided the means to communicate their immediate needs with the staff and provide the staff with a means to identify residents with immediate needs.Procedure.When resident activates call light, the light above resident's door will light as well as the corresponding light at the nurse's station. A staff member will respond promptly, and attend to resident's immediate need.If the call light system malfunctions, an alternative method such as individual bells will be initiated until the call light system is functioning again.

Based on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 67, when: 1. Signage for Enhanced Barrier Precautions (EBP- a set of infection control measures that use gown and gloves to reduce the spread of multi-drug resistant organisms [MDRO- bacteria that are resistant to many antibiotics] and for people with medical devices that remain in the body for an extended period, providing continuous support or treatment) was not posted on, or near the doorway of Resident 335's room to alert staff to use personal protective equipment (PPE- protective clothing, gown, gloves, or other garments used to prevent the spread of germs) prior to entering the room; and, 2. PPE supplies were not available outside the rooms for Resident 14, Resident 35, Resident 42, and Resident 64 while on EBP. These failures had the potential to spread infection and cause health problems to the residents, and staff, who live and work in the facility. Findings: 1. A review of Resident 335's clinical record titled, Resident Face Sheet, indicated Resident 335 was admitted to the facility with diagnoses which included, cellulitis (a common bacterial infection of the skin and underlying tissues) on the back, and bacteremia-staph aureus (a serious bloodstream infection caused by the staph bacteria which can spread through skin-to-skin contact, contaminated surfaces, and shared items). A review of an undated facility provided document titled, Residents on Isolation, indicated Resident 335 was on EBP. A review of Resident 335's care plan titled, Care Plan .Resident requires IV [intravenous- within the vein] medication D/T [due to] STAPH AUREUS BACTEREMIA ., created on 2/20/25, which indicated, .Approach .ENHANCED BARRIER PRECAUTIONS . During a concurrent observation and interview on 2/25/25, at 9:51 a.m., with the Unit Manager/Case Manager (UM/CM) in the hallway outside of Resident 335's room, the UM/CM confirmed Resident 335 was on an IV antibiotic to treat his infection. The UM/CM further confirmed no EBP sign was placed at the doorway to indicate the type of isolation and what PPE was required for staff when taking care of Resident 335. The UM/CM stated not placing the isolation sign could contribute to the spread of infection in the facility. During a concurrent interview and record review on 2/26/25, at 10:14 a.m., with the Infection Preventionist (IP), the IP confirmed that Resident 335 was on the list of residents on EBP due to having staph aureus bacteremia. The IP stated that if a resident was on EBP there should be an EBP sign posted on, or near the doorway of the resident's room. The IP further stated that it was her expectation for nursing staff to post an EBP sign outside of the room, so staff could don (put on) the appropriate PPE prior to entering the resident's room. The IP stated the isolation precaution sign was a method of communication to inform staff about the type of isolation and required PPE. The IP further stated there was a potential risk to spread infection in the facility due to not having EBP signage posted on, or near the doorway of the resident's room. During a concurrent interview and record review on 2/26/25, at 11 a.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Isolation Precautions, Categories Of, revised 1/27/25, was reviewed. The P&P indicated, .Transmission-based isolation precautions will be used for residents who are documented or suspected to have infections or communicable diseases that can be transmitted .f) Signs - A sign will be used to alert staff and visitors of the implementation of isolation precautions, while protecting the privacy of the resident . The DON stated that it was her expectation to have an EBP sign posted outside by the room's entrance door for staff to ensure the required PPE was worn. The DON further stated she expected staff to follow the facility's P&P for isolation precautions. The DON confirmed the facility's P&P for isolation precautions was not followed. The DON stated there was a potential risk of spreading infection in the facility when signage was not used. 2a. Review of Resident 35's medical record titled, Resident Face Sheet, indicated that Resident 35 was admitted to the facility with diagnoses that included chronic kidney disease stage 4 (a condition when the kidneys are severely damaged and only functioning at a very low level) and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). Review of Resident 35's Care Plan History, initiated on 2/25/25, indicated .Problem .HISTORY OF antibiotic resistant infection VRE [Vancomycin-resistant enterococci - a type of bacteria that is present in the stomach and intestines that develop resistance to many antibiotics, especially vancomycin] .Approach .Enhanced Barrier Precautions . During a concurrent interview and record review with the Infection Preventionist (IP), on 2/26/25, at 9:53 a.m., the IP confirmed that Resident 35 was on the list of residents on EBP due to having a dialysis port and a history of VRE. The IP stated that it was expected for staff to wear PPE like gowns and gloves during high contact activities for residents on EBP. The IP further stated that the PPE supplies should be in the linen closets and central supply rooms. The IP stated that the Certified Nurse Assistants (CNA) were supposed to gather the supplies before entering the resident's room. The IP confirmed that the PPE should be readily available for staff. The IP confirmed that Resident 35 was at higher risk for infection due to having a dialysis port in place. The IP stated that it was her expectation for all LN and CNA staff to know and follow precautions and policies for all types of contact precautions in place. During a concurrent observation and interview with LN 2, on 2/27/25, at 10:53 a.m., LN 2 confirmed that an EBP sign was posted outside of Resident 35's room but there was no PPE bin (a container used to store PPE) outside of Resident 35's room. LN 2 confirmed that the PPE gowns were located inside Resident 35's room right by the doorway and the gloves were inside Resident 35's bathroom. LN 2 stated that the staff should don the PPE before direct contact with Resident 35. LN 2 added that the risk of not having the PPE supplies outside of the EBP room would be for possible infection and cross contamination. LN 2 further stated that Resident 35 would be at greater risk of infection due to having the dialysis port in place for dialysis treatments. During an interview with the DON, on 2/27/25, at 12:47 p.m., the DON stated that if a resident was on EBP that there should be an EBP sign posted outside the entrance of the room and an isolation cart or PPE bin should also be outside of the room. The DON further stated that EBP was in place for residents with wounds, feeding tubes (a tube placed in the stomach that provides nutrition), urinary catheters (a tube that drains urine from the bladder into a collection bag), and dialysis ports. The DON stated that it was her expectation for staff to be gowning up and using the PPE when providing care to residents. The DON stated that the IP usually had the PPE bins outside the room so the staff can don the PPE before entering the resident's room. The DON stated that it was her expectation to have the PPE bin outside the room for staff to don the PPE. The DON stated that the risk of not having the PPE supplies outside the room was for infection to spread and the main goal was to prevent and contain any infection. 2b. Review of Resident 64's medical record titled, Resident Face Sheet, indicated that Resident 64 was admitted to the facility with diagnoses that included aftercare following right hip joint surgery, fracture of neck of right femur (upper part of the thigh) and pressure ulcer of sacral region stage 4 (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone on the base of the spine area). During an interview with Resident 64, on 2/26/25, at 9:06 a.m., Resident 64 stated that she had a pressure wound on her bottom that had been going on for a year now. Resident 64 stated that her pressure wound dressing was changed three times a week on Mondays, Wednesdays, and Fridays. During a concurrent observation and interview with Certified Nurse Assistant (CNA) 3, on 2/26/25, at 9:13 a.m., CNA 3 confirmed that Resident 64 had an EBP sign posted outside the room's doorway and stated that it was her first time seeing the sign. CNA 3 stated that there was no mention of a reason why Resident 64 was on EBP. CNA 3 stated that she knew that Resident 64 had an open wound on her bottom but was covered and treated by the wound nurse. CNA 3 stated that if a resident was on EBP, staff were supposed to use PPE like gloves, gowns, and a mask when providing care. CNA 3 confirmed that there was no PPE bin outside the doorway of Resident 64's room. CNA 3 stated that the risk of not having PPE supplies was for the resident to get an infection or for cross contamination. CNA 3 further stated that Resident 64 was at higher risk for infection due to her having the pressure ulcer wound on her bottom. During a concurrent observation and interview with LN 4, on 2/26/25, at 9:27 a.m., LN 4 confirmed that an EBP sign was posted outside Resident 64's doorway. LN 4 confirmed that Resident 64 had a stage 4 pressure ulcer. When asked where the PPE supplies should be located, LN 4 stated that the PPE should be within the first wall of the resident's room upon entrance. LN 4 confirmed that a hand sanitizer and PPE gowns were placed by the doorway inside Resident 64's room close to the restroom door. LN 4 stated that the gloves were inside Resident 64's restroom or in the medication cart. LN 4 confirmed that there was no PPE bin outside Resident 64's doorway. LN 4 stated that the risk of not having PPE supplies readily available would be for infection and cross contamination. LN 4 stated that Resident 64 would be at greater risk of infection due to being diabetic (inability to regulate sugar levels in the body) and having the pressure ulcer. During a concurrent interview and record review with the Infection Preventionist (IP), on 2/26/25, at 9:53 a.m., the IP confirmed that Resident 64 was on the list of residents on EBP due to having a stage 4 pressure ulcer. The IP stated that it was expected for staff to wear PPE like gowns and gloves during high contact activities for residents on EBP. The IP added that the CNA should be aware if residents were on any precautions and the LN should know the reason for the precautions in place. The IP confirmed that Resident 64 was at higher risk for infection due to being diabetic and with the presence of the pressure ulcer. Review of Resident 64's Care Plan History, initiated on 2/25/25, indicated .Problem .Pressure Ulcer/Injury ALTERATION IN SKIN INTEGRITY - STAGE 4, PRESSURE ULCER .Approach .Enhanced Barrier Precautions . During a concurrent interview and record review with LN 2, on 2/27/25, at 10:13 a.m., LN 2 reviewed Resident 64's EHR and confirmed that Resident 64 had a care plan, dated 2/25/25, that indicated EBP was in place related to an unhealed wound. 2c. During a concurrent observation and interview on 2/25/25 at 9:28 AM, in front of Resident 42's room with LN 6, an EBP sign was observed at the entrance to Resident 42's room. LN 6 stated Resident 42 was on EBP due to a Stage III Pressure Ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or a pressure in combination with friction) located on Resident 42's back. LN 6 further stated Resident 42 had wound care with dressing changes every Monday, Wednesday, and Friday. LN 6 confirmed Resident 42 did not have PPE (gown and gloves) at the entrance to the room since it was kept on the medication cart (a locked rolling cart stocked with medication and supplies) and in the utility room. During a concurrent observation and interview on 2/25/25 at 10:23 AM the Director of Staff Development (DSD) confirmed PPE was not available for use outside of Resident 42's room and stated it was supposed to be. 2d. During a concurrent observation and interview on 2/25/25 at 10:13 AM, inside of Resident 14's room, CNA 2 was observed in PPE while caring for Resident 14. CNA 2 stated Resident 14 had a gastrostomy tube (GT - a tube that is surgically inserted into the resident's stomach to allow access for fluids, nutrition, and medications) and was on EBP requiring PPE which included a gown and gloves while performing resident care. An EBP sign was confirmed to be on the door at the entrance to the room. CNA 2 confirmed there were no PPE supplies available at the entrance of the room. CNA 2 stated she retrieved the PPE from the utility room, prior to entering Resident 14's room. During a concurrent observation and interview on 2/25/25 at 10:23 AM the Director of Staff Development (DSD) confirmed PPE was not available for use outside of Resident 14's room and stated it was supposed to be. During an interview on 2/26/25 at 1:38 PM with the DON, the DON stated her expectation for residents on EBP precautions, was for the PPE to be available at the doorway. The DON further stated the staff should not have to go looking for PPE. The DON explained the risk to the residents for not having PPE available was infection or the spread of infection from residents to staff, or staff to residents. Review of the Centers for Disease Control (CDC) website, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 4/2/24, indicated .When implementing Contact Precautions or Enhanced Barrier Precautions, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use, initial and refresher training, and access to appropriate supplies .Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) .For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves .Make PPE, including gowns and gloves, available immediately outside of the resident room . (https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html)

Based on observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards of food service safety for eight residents who received soup for lunch on 2/27/25 when there was no temperature recorded for the soup prior to being served to those eight residents. This failure put the eight residents who received soup from the kitchen on 2/27/25 at risk for food borne illness when it was unknown if the soup being served was in the safe temperature zone (above 140 Fahrenheit to prevent the growth of harmful bacteria). Findings: During a tray line observation on 2/27/25, at 11:45 AM, tomato soup was not available to fulfill a resident request. Dietary staff were observed heating a pan of soup on the stove and after several minutes a serving was provided to tray line staff. Seven separate servings of chicken noodle soup were observed being placed on meal trays. A review of a facility recipe titled, Soup Tomato . indicated, .COOK-END TEMP 63 C [degrees Celsius] . (145.4 degrees Fahrenheit) A review of a facility recipe titled, Soup Chicken Noodle . indicated, .COOK-END TEMP 71 C . (159.8 degrees Fahrenheit) During a concurrent interview and record review on 2/27/25, at 1:49 PM, the Certified Dietary Manager (CDM) confirmed the lunch time temperature log did not indicate a temperature check for the soups served during lunch time. The CDM confirmed the temperature should have been recorded to ensure the food temperature was in the safe zone to prevent food borne illness. During an interview on 2/28/25, at 8:25 AM, [NAME] 1 stated she checked the food temperatures right before she began serving food and documented the temperatures on the log. [NAME] 1 stated every food item served required its temperature checked because people would get sick if food was served at the wrong temperature. [NAME] 1 stated if the temperature was incorrect the food would be reheated or cooled as appropriate. A review of a facility document tiled, Time and Temperature Control, dated 2019, indicated, . Time and temperature are a perfect food safety pair, because to reduce pathogens [harmful germs] in food to safe levels, you have to cook the food to its correct minimum internal cooking temperature then hold the food at this temperature for a specific amount of time . A review of a facility policy titled, Meal Temperature, dated 1/1/21, indicated, .All food items are evaluated for proper food temperature, taste, and appearance prior to meal service .The supervisor/designee must allow adequate time prior to meal service to record the temperatures of foods being served .An accurate temperature of all menu items is to be taken and recorded, utilizing an accurate thermometer .If hot food temperatures are not greater than or equal to the standards, or cold temperature are not less than or equal to the standards, respond accordingly to correct. Do not serve food at unacceptable temperatures .

Based on observation, interview, and record review, the facility failed to ensure one of twenty two sampled residents (Resident 12) was free from physical restraint when Resident 12 was unable to independently unbuckle the self-release belt he wore while seated in his wheelchair. This failure had the potential for Resident 12 to experience a lack in freedom of movement, injury, and psychosocial distress. Findings: A review of Resident 12's Resident Face Sheet, indicated he was admitted to the facility with diagnoses which included Parkinsonism (a progressive disease of the nervous system marked by tremor, muscle rigidity, and slow imprecise movement) and unspecified dementia (condition that causes a decline in memory, thinking, reasoning, and problem solving). A review of Resident 12's Minimum Data Set (MDS, federally mandated resident assessment and screening tool) Section C - Cognitive Patterns, dated 1/4/25, indicated Resident 12's Brief Interview for Mental Status (BIMS, cognitive screening test, a score of 0-7 suggests a severe cognitive impairment, 8-12 suggests moderate cognitive impairment, 13-15 suggests intact cognitive response) score was 7. A review of Resident 12's MDS Section GG-Functional Abilities, dated 1/4/25, indicated Resident 12 required, .Partial moderate assistance-Helper does LESS THAN HALF the effort . for the categories of eating and upper body dressing. A review of Resident 12's Restraint/Adaptive Equipment Use Assessment, dated, 11/13/24, indicated, .resident requested a self release belt for when he's up in chair md (medical doctor) notified md approved observation complete. patient educated on how to use the belt and patient demonstrated how to release belt on his own . A review of Resident 12's Care Plan History, dated 11/13/24, indicated, .Problem .Self release belt when up in wheelchair related to involuntary movement related to his disease process .Approach .resident is able to self release belt . During an observation on 2/26/25, at 10:15 AM, Resident 12 was observed in his room seated in his wheelchair. When asked to demonstrate how his self-release belt was unbuckled, Resident 12 reached down to his belt, grasped the sides of the buckle and wiggled it up and down, he tried to pull on the buckle and stated, I can't. During a concurrent observation and interview on 2/26/25, at 10:25 AM, Licensed Nurse (LN) 6, stated Resident 12 could remove his belt independently. LN 6 prompted Resident 12 to open the belt buckle, Resident 12 tried but was unable. LN 6 prompted him a few more times and then opened the buckle for him. LN 6 confirmed Resident 12 was unable to release the belt buckle independently. During a concurrent interview and record review on 2/26/25, at 2:01 PM, the MDS Coordinator (MDSC) stated Resident 12 had Parkinson's disease which affected his cognition and mobility. The MDSC stated if Resident 12 was unable to release his self-release buckle independently it was considered a restraint. The MDSC confirmed Resident 12's quarterly MDS was completed in January and Resident 12 was not reassessed for the use of the self-release belt at that time but should have been. The MDSC stated it was important for the assessment to have been completed because his condition could change. A review of Resident 12's Restraint/Adaptive Equipment Use Assessment, dated, 2/26/25, indicated, .reassessment done on self release belt while in wheelchair, resident was unable to pull the self release belt open without cueing and further instruction . A review of an undated, facility provided document titled, Know Your Rights under Federal Nursing Home Regulations, indicated, .You have the right to be free from physical .restraint .Physical restraints are any manual method, or physical or mechanical device, material, or equipment attached to or near your body so that you can't remove the restraint easily. Physical restraints prevent your freedom of movement or normal access to your own body . A review of a facility policy titled, Restraints -Physical, dated, 9/12/24, indicated, .[Facility] will attempt to provide an environment which is restraint free and discourages the use of restraints unless medically necessary, and when the safety and/or well-being of a resident is at risk examples of physical restraints as defined by CMS [Centers for Medicare & Medicaid Services] include but are not limited to .Leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions, and lap trays the resident cannot remove easily .the continued need for restraint is reevaluated no less than quarterly by the interdisciplinary team members .

Based on observation, interview, and record review, the facility failed to ensure residents rights to be treated with dignity and respect were honored for one of twenty two sampled residents (Resident 38) when Resident 38's meal was placed in front of her, but not fed to her, for greater than 20 minutes. Findings: A review of Resident 38's Resident Face Sheet, indicated she was admitted to the facility with diagnoses which included Alzheimer's disease (a progressive disease that affects the parts of the brain that control thought, memory, and language). A review of Resident 38's Care Plan History, dated 8/1/19, indicated, Problem .Nutritional Status . AT RISK FOR ALTERED NUTRITIONAL STATUS . Requires assistance with feeding . During an observation in the memory care unit (focuses on the care and well-being of individuals with memory issues) dining room, on 2/25/25, at 12:15 PM, Resident 38 was observed seated at a table with a plate of food in front of her. Resident 38 was alert and looking around the room. Licensed staff were observed feeding another resident seated at the table with Resident 38. During an observation on 2/25/25, at 12:31 PM, Resident 38 was observed crying out (to shout or make a loud noise), her plate of food remained in front of her. Licensed staff continued to feed the other resident at the table. During an observation on 2/25/25, at 12:38 PM, Licensed Nurse (LN) 6 began to feed Resident 38 her meal. The temperature of the potatoes on Resident 38's plate registered 110 degrees Fahrenheit (F ) when LN 6 began feeding her. During an interview on 2/25/25, at 1:38 PM, LN 6 stated she had placed Resident 38's tray in front of her on the table because she thought a Certified Nurse Assistant (CNA) student would be coming to feed the residents. LN 6 further stated when no one came LN 6 started feeding the other resident seated at the table. LN 6 stated Resident 38 may have been wondering why she was not eating too. LN 6 stated it created a dignity issue for Resident 38 when she had to sit and watch the other resident eat. During an interview on 2/26/25, at 1:24 PM, the Director of Nurses (DON) stated it was her expectation that all residents at a table would eat their meals at the same time. The DON further stated it was a dignity issue to not serve residents their meals together. The DON further stated when Resident 38's meal was delayed staff should have informed the kitchen and received a fresh meal tray. During an interview on 2/27/25, at 12:45 PM, the Certified Dietary Manager (CDM) stated food served to residents should be between 145-150 F . The CDM further stated that it was inappropriate to serve food that was 110 F . The CDM stated staff should have requested a new tray or fed Resident 38 when her tray had arrived. A review of an undated, facility provided document titled, Know Your Rights under Federal Nursing Home Regulations, indicated, . you have the right to be treated with respect and dignity . A review of a facility policy titled, Supervision of Resident Nutrition, dated 5/1997, indicated, .Each resident shall receive proper nutrition .Residents needing assistance in eating must be promptly assisted upon being served . A review of a facility policy titled, Meal Temperature, dated 1/1/21, indicated, .All food items are evaluated for proper food temperature, taste, and appearance prior to meal service .Food and drinks should be palatable, attractive and served at a safe and appetizing temperature .to ensure patients/residents' satisfaction .Do not serve food at unacceptable temperatures .

Based on observation, interview, and record review, the facility failed to ensure one of twenty two sampled residents (Resident 42), had a care plan (a formal process that identifies existing needs and recognizes potential needs or risks) developed to address Resident 42's oxygen needs and use. This failure potentially contributed to Resident 42 not receiving the correct rate of oxygen (liters per minute-LPM. A unit of measure for oxygen delivery). Findings: During a concurrent observation and record review, on 2/26/25 at 10:03 AM in Resident 42's room, Licensed Nurse (LN) 6 confirmed Resident 42 was receiving oxygen at a rate of 2.5 LPM. LN 6 reviewed Resident 42's physician orders and confirmed Resident 42 should have been receiving oxygen at a rate of 4 LPM, continuously. During a concurrent interview and record review on 2/26/25 at 12:09 PM, with LN 6, Resident 42's care plans were reviewed. LN 6 stated she was unable to locate an oxygen use care plan for Resident 42. LN 6 confirmed a care plan should have been created for Resident 42's oxygen needs and use. LN 6 further stated a care plan could have prevented Resident 42 from receiving an incorrect rate of oxygen. LN 6 explained the importance of a care plan was to have interventions in place as a guide for nurses to follow which helped them understand the plan of care. During a concurrent interview and record review on 2/26/25 at 1:41 PM, the Director of Nursing (DON) confirmed an oxygen use care plan was never created for Resident 42. The DON stated a care plan was important because it gave the nurses interventions to look out for and a guide to follow. The DON further explained the risk to Resident 42 was a lower amount of oxygen being administered which could lead to shortness of breath, or other complications. A review of a facility provided document for Resident 42 titled, General Order dated 7/23/2024, indicated, .Order Description: OXYGEN AT 4L/MIN [LPM] .CONTINUOUS .Order Class: Physician Order . A review of a facility policy and procedure titled, Interdisciplinary Team/Care Plan Process, revised 12/2021, indicated, .An interdisciplinary assessment team .develops and maintains a comprehensive care plan .designed to .a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems .

Based on observation, interview, and record review, the facility failed to ensure residents rights of privacy and confidentiality were honored for one of twenty two sampled residents (Resident 12) when Resident 12's incontinence (lacking control of bowel and bladder) care needs were posted in public view in his room. Findings: A review of Resident 12's Resident Face Sheet, indicated, he was admitted to the facility with diagnoses which included urinary incontinence (inability to control urination/bladder). During an observation in Resident 12's bedroom on 2/26/25, at 9:46 AM, a handwritten sign and two photos were observed posted on Resident 12's bathroom door facing out into the room. The sign indicated, .[Resident 12's] Cath Bag [urine collection bag] .AM .Remove old condom tip [condom catheter used to direct urine to a collection bag] with Adhesive remover wipe .Use NoSting Prep [skin protectant] to place new condom tip .attach leg bag to top of calf and above ankle .PM .Remove old condom tip with Adhesive remover wipe/spray .attach to 2000ml [milliliter] bag . The photos included pictures of the condom catheter packages, the wipes, and the drainage bags to attach to the catheters. During a concurrent interview and document review (sign and photos) in Resident 12's room, on 2/26/25, at 10:24 AM, licensed nurse (LN) 6 stated the information for Resident 12's condom catheter was posted on the bathroom door to inform staff of which supplies to use. LN 6 further stated, for privacy, the documents could have been posted inside the bathroom door. During a concurrent interview and document review (sign and photos) in Resident 12's room, on 2/26/25, at 1:28 PM, the Director of Nurses (DON) stated any sign posted in a resident's room with personal information should be covered with a blank page. The DON further stated not covering the postings created a dignity issue for Resident 12. A review of an undated, facility provided document titled, Know Your Rights under Federal Nursing Home Regulations, indicated, .you have the right to be treated with respect and dignity .

Based on observation, interview, and record review, the facility failed to ensure appropriate urinary catheter (a flexible tube inserted into the bladder used to drain urine) care and services were provided for one of two residents (Resident 71) with urinary catheters in a sample of 22 residents when: 1. Resident 71's urinary catheter bag (a device that attaches to the end of the tube to collect urine) was on the floor; and, 2. Resident 71's urinary catheter bag did not have a dignity cover (a cover that helps maintain the dignity of people who use catheters). These failures had the potential to affect Resident 71's sense of self-worth and self-esteem and placed Resident 71, and others in the facility, at risk for adverse medical outcomes. (When a drainage bag on the floor touches or comes into contact with anything other than a clean surface, that item becomes contaminated, which could increase the chances of an infection for anyone that comes into contact with the contaminated item.) Findings: A review of Resident 71's Resident Face Sheet, indicated Resident 71 was admitted to the facility with multiple diagnoses including sepsis (a serious condition in which the body responds improperly to an infection) and bilateral hydronephrosis (a condition where both kidneys become enlarged due to a buildup of urine). During a concurrent observation and interview on 2/25/25, at 4:47 PM, with Licensed Nurse (LN) 1 in Resident 71's room, LN 1 confirmed Resident 71 was lying in bed with his urinary catheter bag on the floor and the bag did not have a dignity cover. LN 1 stated that the catheter bag should be off the floor and should be covered. LN 1 added, there was a risk for contamination if the urinary catheter bag was left on the floor. LN 1 further stated having a dignity bag at all times would protect the resident's privacy and dignity. During an interview on 2/27/25, at 1:57 PM, with LN 2, LN 2 stated that the urinary catheter bag should be placed below the bladder and attached to the bedrail when a resident was in bed for infection control prevention. LN 2 further stated the urinary catheter bag should have a dignity cover to protect the resident's privacy. During an interview on 2/28/25, at 8:43 AM, with the Director of Nursing (DON), the DON stated that her expectation for the staff was to ensure the urinary catheter bags were off the floor and with a dignity cover at all times. The DON stated that the urinary catheter bag should not be on the floor because of a potential infection control risk. The DON added that the urinary catheter bag should be covered to protect the resident's dignity and privacy. Review of a facility policy and procedure titled, Bowel and Bladder Program - Indwelling Catheter, revised 2/1/25, indicated, .Residents with indwelling catheters .Catheter bags will be covered to maintain resident dignity . According to the Center for Disease Control and Prevention - Healthcare Infection Control Practices Advisory Committee's Guideline for prevention of Catheter Associated Urinary Tract Infections 2009 updated April 12, 2024, indicated, .Proper Techniques for Urinary Catheter Maintenance .Do not rest the bag on the floor . https://www.cdc.gov/infection-control/hcp/cauti/index.html

Based on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for 1 of 8 residents who received oxygen at the facility (Resident 42) when Resident 42's oxygen order was not followed. This failure placed Resident 42 at risk for respiratory distress and inadequate treatment. Findings: During a concurrent observation and interview on 2/26/25 at 10:03 AM, with Licensed Nurse (LN) 6 in Resident 42's room, Resident 42 was observed receiving oxygen via nasal cannula (NC -a small flexible tube that contains two open prongs intended to sit inside the nostrils). LN 6 observed and confirmed the oxygen concentrator (a device that delivers oxygen) was on and running at 2.5 liters per minute (LPM, a unit of measure for oxygen delivery). During a concurrent interview and record review on 2/26/25 at 10:05 AM, LN 6 reviewed Resident 42's current physician order for oxygen. LN 6 stated the physician's order for oxygen was 4 LPM. LN 6 confirmed the oxygen order was not being followed as prescribed by the physician. LN 6 stated the risk to the resident for not receiving the correct dose was hypoxia (a condition where there is not enough supply of oxygen to the body's tissue). During an interview on 2/26/25 at 1:41 PM, with the Director of Nursing (DON), the DON confirmed the ordered amount of oxygen for Resident 42 was 4 LPM continuously. The DON stated the risk to the resident was Resident 42 could desaturate (to have low blood oxygen levels) or become short of breath. The DON explained it was important to follow the physician prescribed orders. A review of a facility provided document for Resident 42 titled, General Order dated 7/23/2024, indicated, .Order Description: OXYGEN AT 4L/MIN [LPM] VIA NC CONTINUOUS .Order Class: Physician Order . A review of the facility's policy and procedure titled, Oxygen Administration, revised 12/2021, indicated, .The licensed nurse will carry out the oxygen therapy orders .

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage - number or ratio expressed as a fraction of 100) with a resident census of 67. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 2 errors out of 36 opportunities which resulted in a facility wide medication error rate of 5.55% in 1 of 4 residents (Resident 234 ) observed for medication administration. These failures had the potential to result in unsafe medication use and medication errors affecting the resident's health and well-being. Findings: During a medication administration observation, in the facility's Sequoia station, with Licensed Nurse (LN) 3, on 2/27/25 from 8:28 AM to 9:40 AM, the following observations were noted with medication administration to Resident 234 and Resident 79 as follows: a. Resident 234's order for dorzolamide-timolol (an eye drop medication used to treat glaucoma [an eye disease that leads to vision loss]) .1 DROP .BOTH EYES FOR GLAUCOMA . was not administered during observation but was documented as given at 9 AM with a comment noted by LN 3, given as due. b. Resident 234's order for Restasis (cyclosporine-an eye drop medication used to treat dry eyes) .1 DROP .BOTH EYES FOR GLAUCOMA . was not administered during observation but was documented as given at 9 AM with a comment noted by LN 3, given as due. A review of Resident 234's Medications Administration History, dated 02/01/25 - 02/28/25, indicated, .dorzaloamide-timolol .Scheduled Date 02/27/2025, Scheduled Time: 09:00 [9AM], Charted Date: 2/27/2025 10:33 [AM] .Reason/Comments: Late Administration .Comment: given as due . The late medication administration documentation was made by LN 3. A review of Resident 234's Medication Administration History, dated 02/01/25 - 02/28/25, indicated, .Restasis (cyclosporine) .Scheduled Date 02/27/2025, Scheduled Time: 09:00, Charted Date: 2/27/2025 10:33 .Reason/Comments: Late Administration .Comment: given as due . The late medication administration documentation was made by LN 3. During an interview on 2/28/25 at 10:10 AM with the Director of Nursing (DON), the DON stated the expectation for passing medications would be for the nurses to not chart a medication was given if it was not given. The DON further stated the risk to the residents who did not receive medications as ordered, and missed doses of medication, was poor wound healing and not getting the required dose that was prescribed for a specific diagnosis. A review of the facility's policy and procedure titled, Medication Administration dated 9/18, indicated, .Medications are to be administered in accordance with written orders of the prescriber .Medications are administered within 60 minutes of scheduled time .If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time .An explanatory note is entered .

Based on observation, interview, and record review, the facility failed to ensure safe medication storage for a census of 67 when: 1. Employee's personal items were stored in two of two medication storage rooms (a locked room for storage of medication and supplies); and, 2. Expired medication was available for use in medication cart (a mobile cart containing medications used daily to give medications to the residents) #2, located on the Sequoia unit. These failures may pose unsafe medication use in the facility. Findings: 1a. During an inspection on [DATE] at 9:44 AM, of the facility's Sequoia unit medication room with Licensed Nurse (LN) 4, the cabinet under the sink was observed to contain employee's personal items. The following items were observed and confirmed with LN 4: An opened partial bottle of water in a plastic container, two coffee cups, and two tote style bags with personal belongings and a printed copy of the staffing schedule laying on top of one of the bags. All items were located under the sink. 1b. During an inspection on [DATE] at 4:15 PM, of the facility's Redwood/Harmony unit medication room with LN 5, the countertop contained a navy water bottle with a strap, a multicolored backpack, and a lunch box, all confirmed by LN 5. LN 5 stated the personal items belonged to staff. Under the sink another personal bag was observed and confirmed by LN 5. LN 5 stated staffs' personal belongings should not be in the medication rooms or under the sinks. During an interview on [DATE] at 11:19 AM, the Administrator (ADM) stated staffs' personal belongings were not allowed in the medication rooms or under the sinks. 2. During an inspection on [DATE] at 12:02 PM, of medication cart #2, located on the Sequoia unit with LN 7, an opened foil package of Ipratropium bromide/albuterol (two medications in one for breathing problems) was found with an opened date of [DATE]. The label on the container indicated, .once removed from foil pouch, the individual vials should be used within two weeks . LN 7 confirmed the medication was expired and should have been removed from the medication cart. LN 7 further stated the risk to the resident's if given the Ipratropium bromide/albuterol was they could have a reaction to the medication, it could be too weak, and they would not get the right dose. During an interview on [DATE] at 1:22 PM, with the Director of Nursing (DON), the DON stated the expectation for the medication Ipratropium bromide/albuterol was to remove it from the medication cart 14 days after the foil package was opened. The DON further stated the risk to the residents if given was the medication would not be as effective. A review of a facility policy titled, Medication Storage (Nursing Care Center Pharmacy Policy & Procedure Manual -2007 PharMerica Corp), dated ,d+[DATE], indicated, .Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations .Medication storage should be kept clean .organized, free of clutter .

Based on interview, and record review, the facility failed to ensure one of twenty two sampled residents (Resident 64) had their rights related to treatment choices known and protected when a copy of Resident 64's Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) was not kept in Resident 64's record. This failure had the potential to result in Resident 64's preferences for emergent and end of life treatment to not be followed. Findings: A review of Resident 64's medical record titled, Resident Face Sheet, indicated that Resident 64 was admitted to the facility in early 2024 with diagnoses that included aftercare following right hip joint surgery, fracture of neck of right femur (upper part of the thigh), and need for assistance with personal care. A review of Resident 64's medical record titled, Physician Orders for Life-Sustaining Treatment [POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end of life], dated 1/14/24, indicated Section D that an Advance Directive was discussed with the Resident 64 and that Resident 64 had an Advance Directive. A review of Resident 64's physical chart (paper medical record) at the nurses station, indicated that a copy of Resident 64's POLST was in the chart but no copy of an Advance Directive was found. A review of Resident 64's Electronic Health Record (EHR - information stored in the facility's computer system), indicated that Resident 64's Advance Directive was not uploaded into Resident 64's EHR. During a concurrent interview and record review with the Social Services Director (SSD), on 2/26/25, at 2:34 p.m., the SSD confirmed that there was no copy of an Advance Directive found in Resident 64's EHR. The SSD stated that the Advance Directive copy should have been scanned into Resident 64's EHR. The SSD also confirmed that there was not an Advance Directive copy found in Resident 64's physical chart at the nurses station. The SSD stated that the admitting nurse should have reviewed the POLST information during the admission process and should have ensured that a copy of Resident 64's Advance Directive was obtained if the resident had an Advance Directive. The SSD stated that the importance of having the Advance Directive copy was for the resident's wishes to be known and to determine who would be in charge or appointed if they would not be able to make their own decisions. The SSD added that the POLST and Advance Directive copies should be in the resident's chart because these copies would be taken with the resident if they were transferred out to another facility. During a concurrent interview and record review with the Director of Nursing (DON), on 2/27/25, at 12:47 p.m., the DON confirmed that Resident 64's copy of the Advance Directive was not found in Resident 64's EHR. The DON stated that the copy should be in Resident 64's chart since the POLST form specified that there was an Advance Directive. The DON stated that it was her expectation for the Advance Directive copy to have been in Resident 64's chart at all times. The DON stated that the process involved the admission nurse initiating the POLST form with the resident, responsible party, or family, during the admission process. The DON stated that it was her expectation to get the POLST form completed as soon as possible. The DON further stated that the facility conducts a 72-hour conference after admission with the admitting nurse, Social Services and Admissions Coordinator and they should have reviewed these forms to ensure that they were completed. The DON stated that the importance of having the Advance Directive in the chart was to provide legal guidance when providing care. The DON added that the POLST and Advance Directive forms would go with the resident whenever they were sent or transferred out of the facility. A review of the facility's document titled, Physician Orders for Life-Sustaining Treatment [POLST], dated 10/6/09, indicated .Completing a POLST form with the resident: 1. If the resident or representative chooses to complete a POLST form .Discussion will include the resident's Advance Directive (if done) or other statements the resident has made regarding their wishes for end of life care and treatments . A review of the facility's document titled, Advance Directives, dated 8/13/08, indicated .1. On admission, each resident is asked if they have completed an Advance Health Care Directive .a. If a Directive has been completed, the community shall request a copy to be included in the medical record .3. At least quarterly, the completed Advance Health Care Directive will be reviewed with the resident and their responsible party, as applicable .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 of 2 sampled residents (1) received pain management and x-ray services when: 1. Resident 1 did not receive pain management prior to her physical therapy on 13 of 16 therapy days and was not premedicated for pain prior to six of her [MEDICAL TREATMENT] appointments. This failure led to inadequate pain management of Resident 1's [MEDICAL CONDITION] and spine and contributed to her inability to participate in the physical rehabilitation program from which she was subsequently dropped due to a lack of progress. 2. Nursing staff delayed obtaining a chest X-ray for seven days after it was requested. This failure led to a delay in treatment of [REDACTED]. Findings: 1. The admission record for Resident 1 indicated she was admitted to the facility in January of 2015 for rehabilitation services following a right [MEDICAL CONDITION]. The clinical record for Resident 1 contained the following information: A Plan of Care for potential for pain was initiated on 1/8/15, while Resident 1 was at the acute hospital, 6 days prior to Resident 1's actual admitted . The Plan of Care goal was for Resident 1's pain to be resolved with medication. The nursing approaches included, "Offer pain medications in frequencies indicated per (Medical Doctor (MD)) order; don't wait for residents to ask" and "(Licensed) Nurse to assess resident's highest level of pain for each shift." A nurse's note, dated 1/14/15, indicated Resident 1 was admitted that day with [DIAGNOSES REDACTED]. A physician order, dated 1/14/15, indicated Resident 1's admitting [DIAGNOSES REDACTED]. A physician order, dated 1/14/14, indicated Resident 1 was to be given [MEDICATION NAME] 7.5 milligrams (mg) with 3.25 mgs [MEDICATION NAME] (a narcotic combined with a non-steroidal anti-[MEDICAL CONDITION] pain reliever) every 4 hours as needed for moderate to severe pain. There were no additional orders for [MEDICATION NAME]. A physician order, dated 1/14/15, indicated Resident 1 was to be given [MEDICATION NAME], 325 mg every 4 hours as needed for mild pain. The facility policy titled "Pain Management", revised 5/2011, directed staff to use a pain rating scale of 1-10 when assessing residents for pain. The policy indicated a pain level of 0-3 was mild pain, 4-6 was moderate pain, and 7-10 was considered "severe/excruciating" pain. The clinical record for Resident 1 contained the additional following information: A Physical Therapy Plan of Care, dated 1/15/14, noted Resident 1 was referred to Physical Therapy (PT) following a new fracture of her right hip with "hardware displacement of metal rod previously traversing the neck and entering the head of proximal femur (previously placed metal components connecting the broken portions of an earlier fractured femur had broken loose). Patient was to undergo (orthopedic) procedure (surgical bone repair) but canceled due to complications during start of procedure. The Plan of Care indicated Resident 1 was experiencing a constant pain level of 10/10 to both hips. Under the section titled "Discharge Plans" was written "return to home with family (versus) lower level of care." A care plan, dated 1/15/15, for "Fracture other Than Hip/Vertebra - resident has a fractured lumbar (spine in low back) compression (fracture)" directed nurses to administer pain medications as ordered and at least 30 minutes prior to therapy. A care plan for "[MEDICAL CONDITION]: Resident has potential of complications from [MEDICAL CONDITION]", dated 1/15/15, instructed the nurses to "Assess for pain and medicate per orders. Monitor for response and advise (sic) physician of possible side effects. " A nurse's note, dated 1/15/15 and written at 7:54 p.m., indicated the nurse contacted MD 1 to notify him the [MEDICAL TREATMENT] clinic stated Resident 1 had to be able to transfer into a chair. The MD from the [MEDICAL TREATMENT] center stated he wanted her at [MEDICAL TREATMENT] "no matter what" tomorrow. MD 1 stated to call the Orthopedic Physician (OP - bone, muscle, and joint specialist) in the morning and "see what his recommendation is about the weight bearing." ([MEDICAL TREATMENT] is the process of removing impurities from the blood by circulating a patient's blood from their body through a machine to filter the impurities. [MEDICAL TREATMENT] clinics provide the treatment on an outpatient basis and the patients sit in specific reclining [MEDICAL TREATMENT] seats during the treatment.) A nurse's note, dated 1/16/15 and written at 9:23 a.m., indicated a telephone call was made to the OP in regards to Resident 1's bed rest and non-weight bearing status. The OP was informed the [MEDICAL TREATMENT] center was "unable to dialyze the resident until weight bearing status changed". The OP gave new orders for weight bearing as tolerated. The note then indicated a telephone call was made to Responsible Party (RP) 2 to notify her of the change to "weight bearing" status. The note reflected RP 2 had expressed concerns about this change in status. The note explained the facility would transfer Resident 1 from her bed to a gurney, and then the [MEDICAL TREATMENT] clinic staff would transfer her from the gurney to a [MEDICAL TREATMENT] chair. There was no documentation nursing staff identified the potential for increased pain relating to the change in Resident 1's weight bearing status. The "Therapy Specialists Physical Therapy Daily Documentation" (PTD), dated 1/16/15, indicated Physical Therapist (PT) 1 had noted Resident 1's pain level as 8 of 10 at the time of the therapy. (Per facility policy, this pain level was categorized as "severe/excruciating.") The Medication Administration Records (MAR), dated 1/16/15, indicated nursing staff medicated Resident 1 with [MEDICATION NAME] at 7:35 p.m. and a single dose of [MEDICATION NAME] was administered at 10:28 p.m. There was no evidence Resident 1 was medicated prior to physical therapy or in response to the PT documentation indicating Resident 1 had a pain level of 8 (severe) at the time of the therapy. The PTD note, dated 1/17/15, indicated Resident 1 experienced a pain level of "6" during her physical therapy that day. (Per facility policy, a pain level of "6" was categorized as "moderate" pain.) A nurse's note, dated 1/17/15 and written at 5:22 p.m., indicated Resident 1 was transferred to the [MEDICAL TREATMENT] center that day. The corresponding MAR entries, dated 1/17/15, indicated the nurses medicated Resident 1 with [MEDICATION NAME] at 7:01 p.m. and [MEDICATION NAME] at 10:28 p.m. There was no evidence Resident 1 was medicated prior to physical therapy, transfer to her [MEDICAL TREATMENT] appointment, or in response to the PT documentation she was experiencing moderate pain during the therapy. A nurse's note, dated 1/19/15 and written at 6:50 a.m., indicated Resident 1 was transported to her [MEDICAL TREATMENT] appointment at 5:45 a.m. The MAR entries, dated 1/19/15, indicated [MEDICATION NAME] was administered to Resident 1 at 10:30 a.m. No [MEDICATION NAME] or [MEDICATION NAME] had been administered to Resident 1 prior to transporting her to her [MEDICAL TREATMENT] appointment at which she was expected to stand up with her unrepaired spinal fracture. The PTD note, dated 1/20/15, indicated Resident 1 experienced a pain level of 8 (severe) during her physical therapy session. The corresponding MAR entries, dated 1/20/15, indicated no pain medications had been administered to Resident 1 on 1/20/15. The PTD note, dated 1/21/15, indicated Resident 1 experienced a pain level of 8 (severe) during her physical therapy session that day. The corresponding MAR entries, dated 1/21/15, indicated Resident 1 had been medicated with [MEDICATION NAME] at 5:16 a.m. No [MEDICATION NAME] (the medication ordered for moderate to severe pain) was administered to Resident 1 on that day. The PTD note, dated 1/22/15, indicated Resident 1 experienced a pain level of 6 (moderate) during her therapy session that day. The corresponding MAR entries, dated 1/22/15, indicated [MEDICATION NAME] was administered to Resident 1 at 4:35 a.m. No [MEDICATION NAME] was administered to Resident 1 that day. The PTD note, dated 1/23/15, indicated Resident 1 experienced a pain level of 8 (severe) during her therapy session that day. A hand written note indicated, "Resident did not want to get out of bed, complaining of pain (with) (right) hip. " A nurse's note, dated 1/23/15 and written at 4:04 p.m., indicated Resident 1 had returned from [MEDICAL TREATMENT] at 11:30 a.m. that morning. The nurse indicated Resident 1 had, "No complaints of pain." The corresponding MAR entries, dated 1/23/15, indicated [MEDICATION NAME] was administered to Resident 1 at 3:50 p.m. There were no additional notes to explain why the [MEDICATION NAME] was administered to Resident 1 or if it was effective. There was no evidence Resident 1 had received any pain medication prior to her transfer to the [MEDICAL TREATMENT] clinic, prior to the physical therapy, or after the physical therapist had noted Resident 1 had refused therapy because of pain. The PTD note, dated 1/26/15, indicated Resident 1 had experienced a pain level of 8-10 (severe) during her physical therapy that day. The physical therapy aide had noted Resident 1 was complaining of low back and right hip pain of 8-10 out of 10 and a licensed nurse was made aware. The corresponding MAR entries, dated 1/26/15, indicated no pain medication was administered to Resident 1 on that day. The PTD note, dated 1/27/15, indicated Resident 1 experienced a pain level of 8 (severe) during her physical therapy session that day. The corresponding MAR entries, dated 1/27/15, indicated [MEDICATION NAME] was administered to Resident 1 at 12:46 a.m. [MEDICATION NAME] was administered to Resident 1 at 1:31 a.m., 2:23 a.m., and 6:30 p.m. No pain medication had been administered during the hours preceding her physical therapy, as per her plan of care. The PTD note, dated 1/29/15, indicated Resident 1 experienced a pain level of 6-8 (moderate) during her physical therapy session that day. The corresponding MAR entries, dated 1/29/15, indicated no pain medications were administered to Resident 1 that day. A Care Plan Conference Summary, dated 1/28/15, noted the Responsible Party (RP) for Resident 1 had requested a physician order [REDACTED]. The note indicated, "Faxed form placed at (MD notification) binder." (The MD notification binder was the collection point for non-emergency communications directed to the physician.) There was no further documentation to demonstrate facility staff had notified the physician of the request for more pain medication. The PTD note, dated 1/30/15, indicated the physical therapist was unable to assess Resident 1's pain level that day during the physical therapy session. The corresponding MAR entries, dated 1/30/15, indicated no pain medications were administered to Resident 1 that day. The PTD note, dated 1/31/15, indicated the physical therapist had been unable to assess Resident 1's pain level that day during the physical therapy session. A nurse's note, dated 1/31/15 and written at 2:30 p.m., indicated Resident 1 returned from [MEDICAL TREATMENT] at 12 p.m. The corresponding MAR entries, dated 1/31/15, indicated no pain medications had been administered to Resident 1 that day. The PTD note, dated 2/2/15, indicated Resident 1 experienced a pain level of 8 (severe) during her therapy session that day. The physical therapy aide (PTA) noted, "(Resident 1) was seen twice today in therapy. (Resident 1) came back before lunch (after) [MEDICAL TREATMENT]. Pre medicated per nurse. (Resident 1) (complained of) back pain. Afternoon (Resident 1) refused to sit (on the edge of the bed). Nurse/(Supervisor) made aware regarding (Resident 1's) participation in therapy today." The corresponding MAR entries, dated 2/2/15, indicated no pain medication was administered to Resident 1 despite her transport to the [MEDICAL TREATMENT] clinic and 2 attempts to provide therapy with a reported pain level of 8 (severe). The PTD note, dated 2/3/15, indicated Resident 1 experienced a pain level of 8 (severe) during her therapy session that day. The corresponding MAR entries, dated 2/3/15, indicated [MEDICATION NAME] had been administered at 8:32 a.m. and again at 5:59 p.m. No [MEDICATION NAME] had been administered that day. The Physical Therapy Discharge Summary, dated 2/4/15, noted original goals for Resident 1 included the resident "will safely roll from side to side increasing to moderate assistance (26-75% assist)." At the beginning of therapy she required maximum assistance of 2 staff to roll from side to side. At the end of therapy she continued to require maximum assistance of 2 staff to roll from side to. The Summary indicated Resident 1 had not met her goal as of 2/4/15 and under the section titled "Explanation" was noted "pain on (right) hip, weakness". The Physical Therapy Discharge Summary, dated 2/4/15, noted original goals for Resident 1 included the resident "will safely transition from supine (lying) (to and from) sitting position increasing to moderate assistance (26-75% assist)." At the beginning of therapy she required maximum assistance to transition from supine to sitting. At the end of therapy she continued to require maximum assistance to transition from supine to sitting. The Summary indicated Resident 1 had not met her goal as of 2/4/15 and under the section titled "Explanation" was noted "pain on (right) hip, weakness". The Physical Therapy Discharge Summary, dated 2/4/15, noted original goals for Resident 1 included the resident "will safely perform all functional transfers increasing to moderate assistance (26-75% assist)." At the beginning of therapy she required maximum assistance to safely complete all functional transfers. At the end of therapy she continued to require maximum assistance of 2 to safely complete all functional transfers. The Summary indicated Resident 1 had not met her goal as of 2/4/15 and under the section titled "Explanation" was noted "pain on (right) hip, weakness, poor balance." The Physical Therapy Discharge Summary, dated 2/4/15, noted the analysis of Resident 1's long term goals as "(Resident 1) had shown slow and inconsistent progress in functional mobility from (start of care). (discharged from) skilled PT at this time and refer to (Restorative Therapy Assistant) for exercises to maintain joint integrity." Under the section titled "Impact on Burden of Care/Daily Life" the summary indicated, "Complicating factors, including (complaints of) (right) hip pain prevent the patient from achieving all established goals." The discharge instructions noted Resident 1 was discharged to long term care. A nurse's note, dated 2/9/15, indicated Resident 1 returned from [MEDICAL TREATMENT] at 3:30 p.m. The corresponding MAR entries, dated 2/9/15, indicated Resident 1 was medicated with [MEDICATION NAME] at 2 a.m. that morning. No [MEDICATION NAME] was provided that day. The facility policy titled "Pain Management", revised 5/2011, instructed nursing staff to administer pain medications before pain becomes severe. Responses to as-needed pain medication were to be documented on the MAR. The purpose of the policy was, "To assure an accurate assessment of the resident's pain and respond in a timely manner with administration of pain medication ..." The procedures included, "Any resident with an increase in pain to moderate or higher [MEDICATION NAME] 3 days will be reviewed by the Pain Management Committee." The procedures directed, "The licensed nurse shall administer (as-needed) pain medications as ordered per resident request and/or pain score of 4 or higher." The procedures also directed, "If pain ...not relieved with the current medication ..., notify the physician for a review of medications." An interview was conducted with PTA 1 on 2/18/15 at 2 p.m. He reported he had worked with Resident 1, but she was inconsistent with her participation in therapy. He reported she had complained of pain, but it was always his practice to verify with the nursing staff that residents were pre-medicated before therapy was started. An interview was conducted with Physical Therapist (PT) 1 on 2/18/14 at 2:15 p.m. She reported Resident 1 made very little progress during her therapy and was inconsistent with her participation. She reported she verified that Resident 1 had been pre-medicated prior treatment, but the pain was still limiting. An interview was conducted with the Director of Nurses (DON) on 2/18/15, beginning at 3:30 p.m. She reviewed the MARs and the PT notes and confirmed Resident 1 was not routinely medicated for pain prior to her therapy treatments, per her care planned intervention. She stated nursing staff did not bring Resident 1's pain issues to the attention of the Pain Management Committee. She confirmed there was evidence PT had coordinated with nursing regarding the pain Resident 1 was experiencing, but the nurses had not provided treatment or documentation. The DON explained an MD notification binder was at each nursing station and was used as a means of communication with physician. She verified most of the pain medication administered to Resident 1 did not correlate with normal therapy hours. Finally, she confirmed there was no evidence the RP request on 1/29/15 for additional pain management was forwarded to the physician. An interview was conducted with CNA 1 on 2/18/15 at 4:05 p.m. She reported Resident 1 complained her legs hurt. She stated Resident 1 complained of pain when they tried to sit her up at dinner time. An interview was conducted with PT 2 on 2/18/15 at 3:50 p.m. She reported normal hours for the therapy sessions would be between 7 a.m. and 6 p.m. A second interview was conducted with PT 1 on 2/18/15 at 4:25 p.m. She reported she always ensured Resident 1 was medicated prior to beginning therapy. If Resident 1 was still experiencing pain she would wait and come back after the medication became more effective. Resident 1 complained of pain in both legs and initially refused to participate. PT 1 stated, "Mostly she said 'A lot of pain'". PT 1 reported she had heard from several Certified Nursing Assistants that Resident 1 "always complained of pain." PT 1 reported she was aware Resident 1 had re-fractured her hip and a metal rod was still in her hip from the prior fracture and was now displaced. An observation and interview was conducted with Resident 1 on 2/18/15 at 4:30 p.m. Resident 1 was observed directing staff to place her pillows under her legs in a very specific manner at the time she requested them to turn her. As the staff turned her she grimaced and yelled out. She was able to communicate her needs in limited English and gesturing. When asked directly how much pain she usually experienced in her hip and back she reported, "Sometime 3-4, sometime 10." She further reported they sometimes give her something for pain and sometimes they did not. An interview was conducted with CNA 2 on 2/18/15 at 4:35 p.m. She reported Resident 1 "can't tolerate sitting up because her leg is very painful." She reported Resident 1 yelled out in pain whenever they turned or moved her. She stated, "The nurses are aware of her condition. I'm assuming she is getting pain medication when nurses pass meds at 4 p.m." An interview was conducted with RP 2 on 2/19/15 at 9:15 a.m. She reported she had cared for Resident 1 prior to the new fracture. She was administering 10 mg of [MEDICATION NAME] to Resident 1 every 6 hours around the clock. She reported she asked for help, but they walked away. She tried to explain Resident 1 was in pain. She reported the nurses told her Resident 1 was getting [MEDICATION NAME] for pain. She reported Resident 1 was still complaining of pain and she did not know what kind of pain medication she was getting because it was crushed when they brought it to her. An interview was conducted with LN 2 on 2/19/15 at 10:30 a.m. She reported it was facility practice for nursing staff to pre-medicate prior to therapy, but denied any knowledge the therapist reported Resident 1's pain levels to her. An interview was conducted with LN 3, a unit manager, on 2/19/15 at 10:45 a.m. She reported she expected the PT to notify her if Resident 1 was experiencing any pain during therapy, but she did not recall any conversations with the PT regarding any pain Resident 1 was experiencing. LN 3 further reported she was unaware Resident 1's plan of care directed nursing staff to pre-medicate for pain prior to therapy sessions. An interview was conducted with Medical Doctor (MD) 1 on 2/24/15 at 10:30 a.m. He reported he reviewed Resident 1's clinical record prior to the interview. MD 1 stated he would have expected the nursing staff to medicate Resident 1 for pain prior to activity. He reported activity included all the movement associated with transportation to the [MEDICAL TREATMENT] clinic and physical therapy sessions. He confirmed he was not made aware of RP 1's request for routine pain medication at the time she requested it at the care conference on 1/29/15. An interview was conducted with RP 1 on 3/12/15 at 11:30 a.m. She reported Resident 1 was receiving 10 mg of [MEDICATION NAME] every 6 hours while she was being cared for at home prior to the new hip/spine fractures. She was concerned a lack of sufficient pain management impeded Resident 1's ability to participate in therapy and she wanted the facility to fully medicate for pain because the physical therapy would be discontinued due to a lack of participation on the part of the Resident. She reported she thought Resident 1 was getting the additional pain medication after she had requested it on 1/29/15. She reported when she went back to the facility on either 2/7/15 or 2/9/15, Resident 1 told her she was still having pain. RP 1 asked the nurse about Resident 1's pain medications and learned the medication was still being offered only as-needed. She asked the nurse to follow up with her original request for scheduled pain medication at the care conference, but the nurse "made excuses" for not following up, and she did not believe the physician was contacted after this conversation. An interview was conducted with the Director of Nurses on 3/17/15 at 10:40 a.m. She reported the therapists consistently notified the nursing staff whenever a resident was experiencing pain during therapy. She confirmed the nursing staff had not provided pain management in response to the information shared by the physical therapists. 2. The clinical record for Resident 1 contained the following information: A faxed communication note to the physician, dated 1/22/15, indicated the Respiratory Therapist (RT) noted Resident 1 was experiencing wheezing, crackles (lung sounds indicative of a possible infection), and thick yellow secretions. The RT had requested an order for [REDACTED]. The physician had agreed to the request for a chest X-ray on 1/24/15, two days later. A nursing note, dated 1/22/15 and written at 6:07 p.m., indicated LN 1 had placed the communication form in the MD notification binder for MD 1. An RT note, dated 1/22/15, indicated the RT had requested an order for [REDACTED]. There was no evidence in the clinical record nursing staff followed up with MD 1's order for the chest X-ray on 1/24/15. An RT note, dated 1/27/15, indicated Resident 1 continued to have thick yellow secretions and labored breathing. The RT documented she was still awaiting the results of the X-ray she had requested on 1/22/15. MD 1 re-ordered the chest X-ray on 1/27/15 that he originally ordered on [DATE]. A nurse's note, dated 1/27/15 at 11:08 p.m., indicated the LN was still waiting for the X-ray service who earlier confirmed an X-ray technician would be out by midnight. A nurse's note, dated 1/28/15 at 7:37 a.m., indicated the LN received a call from the X-ray service explaining circumstances prevented them from coming the prior evening. The note indicated the X-ray technician would be coming that day. There were no further notes addressing the delayed chest X-ray that day. There was no indication nursing staff had informed the nursing supervisors the order for the X-ray was not implemented. On 1/29/15 the X-ray technician obtained the X-ray. The X-ray report, noted at 1:27 p.m., the presence of mild lung infiltrates (fluid pooling at the base of the lungs, an indication of pneumonia). A Nurse Practitioner reviewed the X-ray results and indicated the presence of new orders in response to the X-ray results. On 1/29/15 MD 1 ordered [MEDICATION NAME] (an antibiotic), 500 mg, once a day for 10 days. He also ordered laboratory tests. An interview was conducted with the Director of Staff Development on 2/25/15 at 2 p.m. She reviewed Resident 1's clinical record and confirmed the following: 1. The original request for the X-ray was placed in the MD notification binder and had not been faxed to the MD. 2. MD 1 did not provide an order for [REDACTED]. 3. The nursing staff failed to implement the order for the chest X-ray received on 1/24/15. 4. The X-ray technician failed to perform the X-ray services for 2 days after MD 1 re-ordered the X-ray on 1/27/15. 5. There was no documentation in the clinical record to indicate nursing staff had brought the delay of service to the attention of MD 1 or to nursing management. An interview was conducted with the RT on 2/25/15 at 3:45 p.m. She reviewed the notes she had written in Resident 1's clinical record and reported she expected her initial request on 1/22/15 for an order for [REDACTED].