Every finding on record at Mission Care Center

Based on interview and record review the facility failed to implement timely and appropriately the facility's policy and procedures for infection control of scabies (a tiny skin bug infestation caused by microscopic mites that burrow under the skin, leading to severe itching and a pimple-like rash) outbreak control measures for three of three sampled residents (Resident 1, Resident 2, & Resident 3). The facility failed to: 1.Identify and maintain an ongoing surveillance (line listing) for all facility staff, specifically including nursing and non nursing personnel, who were in direct contact with Resident 1 (admitted on [DATE] with diagnosis of scabies) and Resident 2 (diagnosed on [DATE] with scabies), as recommended by the Acute Communicable Disease Control (ACDC) Program, Scabies Prevention and Control Guidelines. However, the facility only provided names of licensed nurses and CNAs on the line listing. 2. Place Resident 2 on contact isolation (separation of residents with an infection from residents without an infection) 7/17/2026 when resident was suspected (thought to exist) of having scabies infection due to skin rashes. 3. Placed Resident 2 on contact isolation when Family 1 (FM1) made the facility aware via phone and fax report of laboratory test results from the dermatologist (a physician specialized in skin diseases) office that the resident was confirmed with positive of scabies infection on 7/23/2026. 4. Notify Resident 2's physician after the facility was informed on 7/23/2026 by FM 1 that the laboratory result of Resident 2 was positive for scabies infection. 5. Refer Resident 2's to a dermatologist as ordered by the primary physician due to persistent rashes for three months on 5/12/2026, 6/10/2026, 7/4/2026. 6. Placed Resident 3 on contact isolation when the resident was suspected of having scabies on 7/14/2026, due to itching and skin redness with flaky skin rash. 7. Ensure Certified Nursing Assistant (CNA) 1 who reported she had close contact with Resident 2 on 7/24/2026 in am when providing care without gown because she was not informed that Resident 2 was on contact isolation for scabies. The failure had the potential to lead to continued spread of scabies infection within the facility, delayed diagnosis and treatment for affected residents, increased discomfort and skin irritation, unnecessary exposure of staff and visitors, and further environmental contamination (spread of infection from one person or object to another). Findings: 1. During a review of Resident 1's admission Record (AR) dated 6/26/2026, the AR indicated the facility admitted Resident 1 on 2/25/2019 and readmitted from the General Acute Care Hospital (GACH) on 6/26/2026 with diagnosis of scabies. During a review of Resident 1's History and Physical (H&P) dated 6/30/2026, the H&P indicated scabies confirmed by dermatologist biopsy on 5/2026. During a review of Resident 1's physician order dated 6/29/2026, the order indicated to observe contact isolation for scabies/rashes, place in a single room isolation, all services brought to the resident. Physical therapy and occupational therapy five times a week for four weeks. During a review of Resident 1's care plan titled Left Arm Scabies dated 6/27/2026, the care plan indicated interventions to administer treatment as ordered. During a review of Resident 1's physician order dated 6/29/2026, the order indicated to apply Permethrin cream (a prescription cream used to treat scabies) 5% to all over body apply from neck to toes leave on for 8-12 hours and wash off in the morning. During a review of Resident 1's Biopsy Result on 7/22/2026, the Biopsy Results indicated the right superior back resulted with skin biopsy positive for scabies. 2. During a review of Resident 2's admission Record (AR) dated 12/6/2025, the AR indicated the facility admitted Resident 2 on 12/6/2025, with diagnoses including metabolic encephalopathy (a generalized malfunction of the brain caused by a chemical imbalance in the body), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) hemiplegia and hemiparesis (paralysis that affects just one side of the body-either the left or the right side, Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive (the ability to process thoughts) skills were severely impaired. The MDS also indicated that Resident 2 was dependent on staff for personal hygiene, putting and taking off footwear, lower and upper body dressing, shower/bathe self, toileting hygiene, and oral hygiene. During a review of Resident 2's physician order dated 5/8/2026, the order indicated to apply Triamcinolone acetonide cream (a prescription synthetic corticosteroid used to reduce skin inflammation, relieve itching). The physician order directed to apply to affected area topically (applying medicine directly to a specific surface area of the body) one time a day for itchiness. During a review of Resident 2's medical examination dated 5/12/2026, the medical examination indicated an order for dermatology consultation and to start Resident 2 on Loratadine (a non-drowsy antihistamine used to relieve allergy symptoms, including hives and itching), 10 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) every day. During a review of Resident 2's medical examinations dated 6/10/2026, 7/4/2026, and 7/14/2026, the medical examination records indicated recommendations for dermatology consultations due to a rash. Further review of Resident 2's records indicated no evidence that Resident 2 was referred by the facility to be examined by a dermatologist due to the rash. During a review of Resident 2's physician order dated 7/24/2026, the order indicated that the resident was to be placed on contact isolation for scabies, remain in single room isolation, and have all services brought to the resident. During a review of Resident 2's physician order dated 7/24/2026, the physician order indicated to administer Ivermectin (an FDA-approved medication used to treat parasitic infections) 3 mg give 4 tablets by mouth for eight days. During a review of Resident 2's Medication Administration Record (MAR) for July 2026, the MAR indicated that the first dose of Ivermectin 3 mg was administered to Resident 2 on 7/24/2026 at 2:30 PM. 3. During a review of Resident 3's admission Record (AR) dated 1/8/2026, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), metabolic encephalopathy (a temporary brain dysfunction caused by a chemical imbalance in the body) During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognition (the ability to process thoughts) skills were severely impaired. During a review of Resident 3's physician order dated 7/14/2026, the order indicated to perform biopsy on the left arm site #1 biopsy site, and left arm site #2 biopsy site. During a review of Resident 3's Medication Administration Record (MAR) for July 2026, the MAR indicated that on 7/14/2026, Resident 3 received a shower and Permethrin (a prescription-only skin medicine used to treat scabies by killing the mites and their eggs) 5% topical cream was applied from the neck down to the toes and remained on the skin for 12 hours. During a review of Resident 3's Biopsy Results dated 7/17/2026, the biopsy results were scaling eczematous dermatitis (red, flaky, skin rash). During a review of Resident 3's physician order dated 7/25/2026, indicated an order, pending biopsy results, for the resident to be placed on contact isolation for scabies, remain in single room isolation, and have all services brought to the resident. During an interview on 7/24/2026 AT 3:11 PM with Certified Nurse Assistant (CNA1), CNA 1 stated that on 7/24/2026 at 8AM, she did not put on a gown when she assisted Resident 2 position in bed and set-up Resident's 2 breakfast, because she was not informed by the licensed staff that Resident 2 had scabies and was placed on contract isolation. During an interview on 7/24/2026 at 3:52 PM with Resident 3, Resident 3 was observed in the activity room with four residents. Resident 3 was observed with skin raised bumps over Resident 3's left forearm and Resident 3 complained of itchiness. During an interview on 7/25/2026 at 10:06 AM with the Infection Preventionist (IP), the IP stated Resident 2 was added to the facility's line list on 7/24/2026. The IP acknowledged that all health care workers who had direct contact with Residents 1 and 2 including physical therapy, occupational therapy, speech therapy, activities, Restorative Nurse Assistant (RNA), should have been added to the contact/suspect case list for surveillance but were not added. During an interview on 7/25/2026 at 10:34 AM with Resident 2's family member (FM 1), FM 1 stated FM1 verbalized to the facility the concern for the resident's persistent rash that had been ongoing for two months. FM 1 stated that the physician had informed FM1 that Resident 2 needed a dermatologist consult. FM 1 stated Resident 2 had a dermatologist consultation on 7/17/2026 during which a skin biopsy was performed. On 7/23/2026, FM 1 stated she received a call from the dermatologist that Resident 2 had scabies. FM 1 stated she immediately called the facility and spoke to TXN 1. TXN 1 asked FM 1 for the scabies results in writing. FM 1 obtained the positive skin biopsy report, which were positive for scabies, and faxed the report to the facility on 7/23/2026 at 4:07 PM. During an interview on 7/25/2026 at 2:25 PM with the Director of Nurses (DON), the DON stated that when Resident 2 developed a persistent rash, scabies were not suspected. The DON further stated that moving forward, the facility would include scabies in the differential diagnosis for residents with a persistent rash. The DON stated Resident 3 should have been placed on contact isolation when Resident 3 was treated as a suspected scabies case. The DON stated that it is important to maintain a complete case list of suspected of having scabies, as well as all health care workers who had contact with suspected residents for surveillance purposes. The DON stated that contact isolation was not initiated for Resident 2 until 7/24/2026 because the facility could not accept FM 1's verbal report and waited until faxed biopsy results were received. During a review of ACDC's Scabies Prevention and Control Guidelines for Healthcare Settings, revised on 2/2026, the guidelines indicated that healthcare facilities should implement a scabies prevention program involving all levels of the healthcare team. Itching, rashes, and skin lesions should be documented and brought to the attention of the nursing supervisor and attending physician for further follow-up such as residents suspected of having scabies any resident suspected of having scabies will immediately be placed on contact precautions until examined for scabies. Access to and use clinicians and other healthcare consultants in recognizing scabies is recommended to evaluate difficult or unusual cases. Line staff should be evaluated and treated as appropriate, and in-house residents and exposed discharged residents should be monitored if a scabies outbreak occurs. During a review of the facility's policy and procedure (P&P) titled IPCP Standard and Transmission-Based Precautions revised on 10/2025, indicated that contact precautions are consulted with public health authorities.

Based on interview and record review the facility failed to ensure physician and family notification of one of three residents (Resident 2's) change in condition when Resident 2 was monitored for and sustained self-inflicted scratches for six days. This deficient practice had the potential to delay physician evaluation and treatment, resulting in worsening of the resident's condition and failure to implement timely interventions. Findings: During a review of Resident 2's admission Record (AR) dated 12/6/2025, the AR indicated the facility admitted Resident 2 on 12/6/2025, with diagnoses including metabolic encephalopathy (a generalized malfunction of the brain caused by a chemical imbalance in the body), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) hemiplegia and hemiparesis (paralysis that affects just one side of the body-either the left or the right side). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/14/2026, indicated Resident 2's cognitive (the ability to process thoughts) skills were severely impaired. MDS also indicated that Resident 2's is dependent on staff for personal hygiene, putting and taking off footwear, lower and upper body dressing, shower/bathe self, toileting hygiene, and oral hygiene. During a review of Resident 2's Progress Notes dated 7/7/2026, at 10:03 AM a progress note entered by the Treatment Nurse (TXN 1) as a late entry on Resident 2's medical record on 7/24/2026 indicated Resident 2 was assessed for generalized rash involving multiple areas of the body, diffuse erythematous (skin is red) rash remains present with scattered lesions observed with on and off pruritus (itching) the family and provider were notified. During a review of Resident 2's Order Summary Report dated 7/13/2026, the Order Summary Report indicated to monitor for self-inflicted scratches every shift for 14 days. During a review of Resident 2's Progress Notes dated 7/14/2026, at 12:58 PM a progress note entered by TXN 1 as a late entry on Resident 2's medical record on 7/24/2026 indicated Resident 2 was reassessed with a generalized rash, a rash that remained present with no significant improvement and the family and provider were notified. During a review of Resident 2's Medication Administration Record (MAR) dated 7/13/2026, Resident 2 had episode of self-inflicted scratches on 7/14/2026, 7/15/2026, 7/16/2026, 7/17/2026, 7/20/2026, and 7/24/2026. During a concurrent interview and record review on 7/25/2026 at 2:13 PM Resident 2's MAR dated 7/14/2026, LVN 1 documented episode of self-inflicted scratches during the day shift. LVN 1 stated Resident 2 sustained self-inflicted scratches, documented the event on the MAR, did not notify the physician, and did not initiate interventions or care plan to address Resident 2's self-inflicted scratches. Record review revealed no care plan and no interventions addressing the resident's self-inflicting scratching. LVN 1 stated the physician and Resident 2's family should have been notified to address the self-inflicting scratches. During an interview with the DON on 7/25/2026 at 5:24 PM, DON stated the assessments entered on Resident 2's chart was not performed by the TXN 1 the physician and the family when not made aware of the change in condition. During a review of the facility's Policy and Procedure (P&P) titled Change of Condition Reporting revised on 9/2025, the P&P indicated that all changes in a residents' condition are to be communicated to the physician. The P&P indicated that the Licensed nurse would notify the resident's family of changes in condition and document the notification. Additionally, the P&P indicated that residents with acute medical changes and some routine changes are to be included on the 24-hour report and residents progress and needs are to be clearly communicated at each shift report.

Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan to address Resident 2's self-inflicted scratches in accordance with facility's Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Planning This deficient practice had the potential to result in delayed wound healing, increased skin infection risk, and worsened tissue damage. Findings: During a review of Resident 2's admission Record (AR) dated 12/6/2025, the AR indicated the facility admitted Resident 2 on 12/6/2025, with diagnoses including metabolic encephalopathy (a generalized malfunction of the brain caused by a chemical imbalance in the body), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) hemiplegia and hemiparesis (paralysis that affects just one side of the body-either the left or the right side, Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/14/2026, indicated Resident 2's cognitive (the ability to process thoughts) skills were severely impaired. MDS also indicated that Resident 2's is dependent on staff for personal hygiene, putting and taking off footwear, lower and upper body dressing, shower/bathe self, toileting hygiene, and oral hygiene. During a review of Resident 2's Order Summary Report dated 7/13/2026, the Order Summary Report indicated to monitor for self-inflicted scratches every shift for 14 days. During a review of Resident 2's Progress Notes dated 7/14/2026 at 12:58 PM, the Progress Note written by treatment nurse (TXN) 1 as a late entry on 7/24/2026 indicated Resident 2 was reassessed with a generalized rash, a rash that remained present with no significant improvement and the family and provider were notified. During an interview on 7/25/2026 at 2:13 PM with Licensed Vocational Nurse (LVN 1), LVN 1 stated that a care plan should have been implemented for Resident 2 when Resident 2 was identified with self-inflicted scratches and monitoring was ordered by the physician. During an interview on 7/25/2026 at 2:25 PM with Director of Nurses (DON), DON stated that a care plan should have been implemented for Resident 2 when self-inflicted scratches were observed and monitoring was ordered by the physician. DON stated that nursing should have a care plan to guide the nurses with interventions to manage Resident 2's skin condition. DON also stated that when Resident 2 was observed to have a change of skin condition a comprehensive person-centered care plan should have been implemented. During a review of the facility Policy and Procedure (P&P) Comprehensive Person-Centered Care Planning revised on 10/2025, indicated, that the care plan will include healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality of care.

Based on observation, interviews, and record review, the facility failed to maintain complete and accurate clinical records for one of three sample residents (Resident 2). Skin assessment and interventions were documented for Resident 2 on dates when the assigned treatment nurse (TXN 1) reported she was on vacation and did not perform the assessments. This resulted in an inaccurate documentation. This deficient practice resulted in an inaccurate documentation that did not accurately reflect Resident 2's care provided, potentially delaying appropriate interventions. Findings: During a review of Resident 2's admission Record (AR) dated 12/6/2025, the AR indicated the facility admitted Resident 2 on 12/6/2025, with diagnoses including metabolic encephalopathy (a generalized malfunction of the brain caused by a chemical imbalance in the body), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) hemiplegia and hemiparesis (paralysis that affects just one side of the body-either the left or the right side). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 6/14/2026, indicated Resident 2's cognitive (the ability to process thoughts) skills were severely impaired. MDS also indicated that Resident 2's is dependent on staff for personal hygiene, putting and taking off footwear, lower and upper body dressing, shower/bathe self, toileting hygiene, and oral hygiene. During a review of Resident 2's Progress Notes dated 7/7/2026, at 10:03 AM a progress note entered as a late entry on Resident 2's medical record on 7/24/2026 indicated Resident 2 was assessed for generalized rash involving multiple areas of the body, diffuse erythematous (skin is red) rash remains present with scattered lesions observed with on and off pruritus (itching) the family and provider were notified. During a review of Resident 2's Progress Notes dated 7/14/2026, at 12:58 PM a progress note entered as a late entry on Resident 2's medical record on 7/24/2026 indicated Resident 2 was reassessed with a generalized rash, a rash that remained present with no significant improvement and the family and provider were notified. During a concurrent interview and record review on 7/25/2026 at 2:25 PM Resident 2's Progress Notes dated 7/7/2026 at 10:03 AM, and 7/14/2026 at 12:58 PM were reviewed with the Director of Nurses (DON), DON stated the expectation of staff is to document findings and interventions as soon as possible. DON stated that DON was not sure why there was no change in condition and care plan initiated when TXN 1 assessed Resident 2's skin and found the generalized rash and rash remained present with no significant improvement. During a concurrent interview and record review on 7/25/2026 at 2:58 PM Resident 2's Nurses Progress dated 7/7/2026, and 7/14/2026 with the TXN 1, TXN 1, stated that based on the documentation on 7/7/2026 at 10:03 AM and 7/14/2026 at 2:25 PM there should have been a change in condition and monitoring as well as a care plan. TXN 1 stated there were none because she did not actually do the assessments, TXN 1 stated she did not see Resident 2 on 7/7/2026 and was on vacation on 7/14/2026, stated she was told by other un-named nurses to document on Resident 2's medical record. During a record review on 7/25/2026 at 5:09 PM of TXN 1's Labor Hours Report (Payroll Timecard) with the DON, DON stated TXN1 was not assigned any duties during the period of (7/13/2026 - 7/17/2026) since TXN 1 was on vacation. During an interview on 7/25/2026 at 5:12 PM with Administrator (ADMIN), ADMIN stated that DON and Administrator (ADMIN) were present on 7/24/2026 and TXN1 did not ask for guidance regarding entering documentation on Resident 2's medical record of the unperformed assessment and interventions on 7/7/2026 and 7/14/2026. During an interview on 7/25/2026 at 5:24 PM with DON, DON stated that for 7/7/2026, and 7/14/2026 the assessments and interventions documented on Resident 2's medical record was not performed by TXN1 but were documented by TXN 1. DON stated that TXN 2 was assigned treatments for 7/14/2026 when TXN 1 was on vacation. During a review of the facility's Sign-In Staff dated 7/14/2026, TXN 2 was assigned and signed in as the Treatment Nurse for 7/14/2026. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation dated 4/2026, the P&P indicated that charting and documentation are legal records that protect the resident, physician, nurse and the facility. The P&P further indicated that documentation serves as a source of information regarding changes in a resident's condition and assists in the development of an individualized plan of care for each resident

Based on interview and record review, the facility failed to provide requested medical records within 48 hours, as written in their policy titled Protected Health Information, for one of three residents sampled for access to medical records (Resident 1) when Family Member (FM) 1 (Resident 1's responsible party [RP]) submitted a written request for Resident 1's medical records on 6/2/2026 at 8:42 AM and the facility did not provide the records until 6/5/2026 at 11:52 AM (75 hours later). This deficient practice violated Resident 1 and his RP's right to timely access to medical information and had the potential to interfere with the RP's ability to make informed decisions regarding Resident 1's care.Findings:During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including encephalopathy (a neurological disorder characterized by impaired brain function, resulting in symptoms such as confusion, memory problems, or changes in behavior) and a communication deficit. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 5/27/2026, the MDS indicated Resident 1 never/rarely made decisions regarding tasks of daily life and was rarely/never understood. During a review of the facility's records request faxed on 6/2/2026 at 8:42 AM, the faxed record indicated a request for a copy of Resident 1's medical records, billing records, itemized billing statements, charges, payments, adjustments, and radiology imaging be sent to FM 1's law firm. During a review of the facility's e-mail sent from the Medical Records Director (MRD) on 6/5/2026 to FM 1's law firm, the e-mail indicated MRD sent Resident 1's medical records to FM 1's law firm on 6/5/2026 at 11:52 AM. During an interview with the MRD on 6/16/2026 at 1:03 PM, the MRD stated that when residents or their RP requested medical records, the facility had 48 hours to send the medical records. The MRD stated that Resident 1's medical records should have been sent to FM 1's law firm within 48 hours but it was not. The MRD further stated that she failed to follow up on FM 1's request because she believed her assistant sent the records, but her assistant did not. The MRD also stated that she did not follow the facility's policy when she did not send Resident 1's medical records to FM 1's law firm within 48 hours. During an interview with the Director of Nursing (DON) on 6/16/2026 at 2:02 PM, the DON stated that it was a resident's and their RP's right to obtain copies of their medical records, and since if the facility did not provide Resident 1's medical records within the specified timeframe of 48 hours, Resident 1's rights were violated. During a review of the facility's Policy and Procedure (P&P) titled, Protected Health Information and revised/reviewed on 11/2025, the P&P indicated, A resident may have access to his or her records within twenty-four (24) hours. of the resident's written or oral request and A resident may obtain photocopies of his/her records by providing the facility with a forty-eight (48) hour. advance notice of such request .

Based on observation, interview, and record review, the facility failed to ensure proper food safety and sanitation practices to prevent foodborne illness (also known as food poisoning caused by consuming contaminated food or water containing bacteria, toxins, viruses leading to symptoms like nausea, vomiting, diarrhea and stomach cramps) to the residents in accordance with the facility's policy and procedure titled Labeling and Dating of Foods. by failing to: 1.Perform hand hygiene after certified nurse assistant (CNA) 1 was observed touching a clean meal tray without washing or sanitizing hands after touching a dirty, soiled meal tray. 2.Perform hand hygiene after [NAME] 1 was observed using a rag to clean the soiled kitchen table surface prior to opening the refrigerator to obtain a bell pepper. 3. Ensure food items stored in a refrigerator and freezer were properly labeled with a use- by date (last date recommended for the use of the product while at peak quality). This deficient practice had the potential to result in contamination of food and food contact surfaces, increasing the risk of foodborne illness to residents. Findings: 1.During a concurrent observation and interview on 3/16/2026 at 8:42 AM with Dietary Supervisor 1, the following were observed: a. Pepperoni that was removed from the original package did not have an open or use by date. b. Two sour cream container was labeled with an open date of 2/25/2026 indicated a use by date of 3/15/2026 or 7 days. c. Dry cereal stored in individual bowls did not indicate an open or use by date. d. Hungarian – style paprika indicated a use by date of 2/1/2026, In a concurrent interview the DS confirmed expired food items should be discarded and stated all food items should be labeled with an open date and follow the storage guidelines. During an interview on 3/6/2026 at 9 AM with the Administrator (ADM), ADM stated food items removed from their original packaging should be labeled with an open date and a use by date. ADM further stated that proper labeling was necessary to ensure food was not spoiled and remained safe for consumption. The ADM stated failure to label food appropriately could cause a health risk to residents. During another observation on 3/16/2025 at 8:37 a.m. in the kitchen, Refrigerator 3 had two expired sour cream containers with the expiration dates of 2/8/2026 and 3/15/2026. During a concurrent observation and interview on 3/17/2026 at 12:05 p.m. with Dietary Supervisor (DS)) 1, DS1 stated consumption of expired dairy products could lead to food poisoning. Cooks are the ones required to discard the expired food items, at the end of each working day. 2.During an observation on 03/16/2026 at 12:22 PM in the dining room, certified nursing assistant (CNA) 1 was observed placing a dirty tray down onto the tray cart and then immediately touching a clean tray without performing hand hygiene or changing gloves. During an interview on 3/16/2026 at 12:28 PM with CNA 1, CNA 1 stated after touching a dirty tray, CNA 1 should have used hand sanitizer after placing the dirty tray down and prior to handling another residents' clean meal tray. During an interview on 3/16/2026 at 12:30 PM with RN 1, RN 1 stated that hand sanitizer should be used between handling a dirty tray and a clean tray. RN 1 stated by not performing hand hygiene in between touching a dirty meal tray and clean meal tray was an infection control issue and had the potential for cross contamination. 3.During a concurrent kitchen observation and interview on 3/17/2026 at 11:49 AM with [NAME] 1, [NAME] 1 was observed using a wet rag obtained from a bucket filled with chemical sanitizer to clean dirty kitchen surfaces, and the proceeded to open the refrigerator and removed bell peppers and placed the bell peppers on the kitchen table. [NAME] 1 did not perform hand hygiene or glove change prior to opening the refrigerator or after using the wet rag. [NAME] 1 stated hand hygiene should have been performed prior to food handling. During an interview on 3/17/2026 at 11: 55 AM with Certified Dietary Manager (CDM), CDM stated not performing hand hygiene after touching dirty services or prior to handling any food item could cause cross contamination and possible illnesses. During a record review of Refrigerated Storage guidelines dated 2023, the guidelines indicated cream, yogurt, cottage cheese, cream cheese, soft cheese, or sour cream had an expiration date of 7 days after opening, or to follow the expiration date, whichever came first. During a review of facility's policy and procedures (P&P) titled Food Handling, dated 2023, the P&P indicated food will be prepared and served in a safe and sanitary manner. All food & nutrition Services personnel will wash their hands prior to handling all food. Food & Nutrition Services personnel should never use bare hand contact with any foods, ready to eat or otherwise. This includes produce washing and food item preparation. Gloves should be changed before handling washed food items, as referenced in the glove use policy. During a review of facility's policy and procedures (P&P) titled Hand Washing Procedure, dated 2023, the P&P indicated Hand washing is important to prevent the spread of infection hands need to be washed after handling soiled dishes and utensils. During a review of facility's policy and procedure (P&P) titled Labeling and Dating of Foods) dated 2023, indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. The food delivered to facility needs to be marked with a delivery or received date. Some cultured dairy products such as milk, cream, yogurt, and sour cream are exempt from food code open date labeling requirements. This food shall be discarded by seven days after opening them. For other food that is commercially processed, ready to eat and intended to be stored cold greater than 24 hours will be marked with a Use By date. The Use by date will incorporate the open date for TCS foods as defined by the Federal Food Code. The Use by date signified the date in which food must be consumed or discarded.

Based on observation, interviews, and record reviews, the facility failed to maintain trash in covered, properly contained, and sanitary receptacles. Three out of 3 large trash bins were observed overflowing with waste on the ground. This failure created the potential for vermin infestation and infection riskFindings: During an observation on 3/16/2026 at 2:21 pm, in the facility's trash bin area, three large trash bins were overflowing with multiple paper cups and paper towels were on the ground next to the trash bins. During an interview on 3/16/2026 at 2:30 pm, with the Dietary Supervisor (DS), the DS stated the trash bins need to be covered and secured at all times. DS stated that overflowing trash bins can develop pests and rodents in the facility. During an interview on 03/19/2026 at 9:39 am, with Director of Nursing (DON), the DON stated that if trash bins are not closed adequately and there is trash on the ground, it can attract vermin (small animals and/or insects like fleas, rats and cockroaches) in the facility which can spread infection. During a review of the facility's policy and procedure (P&P) titled, Garbage and Trash, dated 2023, the P&P indicated all food waste must be placed in sealed leak-proof, non - absorbent, tightly closed containers. The trash must be adequate, clean, vermin - proof areas must be provided for storage of garbage and rubbish.

Based on observation, interview and record review the facility failed to implement the facility's policy and procedure for infection control by failing to: 1.Label the nasal cannula tubing (small, flexible plastic tube inserted into the body to deliver oxygen) for two of three sampled residents (Resident 52 and 27). 2. Ensure License Vocational (LVN) 2, performed hand hygiene (the act of cleaning your hands to remove germs, dirt, and viruses) when entering and exiting a room with Enhance Barrier Precautions (EBP- a protocol requiring staff to perform hand hygiene, using gowns and gloves when entering a resident's room who has a wound vac [medical device that uses suction to accelerate healing in skin wounds]). 3. Ensure the Enhance Barrier Precautions sign was posted outside the room for one of three sampled residents (Resident 52). 4. Ensure LVN 2 performed hand hygiene after administering Resident 10's suppository (a type of medication that is administered through the rectum) and before administering Resident 10s' oral medication. This deficient practice placed the residents at risk of developing infections Findings: 1.During review of Resident 52's medical record, resident was originally admitted on [DATE], diagnosed with acute respiratory failure with hypoxia (when body's tissues and organs do not receive enough oxygen to function properly) and pleural effusion (water on the lungs). During review of Resident 52s's physician orders dated 3/16/2026, the order indicated residents' oxygen tubing be changed every week. During review of Resident 27's medical record, resident was originally admitted on [DATE], diagnosed with chronic obstructive pulmonary disease (lung disease that makes it hard to breathe), immunodeficient (body's immune system is weak) and obstructive sleep apnea (sleep disorder where your breathing repeatedly stops). During review of Resident 27's physician orders dated 2/16/2026, the order indicated residents' oxygen tubing be changed every week. During an observation on 3/16/2026 at 8:50 a.m. in Resident 52's room, Resident 52's nasal cannula tubbing was not dated. During an observation on 3/16/2026 at 8:53 a.m. in Resident 27's room, Resident 27's nasal cannula tubbing was not dated. During an interview on 3/18/2026 at 9:50 a.m. with License Vocational Nurse (LVN) 4, LVN 4 stated, nasal cannula therapy tubing is to be changed and labeled weekly. Not doing so could lead to resident inhaling bacteria. During an interview on 3/18/2026 at 10:08 a.m. with the Director of Staff Development (DSD), DSD sated cannula tubbing is replaced and labeled once a week by the assigned RNs or LVNs. This practice helps staff track how long the nasal tubing has been in use. DSD explained that failure to change the tubing as required could affect the amount of oxygen delivered to the resident. During a concurrent interview and record review on 3/18/2026 at 10:14 a.m. with Infection Preventionist (IP), the facility's policy and procedure (P&P) title, Oxygen Therapy, dated 12/2025 was reviewed. The P&P indicated, nasal cannula tubing is to be replaced every 7 days or as needed when dirty or soiled. Oxygen tubing to be dated when changed. IP stated not changing the oxygen tubbing could cause an infection and bacteria to collect and be passed on to the resident. 2 During a review of Resident 52's physician orders, dated 3/16/2026, the physician orders indicted EBP was needed due to wound vac therapy being used. During a concurrent observation and interview on 3/17/2026 at 12:05 p.m. outside Resident 52's room, LVN 2 did not perform hand hygiene when entering and exiting Resident 52's room who was on EBP. LVN 2 stated he did not perform patient care, therefor did not need to perform hand hygiene when entering and exiting a room. During a concurrent interview and record review on 3/18/2026 at 12:50 p.m. with Infection Preventionist (IP), the EBP sign dated 9/9/2024 was reviewed. The EBP sign indicated everyone must clean their hands on room entry and when exiting a room with EBP in place. If the staff does not perform hand hygiene when entering and exiting a room, it could cause the spread of infections and bacteria amongst all the residents. 3.During an observation on 3/16/2026 at 8:49 a.m., inside Resident 52's room, the resident was lying in bed with a wound vac connected. During an observation on 3/16/2026 at 8:50 a.m. outside Resident 52's room, no EBP sign was posted. During an interview on 3/18/2026 at 12:50 p.m. with Infection Preventionist (IP), IP stated that enhanced barrier precautions (EBP) are implemented when residents have a wound vac in place. The IP further explained that failing to use proper Personal Protective Equipment (PPE) when entering and exiting a resident's room can contribute to the spread of infections and bacteria. 4.During a review of Resident 10's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included left arm fracture (a break in the bone), falls, and cellulitis (skin infection) of the left arm. During a review of Resident 10's History and Physical (H&P), dated 12/26/2025, the H&P did not indicate if the resident has the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 1/23/2026, the MDS indicated that the resident has intact cognition (the ability to process thoughts and emotions). During a review of Resident 10's physician orders included an order dated, 12/25/2026, for Bisacodyl (medication used to treat constipation) Suppository 10 MG (milligram, a unit of measuring weight) Insert 1 suppository rectally every 24 hours as needed for Bowel Care. During a review of Resident 10's physician orders included an order dated, 12/25/2026, for Calcium Carbonate Tablet chewable 500 MG (milligram, a unit of measuring weight) to be give 1 tablet by mouth two times a day for indigestion. During a medication administration observation and interview on 3/17/2026 at 9:24 AM with LVN 2 inside Resident 10's room, LVN 2 stated he will not administer Resident 10's bisacodyl suppository. LVN 2 donned a new pair of gloves and assisted Resident 10 to lay on the bed. With LVN 2's right hand, LVN 2 inserted the bisacodyl suppository inside Resident 10's anus. Once the medication was inserted by LVN 2, LVN 2 assisted Resident 10 back into a sitting position and helped the resident sit on a chair beside the resident's bed. During a medication administration observation and interview on 3/17/2026 at 9:32 AM with LVN 2 inside Resident 10's room, LVN 2 stated he will now administer Resident 10's calcium carbonate. LVN 2 removed the gloves that were used to administer the bisacodyl, but LVN 2 did not perform hand hygiene. LVN 2 then grabbed the medication cup which contained calcium carbonate. On 3/17/2026 at 9:32 AM, LVN 2 was instructed by the surveyor to stop the administration of calcium carbonate. During an interview on 3/17/2026 at 9:37 AM, LVN 2 stated that he wore gloves when he administered Resident 10's bisacodyl. LVN 2 stated that he forgot to perform hand hygiene after administering Resident 10's bisacodyl. During an interview on 3/19/2026 at 9:53 AM with the Infection Preventionist Nurse (IP), the IP stated that staff must wash hands or use a hand sanitizer after administering a suppository even if gloves were used. The IP stated that the gloves that were used during the administration of suppositories might be infectious. The IP further stated that failing to perform hand hygiene could cause infections. During an interview on 3/19/2026 at 10:00 AM with the Director of Nursing (DON), the DON stated that staff should perform hand hygiene after administering a suppository. The DON stated that even if the nurse removes the used gloves after the administration of a suppository, the nurse must still wash their hands or use a hand sanitizer. The DON further stated that not performing hand hygiene places the resident at risk for potential infections such as gastrointestinal infections. During a review of the facility's policy and procedure (P&P), titled Medication Administration Rectal Suppositories, dated 1/2019, the P&P indicated the following sequence of procedures to the administration of a suppository: 4. Put glove on right or left hand. 7. Insert suppository gently into rectum beyond sphincter about 3 inches. 15. Wash hands. During a review of the facility's P&P, titled Medication Administration, dated 1/2019, the P&P indicated that hands are washed with soap and water before and after administration of topical, ophthalmic (through the eyes), otic (through the ears), parenteral (through injection), enteral (through the mouth), rectal, and vaginal medication, and with any resident contact. During a review of the facility's P&P titled, Infection Control, revised 4/2025, the P&P indicated that it is the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. The P&P also indicate that standard precautions are infection prevention practices that apply to the care of all residents. The P&P indicated that standard precautions include hand hygiene.

Based on observation, interview and record review, the facility failed to ensure informed consent was obtained prior to the use of psychotropic medications for one of eight residents (Resident 17) in accordance with the facility's policy and procedure titled Chemical Restraints and Psychotropic Medication Management. This deficient practice had the potential to violate resident' rights to be informed prior to administering medications without their knowledge or approval. This also placed the resident to be at risk for unnecessary chemical restraint that limit their ability to participate in care decisions. Findings: During a review of the admission Record ( AR) indicated Resident 17 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder ( a mental health condition that includes hallucinations or delusions along with mood disorder symptoms ), bipolar disorder ( extreme mood swings), and insomnia (sleep disorder where a person has difficulty falling asleep or remaining asleep) . During a review of Resident 17's Minimum Set Data (MDS- a federally mandated resident assessment tool) dated 1/22/2026, indicated resident had moderated cognitive impairment, meaning resident has some problems with memory and thinking, but is still able to participate in care decisions to a degree. During a review of the Physician's Order report indicated to give Resident 17 the following: Abilify (Aripiprazole - antipsychotic [medication used to treat mood and behavioral disorders]) 5milligrams (mg) give 1 tablet by mouth every 12 hours for psychosis (seeing people that aren't there), dated 01/20/2026. Divalproex Sodium (mood stabilizer) Oral Tablet Delayed Release 250milligrams (Divalproex Sodium) Give 1 tablet by mouth two times a day for mood stabilizer (excessive mood swings), dated 01/20/2026. Duloxetine (antidepressant-medication used to treat severe sadness and hopelessness) Capsule 60milligrams (mg) give 1 capsule by mouth two times a day for Depression (Verbalization of hopelessness), dated 01/202026. Klonopin one milligram (a medication used to stabilize mood and causes sedation or sleepiness]) give 1 tablet by mouth every 8 hours for Anxiety (Verbalization of anxiousness), dated 01/20/2026. Trazodone (antidepressant) 100milligrams (mg) give 1 tablet by mouth at bedtime for depression dated, 01/202026. During a review of Resident 17's informed consent dated 01/20/2026, indicated the Physician obtained informed consent for Duloxetine, Trazodone and Abilify. The informed consent form included Resident 17's signature however, it did not include the date the resident signed, leaving the consent form incomplete. During a concurrent interview and record review on 03/18/2026 at 10:50AM with Director of Nursing (DON), a review of medication consents and physician orders was conducted. Concurrent review of consent forms for Duloxetine, Trazodone, and Ability showed the forms were signed, however, no date was documented, leaving the consents incomplete. The DON stated that for consent forms to be complete and valid, they must be both signed and dated, and if not complete, the validity of the consent is questionable. During another concurrent interview and record review on 03/18/2026 at 10:50 AM, the DON stated there was no documented evidence an informed consent forms for both Divalproex sodium and Klonopin were obtained from Resident 17 or the responsible party, if any. During an interview on 3/18/2026 at 11:15 AM, with Resident 17, Resident 17 stated she is missing consent for Klonopin and Depakote (used for behavioral symptoms). Resident 17 Stated, I was told they were not antipsychotic medications and did not need a consent. During an interview on 3/18/2026 at 11:20AM, with Director of Staff Development (DSD), DSD stated she was unable to produce the missing informed consent forms for Divalproex sodium and klonopin. The DSD stated both medications require informed consent and should have been completed on the day the medication was started to be administered. The DSD further stated the resident should date the consent form at the time of signing to ensure the form is complete and to verify when consent was obtained. During a review of the facility's policy and procedure ( P&P) titled Chemical Restraints and Psychotropic Medication Management dated 12/2025, the policy indicated the facility is to ensure residents are free from chemical restrains imposed for purposes of discipline or convenience and that such medications are only used to treat a specific , documented medical condition. Additionally, the policy stated the Social Services Director (SSD) or designee is responsible for reviewing new admissions to ensure informed consent is obtained prior to the initiation or psychotropic medications.

Based on observation, interview, and record review, the facility failed to promote one of six sampled residents (Resident 35) the right to choose and participate in decision making regarding diet preferences that was important to the resident. This deficient practice violated the resident's rights of Resident 35 that make choices that could result unplanned weight loss and decline in the quality of life. Findings: During a review of Resident 35's admission Record indicated Resident 35 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), major Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN - high blood pressure). During a review of Resident 35's Minimum Data Set (MDS - a resident assessment tool) dated 1/19/2026, indicated Resident 35 was cognitively (thought process) intact. The MDS indicated that Resident 35 needed substantial/maximal assistance with shower/bathe self, toileting hygiene. Partial/moderate assistance with putting on/taking off footwear, lower/upper body dressing. Supervision or touching assistance with personal and oral hygiene. Set up or clean up assistance with eating. During a review of Resident 35's Order Summary Report dated 8/28/2025 indicated a physician order of No added salt diet easy to chew-level 7 texture (regular easy to chew for adults) thin liquids (water consistency) During a review of Resident 35's Care Plan Has Potential Nutritional Problem revised on 2/16/2026, indicated the goal to maintain adequate nutritional status as evidenced by maintaining weight. Care plan indicated to serve the resident with no added salt, regular texture, thin liquids consistency. During a concurrent observation and interview on 3/16/2026 at 10:10 AM Resident 35 had snacks at bedside a can of peanuts and a bag of pretzels, Resident 35 stated these were her favorite snacks. Resident 35 stated that her food was changed to baby puree food (smooth blended food - like mashed fruits, veggies or meats), and that she does not have chewing or swallowing problems. Resident 35 stated that the staff did not come to talk to her about the change of the texture of her food and that this change started a few months ago. Resident 35 stated that she has told staff numerous times that she does not like the puree texture of her food and has taken pictures to show the staff that she is receiving puree texture food that she does not like to eat. During a review of Resident 35's Speech Therapy treatment encounter notes dated 3/17/2026, indicated a swallowing evaluation was done to evaluate if Resident 35 was able to tolerate regular texture food. The swallowing evaluation indicated that Resident 35 demonstrated safe tolerance to regular texture and MD was made aware of Resident 35's speech therapy recommendation and the diet was upgraded to regular texture. During an interview on 3/18/2026 at 2:30 PM with the Director of Nurses (DON) stated that the facility could not find the reason why Resident 35 was placed on an easy chew-level 7 texture diet. DON stated that she could not find documentation from the physician, speech therapy, or staff of why the resident had a change from regular diet to the easy-chew texture food. During a review of the facility's policy and procedure (P&P) titled Food and Nutrition Services revised on 7/21/21, indicated that each resident's nutritional status is assessed on admission, and quarterly. P&P indicated that the care plan shall be updated and revised as appropriate. During a review of the facility's P&P titled Change in Condition revised on 12/2025, indicated that if at any time a change of condition occurs such as a change in ability to eat or drink the nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of existing orders. P&P indicated that the IDT will collaborate with the attending physician, resident and or resident representative to review the plan of care.

Based on observation, interviews, and record review, the facility failed to ensure that information essential for resident understanding-such as activity calendars, facility rules and regulations, and meal menus-was provided in the resident's preferred language for 1 of 1 sampled resident reviewed for language needs (Resident 18). This failure resulted in Resident 18 being unable to understand posted information about facility activities, meal options, and facility rules, despite having a documented preference for Mandarin and moderately impaired cognitive function. Findings: During a review of Resident 18's admission Record (AR), the AR indicated the facility admitted the resident on 12/10/2025 with diagnosis that included but not limited to fracture (broken bone) of tibia (bone between knee and ankle) and fall. During a review of resident 18's Minimum Data Set (MDS - a resident assessment tool) dated 12/25/2025, the MDS indicated Mandarin is Resident 18's preferred language. MDS indicated Resident 18 has moderately impaired cognitive/brain function. During an observation on 03/16/2026 at 9:38 am in Resident' 18's room, the March 2026 Activity Calander, facility information, rules and regulations and weekly meal menu posted on the wall in front of the resident's bed, were in English. During an interview on 3/16/2025 at 9:44 am with Resident 18 (with an interpreter via phone) the help of interpreter, Resident 18 stated she is not able to speak or read English. Resident 18 stated she is unable to read the facility rules, regulations, activity calendar and weekly meal menu posted in resident's room. During an interview on 03/17/2026 2:02 pm with Activity Director (AD), Activity Director stated Resident 18 use google translate whenever resident need to communicate with the facility staff. Per AD, AD and facility staff have used google translate whenever needed to communicate with the resident during resident's visit. During an interview on 03/18/2026 at 1:43 pm with LVN 4, LVN 4 stated the facility has a dedicated interpreter phone number that can be called to communicate with non-English speaking residents. LVN 4 and facility staff has used Google translation on occasions to. communicate with non - English speaking residents in the facility. During an interview on 03/18/2026 at 1:59 pm with Director of Nursing (DON), the DON stated the facility staff must use interpreter services to communicate with non-English speaking residents in the facility. The DON stated Google translation is not to be used by the facility staff per the facility policy. During a review of the facility's Policy and Procedure (P&P) titled Comprehensive Resident Centered Care Plan, reviewed 12/2025, the P&P indicated the facility inter disciplinary team will develop and implement a comprehensive person-centered, culturally competent, and trauma-informed care plan for each resident. The P&P indicated the facility will provide interpreter services for non-English speaking residents, if needed or appropriate.

Based on observation, interview and record review, the facility failed to notify the physician for the significant change of condition when one out of six sample residents (Resident 4) who had a decrease in appetite and was not assessed for weight loss from 2/27/2026 to 3/18/2026 in accordance with the policy and procedures titled Change In Condition. This deficient practice had delayed in the doctor being notified and Resident 4 not being reassessed for weight loss. Findings: During a review of Resident 4's admission Record Resident 4 was admitted to the facility on [DATE], with diagnoses that included cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 12/26/2025, the BIMS (Brief Interview for Mental Status - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score was 8 moderate cognition (thought process). The MDS indicated that Resident 4 needed setup or clean up assistance with eating. During a review of Resident 4's Order Summary Report dated 3/1/2026 indicated that Resident 4 had a physician order for Regular diet with thin liquids large meat/protein portion and fortified foods. During a review of Resident 4's Order Summary Report dated 11/6/2025 indicated that Resident 4 had a physician order for Diabetic Health Shake with meals for malnutrition risk poor intake with breakfast, lunch and dinner. During a review of Resident 4's Order Summary Report dated 11/21/2025 indicated that Resident 4 had a physician order for monitoring episodes of poor oral intake every shift. During a review of Resident 4's Care Plan (Has Potential Nutritional Problem) revised 2/16/2026, indicated to monitor and report to the physician as needed for any signs and symptoms of decreased appetite, and unexpected weight loss. During a review of Resident 4's Medication Administration Record (MAR) dated 3/17/2026 - 3/18/2026 indicated an intake of less than 50%. During a concurrent observation and interview on 3/18/2026 at 12:30 PM with Certified Nurse Assistant (CNA 2) during lunch, Resident 4 tray was picked up by CNA 2, the tray was observed with 0% meal intake and a protein health shake unopened. CNA 2 stated that she did not set it up protein health shake for Resident 4 because he did not like the protein shake. CNA 2 stated that she had not told the licensed staff that Resident 4 did not want to eat. During a concurrent observation and interview on 3/18/2026 at 1:00 PM with the Director of Nurses (DON) observed Resident 4's lunch tray and agreed that Resident 4 meal intake was 0% and that the protein health shake was unopened. DON stated that CNA 2 did not notify licensed staff that Resident 4 did not like the protein shake. DON verified that Resident 4 has had decrease appetite and that not eating his meal is a concerned and the attending physician should have been made aware. During a review of the facility's policy and procedure (P&P) titled Change In Condition revised on 12/2025, indicated that at any time if one of the team members recognizes a change in a residents ability to eat or drink, or in food intake the nurse will perform and document an assessment of the resident and will communicate with the provider to obtain new orders or interventions.

Based on observation, interview and record review, the facility failed to prevent development of pressure ulcer (an area of damaged skin and tissue caused by prolonged unrelieved pressure) by ensuring one of three sampled residents (Resident 43), was repositioned every two hours per the physician's order. This failure had the potential to increase the risk in the resident developing a pressure ulcer. Findings: During a review of Resident 43's face sheet, the face sheet indicated the resident was admitted on [DATE], with the diagnoses that included Parkinson's disease (Parkinson's disease is a progressive neurological disorder that primarily affects movement. It is characterized by the degeneration of nerve cells in the brain, abnormalities of gait and mobility). During a review of Resident 43's Minimum Data Set (MDS- standardized, comprehensive assessment form used to record a resident's physical, mental, and social health status) dated 10/1/2026, the MDS indicated the resident has a moderate cognitive impairment (ability to think and reason) . The MDS indicated Resident 43 is at risk for developing a pressure ulcer and needs substantial/maximal assistance for repositioning (moving a person with limited mobility into different positions), During a review of Resident 43's physician's orders dated 2/20/2026, the order indicated Resident 43 was to be repositioned every two hours while in bed. During a review of Resident 43's Point of Care Response History record from 2/16/2026 to 3/17/2026, the record indicated Resident 43 was turned and repositioned three times a day. During multiple observations on 3/16/2026 at 8:55 a.m., 11:15 a.m. and 4:30 p.m., in Resident 43's room, Resident 43 was lying in bed on his back with the head of the bed elevated at a 45 degrees angle. During an interview on 3/17/2026 at 12:34 p.m. with Resident 43, Resident 43, stated he was always lying on his back and not assisted to reposition in bed. During an interview on 3/18/2026 at 10:36 a.m. with Director of Staff Development (DSD), DSD stated there were no logs to tracking systems or documentation when the residents are repositioned, Certified Nursing Assistants (CNA)s are required to reposition the residents, according to the physician's orders. DSD stated not repositioning the residents could a cause a pressure ulcer to develop or cause an active pressure to worsen. During a review of the facility's policy and procedure (P&P) titled, Skin and Wound Monitoring and Management, dated 12/2025, the P&P indicated nursing staff shall implement resident care plans according to physician's orders.

Based on observation, interview, and record review, the facility failed to do ongoing assessment, perform weekly weights and provide revised interventions for one of six sampled residents (Resident 4) who has had weight loss. This deficient practice placed the resident at risk for altered nutritional status and further weight loss. Findings: During a review of Resident 4's admission Record Resident 4 was admitted to the facility on [DATE], with diagnoses that included cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool) dated 12/26/2025, the MDS indicated that Resident 4 was moderately cognitive (thought process) impaired. The MDS indicated that Resident 4 needed setup or clean up assistance with eating. During a review of Resident 4's Weights and Vitals Summary indicated equivalent to weight loss of 14.7 percent (%) weight loss in five (5) months as indicated in the following: On 9/24/2025 a documented weight of 147 pounds (lbs.) On 10/2/2025 a documented weight of 149 lbs. On 11/3/2025 a documented weight of 142 lbs. On 12/8/2025 a documented weight of 138 lbs. On 1/1/2026 a documented weight of 135 lbs. On 2/2/2026 a documented weight of 135 lbs. On 3/2/2026 a documented weight of 127 lbs. During a review of Resident 4's Order Summary Report dated 11/21/2025, indicated to monitor episodes of depression as evidence by poor oral intake every shift. During a review of Resident 4's Order Summary Report dated 2/27/2026, indicated an order for weekly weights for 4 weeks. During a review of Resident 4's Order Summary Report dated 3/12/2026, indicated an order for 4 ounces of sugar free ice cream two times a day with lunch and dinner. During a review of Resident 4's Nutrition interdisciplinary team (IDT - a coordinated group of experts from several different fields who work together) dated 3/12/2026 indicated that Resident 4's weight was below goal of 144-154 lbs. IDT recommendation was to add ice cream with lunch and dinner. During an interview on 3/18/2026 at 12:30 PM with the DON stated that Resident 4 did not eat his food and the percentage of the meal intake was 0%, DON stated that this change of condition should have been reported to the attending physician. During a concurrent observation and interview on 3/18/2026 at 1:00 PM with the Director of Nurses (DON) while observing Resident 4's lunch tray ice cream was not served with lunch. The DON stated that ice cream should have been served with the lunch meal as ordered by the physician. During an interview on 3/18/2026 at 1:10 PM with the DON, DON stated Resident 4 should have been on weekly weights as of 2/27/2026 for weight monitoring due to weight loss but was not performed. During a review of Resident 4's care plan Has Potential Nutritional Problem revised date 2/16/2026, indicated that Resident 4 eats less than 50% offer meal replacement, monitor and report to the attending physician as needed for any signs/symptoms of decreased appetite. During a review of the facility's policy & procedures (P&P) titled Food and Nutrition Services revised date on 7/21/2021, indicated that the facility will be monitoring and evaluating the resident's response to the interventions, especially when there is no progress toward the nutritional goal. The P&P indicated that weekly weights are entered into the electronic health record in the weights and vital signs.

Based on observation, interview, and record review, the facility failed to ensure proper maintenance of an intravenous (IV) site for 1 of 8 sampled residents (Resident 25). Resident 25 was observed with a double lumen midline catheter with an expired dressing and no Curos disinfecting cap in place. This deficient practice was inconsistent with the facility's Infection Control Policy - Intravenous Therapy, dated 12/2025, which required IV dressings to be dated and changed as scheduled and required cleansing or protection of the lumen port to prevent contamination. This failure had the potential to expose the IV site and lumen to contamination, increasing the risk for infection, including bloodstream infection and sepsis. Findings: During a review of Resident 25's admission Record (AR), it was noted the facility admitted the resident on [DATE] with diagnoses including sepsis, acute respiratory failure with hypoxia, and extended spectrum beta lactamase (ESBL) infection. During a review of Resident 25's Minimum Data Set (MDS), dated [DATE], indicated the resident had moderate cognitive impairment and was independent with bathing, dressing, toileting, and eating. During an observation on [DATE] at 12:06 p.m., Resident 25 was observed with a midline catheter. The dressing at the catheter insertion site was expired ([DATE]) and past the due date for change. No antiseptic (Curos) cap was present on the lumen of the catheter. During a concurrent observation and interview on [DATE] at 12:15 p.m. with the Director of Staff Development (DSD) in Resident 25's room, the midline dressing was observed with a date of [DATE] and no time documented. The DSD stated the dressing was to be changed weekly on Sundays and confirmed the dressing was past due. The DSD further stated the dressing must be dated to ensure timely changes and reduce the risk of infection. During a review of the facility's policy and procedure titled Infection Control Policy - Intravenous Therapy, dated 12/2025, indicated the policy's purpose was to provide guidelines for the prevention of infections associated with intravenous therapy. The policy stated that site care included marking the tape with the date and initials and placing it over the dressing. The policy further indicated the exterior lumen port must be cleansed with alcohol prior to disconnecting old tubing, connecting new tubing, and prior to removal and replacement of the Luer lock cap.

Based on observation, interview, and record reviews, the facility failed to ensure oxygen therapy was provided in accordance with physician orders and infection control practices for 2 out of 8 sampled residents (Resident 40 and 62) when: The oxygen tubing for Residents 40 and 62 was not dated or was past the facility's required replacement interval. The oxygen therapy for Resident 40 was observed not in place as ordered by the physician. The facility staff failed to consistently monitor and verify oxygen placement for a resident known to remove the nasal cannula. These deficient practices had the potential to result in residents not receiving prescribed oxygen therapy and exposure to infection risk from outdated or improperly maintained oxygen equipment. Findings: 1. During a review of Resident 40's admission Record, the admission Record indicated the facility admitted the resident on [DATE] with diagnoses including acute respiratory failure with hypoxia, asthma, and atrial fibrillation. During a review of Resident 40's Minimum Data Set (MDS), dated [DATE], the MDS indicated the resident had severe cognitive impairment and was totally dependent for activities of daily living, including eating, oral hygiene, toileting, and personal hygiene. During a review of Resident 40's care plan titled Has Oxygen Therapy r/t respiratory failure and asthma, dated [DATE], the care plan indicated a goal for the resident to have no signs or symptoms of poor oxygen absorption, with an intervention to administer oxygen as ordered by the physician. During a review of Resident 40's care plan titled At risk for altered respiratory status and difficulty breathing r/t respiratory failure, dated [DATE], the care plan indicated a goal for the resident to have no complications related to shortness of breath and no symptoms of poor oxygen absorption, with an intervention to provide oxygen as ordered. During a review of Resident 40's care plan titled Resident has episodes of removing the nasal cannula, dated [DATE], the care plan indicated a goal for the resident to cooperate with care, with an intervention to monitor episodes of removing the nasal cannula. During a review of Resident 40's Order Summary Report, dated [DATE], the Order Summary Report indicated the resident was to receive continuous oxygen at 2 liters per minute via nasal cannula, with instructions to maintain oxygen saturation above 90 percent every shift, for respiratory failure with hypoxia and asthma. 2. During a review of Resident 62's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses of atelectasis and sepsis. During a review of Resident 62's Minimum Data Set (MDS), dated [DATE], the MDS indicated the resident had moderate cognitive impairment and required touch only assistance for eating and oral hygiene, and maximal assistance with personal hygiene. During a review of Resident 62's Order Summary Report, dated [DATE], the Order Summary Report indicated ipratropium-albuterol solution was to be administered by inhalation every four hours as needed for shortness of breath and wheezing via nebulizer. During an observation on [DATE] at 9:38 AM, Resident 62 was observed lying in bed with treatment tubing and a face mask on the bed. The tubing was labeled with a date of [DATE], indicating it was past the facility's replacement interval. During a concurrent observation and interview with the Infection Preventionist (IP) on [DATE] at 9:40 AM, the IP stated that oxygen tubing is to be changed weekly on Sundays. The IP confirmed the observed tubing was expired, stating that outdated tubing could lead to bacterial buildup and infection, and emphasized that tubing must be properly labeled to ensure timely replacement. During an observation on [DATE] at 9:57 AM, Resident 40 was observed lying flat in bed with oxygen not in place. The resident was holding the oxygen tubing on her chest. The tubing did not have a label indicating when it was last changed. During a concurrent observation and interview with the Director of Staff Development (DSD) on [DATE] at 10:05 AM, the oxygen tubing was observed not in the resident's nose and was not dated. RN1 stated that oxygen tubing should be dated to ensure timely replacement and identified the lack of labeling as an infection control concern. RN1 further stated that with the oxygen not in place, the resident may not be receiving the prescribed oxygen, which could result in desaturation. During an interview with Licensed Vocational Nurse (LVN 5) on [DATE] at 9:19 AM, LVN 5 stated that Resident 40 frequently removes her nasal cannula. LVN 5 acknowledged that staff do not consistently verify that the oxygen remains in place after reapplication and stated that oxygen saturation is checked once per shift during routine vital signs at approximately 7:00 AM, 3:00 PM, and 11:00 PM, rather than at the time oxygen is found removed. During a review of the facility's policy and procedure titled Oxygen Therapy, revised 12/2025, the policy indicated that oxygen tubing is to be replaced every seven days or as needed when dirty or soiled, and that tubing is to be dated when changed. The policy stated oxygen is to be administered as ordered by the physician and addressed in the resident's plan of care.

Based on observation, interview, and record review, the facility failed to ensure one out of two sampled residents (Resident 10) received correct dose of calcium carbonate (a dietary supplement that body needs to function and to treat indigestion or heart burn) as prescribed by the physician and in accordance with the facility's policy and procedure titled Medication Administration. This deficient practice placed Resident 10 at risk of ingesting more than the prescribed medication dosage or overdose which included symptoms such as constipation, nausea, vomiting, confusion and irregular heartbeat. Findings: During a review of Resident 10's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included left arm fracture (a break in the bone), falls, and cellulitis (skin infection) of the left arm. During a review of Resident 10's History and Physical (H&P), dated 12/26/2025, the H&P did not indicate if the resident has the capacity to understand and make decisions. During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 1/23/2026, the MDS indicated that the resident has intact cognition (the ability to process thoughts and emotions). During a review of Resident 10's physician order, dated, 12/25/2026, for Calcium Carbonate Tablet chewable 500 MG (milligram, a unit of measuring weight) to be give 1 tablet by mouth two times a day for indigestion. During a medication administration observation and interview on 3/17/2026 at 8:59 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed preparing Resident 10's calcium carbonate. LVN 2 stated he has a bottle of calcium carbonate 750 MG per tablet. LVN 2 stated he will cut the 750 MG per tablet into four quarters and administer only three of the four quarters (total of approximately 562.5 MG). LVN 2 proceeded to cut the calcium carbonate 750 MG per tablet into four quarters and put three of the four quarters into a medication cup. During a concurrent interview and record review on 3/17/2026 at 9:04 AM with LVN 2, Resident 10's medication order for calcium carbonate was reviewed. LVN 2 stated that the physician ordered Resident 10 to receive 500 MG tablet of calcium carbonate. During a medication administration observation and interview on 3/17/2026 at 9:32 AM with LVN 2 inside Resident 10's room, LVN 2 stated he will now administer Resident 10's calcium carbonate. On 3/17/2026 at 9:32 AM, LVN 2 was instructed by the surveyor to stop the administration of calcium carbonate. During a concurrent interview and observation on 3/17/26 at 9:32 AM with LVN 2, the medication containing the calcium carbonate was inspected. LVN 2 stated that the medication cup contained 562.5 MG of calcium carbonate, and not the prescribed dose of 500 MG. LVN 2 stated that he made a mistake when he prepared the medication. LVN 2 added that it is a medication error because the medication that he was about to give was 62.5 MG more than what was ordered by the physician. During an interview on 3/19/2026 at 10:00 AM with the Director of Nursing (DON), the DON stated that prior to preparing and administering medications, the nurse must first clarify if the medication's dose is correct. The DON also stated that all medications must be administered according to what was ordered by the physician. The DON also stated that if the wrong dose is administered, the medication might be ineffective or the resident could suffer an overdose (occurs when an individual consumes an excessive, toxic amount of a drug or substance, whether voluntarily or involuntarily, resulting in severe physical or mental harm). During a review of the facility's policy and procedure (P&P), titled Medication Administration, dated 1/2019, the P&P indicated that the administration of partial tablets is clearly identified or highlighted on the resident's MAR. The P&P indicated that medications are administered in accordance with written orders of the attending physician.

Based on interview and record review the facility failed to prevent unnecessary use of psychotropic medications (medications that affects mood and behavior) in accordance with the physician's order, and the facility's policy and procedure titled Chemical Restraints and Psychotropic Medication Management for two of the three sampled residents (Resident 6 and 61) by failing to ensure: 1.Resident 6 was monitored for the behavior indicated for the use of Abilify (antipsychotic medication given for psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] and other behavioral mental health conditions) for one of six sampled residents. 2. Resident 61 was monitored for the side effects (undesired effect) and effectiveness of quetiapine fumarate (a medication that may be used to treat insomnia [ a condition of having difficulty falling to sleep and/or remaining asleep) by documenting the presence of side effects if any and the resident's hours of sleep as indicated in the facility's policy and procedure (P&P) titled Chemical Restraints and Psychotropic Medication Management. This deficient practice had the potential to result in the residents receiving unnecessary medications or not sufficient dosage of medication to treat the behavioral disorder, and the potential to experience side effects with delayed or no treatment and prolonged use of the medication. Findings: 1.During a review of Resident 6's admission Record Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), psychosis. During a review of Resident 6's Minimum Data Set (MDS – resident assessment tool) dated 12/24/2025, indicated Resident 6 was moderate cognitive (thought process) impairment. The MDS indicated that Resident 6 was dependent on putting on/taking off footwear, lower body dressing, shower/bathe self, toileting hygiene. Substantial/maximal assistance personal hygiene, upper body dressing, oral hygiene and supervision or touching assistance with eating. During a review of Resident 6's Order Summary Report dated 3/1/2026, indicated a physician order for Abilify15 milligrams (mg- metric unit of measurement) once a day for psychosis for hearing voices that are not there. During a review of Resident 6's Medication Administration Record (MAR) from dated 3/1/2026 to 3/15/2026, indicated Resident 6 had received Abilify 15 mg once a day. During a review of Resident 6's Care Plan (Anti-psychotic Medication Use) the care plan indicated that Resident 6 will show decreased episodes of signs and symptoms of psychosis through the review date. During a review of Resident 6's Psychiatry Evaluation dated 2/19/2026, indicated that Resident 6 was going to continue with medication for symptom management and medication adjustment was not indicated. The evaluation indicated to continue to monitor behavior. During a review of Resident 6's Psychiatry Evaluation dated 2/19/2026, the evaluation did not indicate the specific behavior to monitor. During a record review and concurrent interview on 3/18/2026 at 2:53 PM with the Director of Nurse (DON) stated that the monitoring of Resident 6's psychotic behavior of hearing voices that are not there should have been monitored and documented. The DON confirmed that there was no documented evidence indicating that Resident 6's symptoms of hearing voices that are not there were monitored and documented. The DON stated the importance of monitoring the behavior was to determine if the medication dosage could be reduced or discontinued the medication and to guide clinical decisions and ensure residents do not receive unnecessary medications. During a review of the facility's policy and procedure (P&P) titled Chemical Restraints and Psychotropic Medication Management revised date 12/2025, indicated that residents who use psychotropic drugs receive gradual dose reduction (GDR – a stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). The P&P indicated that the licensed nurses would review its indication, behavior monitoring, and related adverse side effects. 2. During a review of Resident 61's admission Record (AR), the AR indicated that the resident was admitted on [DATE] with diagnoses that included falls, Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills), and left leg fracture (a break in the bone). During a review of Resident 61's History and Physical (H&P), dated 3/13/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 61's physician orders, the orders included an order, dated 3/12/2026, for quetiapine fumarate (a medication that may be used to treat difficulty in sleeping) tablet 25 MG (milligram, a unit of measuring weight) given one tablet by mouth at bedtime for insomnia (difficulty sleeping or remaining asleep). During a review of Medication Administration Record (MAR) for 3/2026, the MAR did not have documented evidence that Resident 61's hours of sleep was being monitored. During a review of Resident 61's progress notes since admission to 3/16/2026, the progress notes did not have documented evidence that Resident 61's hours of sleep was being monitored. During a review of Resident 61's care plan for mood disorder, dated 3/16/2026, the care plan included interventions for staff to administer medications as ordered and to monitor the side effects and effectiveness. During a review of Resident 61's consent form titled, Consent for Treatment: Use of Anti-Psychotropic Medication, dated 3/12/2026, the form indicated that quetiapine was ordered for the treatment of Resident 61's insomnia [manifested by the] inability to fall asleep. The form also indicated that the expected benefit of the medication was to increase the resident's hours of sleep. The form also indicated that on the section titled, expected duration of medication therapy, the administration of [the] medication will only continue as long as necessary. During a concurrent interview and record review on 3/16/2026 at 2:14 PM with Licensed Vocational Nurse (LVN) 3, Resident 61's medical records were reviewed, including the MAR and progress notes. LVN 3 stated that the records did not have documented evidence that Resident 61's hours of sleep were being monitored. LVN 3 stated that Resident 61's hours of sleep should have been monitored to identify if the resident's quetiapine is effective or not. LVN 3 also added that monitoring the hours of sleep could aid the facility in identifying if the medication was causing the resident to have side effect of excessive drowsiness, which could indicate a discontinuation of the medication. During another concurrent interview and record review on 3/16/2026 at 2:14 PM LVN 3, Resident 61's medical records were reviewed, including the consent form for Resident 61's quetiapine. LVN 3 stated that the consent form indicated that quetiapine was ordered for Resident 61's insomnia, that required monitoring and documenting Resident 61's hours of sleep as a tool to gauge if the medication is effective and still necessary to treat insomnia. During an interview on 3/19/2026 at 10:00 AM with the Director of Nursing (DON), the DON stated that if a medication is ordered to help the resident sleep, then the resident's hours of sleep should be monitored. The DON stated that monitoring the hours of sleep helps the facility know if the medication is working or not. The DON added that if the medication is not working, then the medication could be unnecessary and must be discontinued. The DON further added the monitoring the hour of sleep also helps the facility in knowing if the medication is affecting the resident too much, such as when a resident appears drowsy, which may indicate a need to reduce the dose of the medication. During a review of the facility's policy and procedure (P&P) titled, Chemical Restraints and Psychotropic Medication Management, undated, the P&P indicated that the licensed nurse shall review the classification of the drug, the appropriateness of the diagnosis, its indication, behavior monitors and related side effects prior to verification of admission orders with the attending physician. The P&P also indicated that the interdisciplinary team will review to ensure monitoring for adverse consequences and effectiveness of medications are in place.

Based on observation, interview, and record review, the facility failed to follow their policies and procedures (P&P) for the proper storage and disposal of medications for two of three Medication Carts (MC 1) by failing to ensure: 1.A used syringe (a medical instrument consisting of a small, hollow tube, a plunger, and usually a needle, designed to inject fluids into or withdraw fluids from the body) was not left on top of MC 1's waste container. 2. An unlabeled small white pill was not left on top of the medication cart This failure had the potential for the residents to take and ingest the medication and the potential to expose residents, visitors, and staff to the unsecured items in the MC. Findings: 1.During an observation on 3/18/2025 at 10:10 am, in the facility hallway, Licensed Vocational Nurse (LVN) 3 left the medication cart to enter a resident's room. There was an unlabeled small white pill on top of the medication cart. During an interview on 3/18/2025 at 10:10 am with LVN 3, LVN 3 stated she could not identify the white pill. LVN 3 stated if someone were to ingest the white pill it could cause harm to that individual. During an interview on 3/28/2025 at 1:59 pm, with the Director of Nursing (DON), the DON stated all medications should be locked with only authorized staff having access to the medications. If any unauthorized individual could have used that unlabeled pill, the pill could have harmed that individual. During the review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated 1/2019, the P&P indicated the medication supply to be accessible only to the licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer the medications. 2.During an inspection of the facility's medication cart (MC) 1 on 3/16/2026 at 12:40 PM, MC 1 contained a pharmaceutical waste container on the right side of MC 1. The top of the waste container lid had a syringe. The syringe was visible and could be taken out of the waste container by hand. The syringe was not secured inside of the waste bin. During a concurrent observation and interview on 3/16/2026 at 12:42 PM with Licensed Vocational Nurse (LVN) 3, a syringe was observed on top of the waste container. LVN 3 stated that there was a syringe on top of the waste container, and LVN 3 added that the syringe was a medication that she administered. LVN 3 stated that the syringe should not be there because it is easily accessible to residents and visitors. LVN 3 further added that the syringe must be inside the waste container. During an interview on 3/19/2026 at 10:00 AM with the Director of Nursing (DON), the DON stated that nurses must throw used syringes inside of waste containers. The DON added that the used syringes could contain infectious material that could spread infections to residents. During a review of the facility's policy and procedure (P&P) titled, Disposal of Medications, Syringes, and Needles, dated 1/2019, the P&P indicated that used syringes and needles are disposed of safely and in accordance with applicable laws and safety regulations. The P&P also indicated that immediately after use, syringes and needles are placed into puncture resistant, one-way containers specifically designed for that purpose. The P&P also indicated that disposal containers are fitted with a lid that prohibits reaching into the container.

Based on observation, interview and record review, facility failed to maintain a clean and sanitary physical environment in one of one staff-use emergency safety areas observed, the laundry room eye wash station. This failure had potential to compromise staff safety during emergency use of the eyewash station (an emergency area used to flush the eyes readily available with clean and appropriate temperate water in case of facility staff getting exposure to hazardous chemicals or irritants). Findings: During an observation on 03/17/2026 at 9:16 am, in the facility's laundry area, the eye wash station was observed with green and black stains on the basin surface. During an interview on 03/17/2026 at 9:41 am, with the Housekeeping/Laundry Supervisor (HS), the HS stated that using a dirty eye wash station could lead to an eye infection in staff. During an interview on 03/18/2026 at 1:59 pm, with the Director of Nursing (DON), the DON stated if staff use an unclean eye wash station during an emergency, it could worsen an eye injury or irritation. During a review of facility's policy and procedure (P&P) titled, Maintenance Policy dated 12/2025, the P&P indicated to maintain safe, clean, and functional environment for residents, staff, and visitors, the facility was required to conduct routine inspection of eye-wash stations, electrical and fire safety systems.

Based on interview and record review, the facility failed to safeguard controlled medications (medications that can cause physical and mental dependence), as indicated in the facility's Controlled Medications policy and procedure, for two of two sampled residents (Resident 1 and Resident 2), by failing to: 1. Ensure unauthorized staff (Registered Dietitian [RD]) did not have access to the controlled medications of Resident 1 and Resident 2. 2. Ensure Licensed Nurse 1 (LVN 1) safeguarded the keys to the Medication Cart number two where controlled medications for Resident 1 and Resident 2 were kept. As a result, on 10/21/2021 at approximately 11:10 am, LVN 1 left the Medication Cart Keys unsupervised. RD unlawfully took the keys, opened the Medication Cart number two on 10/21/2021 at approximately 11:17 am, and took nine tablets of Oxycodone-Acetaminophen (controlled medication use to treat moderate to severe pain) 5/325 (5 milligrams [mg, unit of measurement] of Oxycodone and 325 mg of Acetaminophen) that belonged to Resident 1. RD took three tablets of [MEDICATION(S)]-Acetaminophen (controlled medication used to relieve moderate to severe pain) 5/325 mg (5 mg of [MEDICATION(S)] and 325 mg of Acetaminophen) that belonged to Resident 2 from the facility's Medication Cart (used to transport medications) number two. These deficient practices resulted in RD, an unauthorized user, to have access to the controlled medications resulting in the loss of Resident 1 and Resident 2's controlled medications. On 10/22/2021 at 5:50 pm, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (ADM), and the Director of Nursing (DON) regarding the facility's failure to follow a system to safeguard controlled medications. On 10/24/2021 at 1:13 pm, the Department lifted the IJ after the ADM and the DON submitted an acceptable Plan of Action (POA, interventions to correct the deficient practices). The Department verified and confirmed the POA's implementations while onsite. The POA included: 1.The DON and pharmacy consultant conducted an in-service training with the licensed nurses regarding controlled medication storage, disposal, record keeping, and labeling with special focus on the proper handling of the Medication Cart keys, policy and procedure on controlled medications, drug diversion and misappropriation of property. 2. LVN 1 was put on a Performance Improvement Plan (used to address failures to meet specific job goals). 3. The facility changed the code for the medication room. 4. The DON and pharmacy consultant conducted a skill check and competencies of the licensed nurses regarding controlled drug storage. 5. The DON and designee evaluated the facility's systems and processes for safe and secure storage of controlled medication. 6. A Licensed Nurses ONLY, sign was placed on the door of the medication room. 7. Nursing staff completed training on Controlled Substances, Implications For drug diversion (when prescription medicines are obtained or used illegally), and Pain Management; Reporting Elder and Dependent Adult Abuse in California and 2021 Compliance and Code of Conduct Refresher. 8.Visitor badges were provided to all visitors and other healthcare providers not employed by the facility while they were in the facility. Visitors and other healthcare providers would not be allowed in the nurse's station and medication rooms. Findings: A review of Medication Disposition Log dated 10/21/2021, indicated Resident 1 had nine missing tablets of Oxycodone-Acetaminophen 5-325 mg, and Resident 2 had three missing tablets of [MEDICATION(S)]-Acetaminophen 5-325 mg. A review of a Report of Suspected Dependent Adult/Elder Abuse dated 10/21/2021, indicated LVN 1 reported to the ADM there were unaccounted narcotic medication (unidentified, controlled medication, drug or substance that affects mood or behavior) for Resident 1 and Resident 2. A review of Resident 1's Admission Record indicated the resident was admitted to the facility on [DATE]with diagnoses of status post (refer to a treatment often a surgical procedure that a patient has experienced previously) above the knee amputation (surgical removal of part of the body, such as an arm or leg). A review of Resident 1's Physician Order dated 9/25/2021, indicated an order for Oxycodone-Acetaminophen tablet 5-325 mg, one tablet by mouth every four hours as needed for moderate generalized pain. A review of Resident 1's Medication Count Sheet for Oxycodone-Acetaminophen 5-325 mg dated on 9/25/2021, indicated there were twenty-five tablets remaining in the bubble pack (medication organized and filled, allowing to take each dose by punching out each bubble). A review of Resident 1's Care Plan titled Pain Medication Therapy related to Oxycodone, dated 9/27/2021, indicated the resident would be free of any discomfort or adverse side effects from pain medication. The care plan interventions included to administer medication as ordered. A review of Residents 1's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/2/2021, indicated the resident had moderately impaired cognition (mental process involved in knowing, learning, and understanding things). Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing support) from staff with activities of daily living including bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE]with diagnoses including bilateral leg venous stasis (inflammation of the skin in the lower legs), gastritis (inflammation of the stomach lining), and peripheral [CONDITION(S)] (weakness, numbness, and pain from nerve damage, usually in the hands and feet). A review of Resident 2's Physician Order dated 10/12/2021, indicated an order for [MEDICATION(S)]-Acetaminophen 5-325 mg, one tablet by mouth every four hours as needed for severe generalized body pain. A review of Resident 2's Care Plan dated 10/12/2021, indicated the resident had pain to the right knee, flank (side of the body between the ribs and the hip), and right hip upon movement. The care plan indicated the goal was for Resident 2 to verbalize adequate relief of pain. The care plan interventions included to anticipate need for pain relief and to give medications as ordered. A review of Resident 2's Medication Count Sheet for [MEDICATION(S)]-Acetaminophen 5-325 mg dated 10/12/2021, indicated there were twelve tablets remaining in the bubble pack. A review of Residents 2's MDS dated [DATE], indicated the resident had intact cognition. Resident 2 required extensive assistance from staff with activities of daily living including bed mobility, transfer, locomotion (ability to move from one place to another) on and off unit, dressing, toilet use, and personal hygiene. During an interview on 10/22/2021 at 12:08 pm, LVN 1 stated she was assigned to Medication Cart two on 10/21/2021. LVN 1 stated she counted the narcotic medication and received the narcotic medication keys (keys used to open the drawer containing narcotic medications) at the beginning of her shift at 7AM. LVN 1 stated on 10/21/2021 at around 2 pm, she discovered that her narcotic keys were not in her pocket and were missing. LVN 1 did not know how long she did not have the narcotic keys in her possession. LVN 1 stated the last time she used her narcotic key was around 11 am. LVN 1 searched and found her narcotic keys on top of Medication Cart 2 on 10/21/2021 at 2:10 pm. LVN 1 asked LVN 3 to recount with her the narcotic medications in Medication Cart 2. LVN 1 stated the medication count sheets for Oxycodone-Acetaminophen for Resident 1 and [MEDICATION(S)]-Acetaminophen for Resident 2 were present but the medication bubble packs were missing. LVN 1 reported the incident immediately to the DON. During an interview on 10/22/2021 at 12:53 pm, Registered Nurse Supervisor (RN Sup) stated only the assigned medication nurses had access to their assigned medication carts and narcotic keys until endorsement to the next shift. RN Sup stated the narcotic keys should stay with the licensed nurses (in general) all throughout the shift for safety to maintain the integrity of the narcotic count and prevent other people to access the medication cart. During an interview on 10/22/2021 at 1:15 pm, LVN 2 stated incoming and outgoing medication nurses counted the narcotic medications, signed the narcotic count verification log, and endorsed narcotic keys indicating the narcotic counts were accurate. LVN 2 stated the assigned medication nurse was the only one with the narcotic keys and access to the assigned medication cart. LVN 2 stated she kept and checked the narcotic keys in her pocket all the time. LVN 2 stated she would never leave the narcotic keys unattended because of the possibility that narcotic medications would be stolen. LVN 2 stated she was in charge and responsible for the narcotic keys and controlled medications of her assigned medication cart. During an interview on 10/22/2021 at 2:03 pm, the DON stated incoming and outgoing medication nurses counted and reconcile (process of creating the most accurate list possible of all medications) controlled medications every shift change. The DON stated on 10/21/2021 at 2:30 pm, LVN1 reported one bubble pack of Oxycodone-Acetaminophen belonging to Resident 1 and one bubble pack of [MEDICATION(S)]-Acetaminophen belonging to Resident 2 were missing. LVN 1 and LVN 3 conducted controlled medication reconciliation on Medication Cart 2 and confirmed two bubble packs were missing. The DON stated LVN 1 should always have the narcotic keys with her to avoid the keys from getting lost or used by unauthorized individuals. DON stated any missing narcotic medications would be reported and investigated. During an interview on 10/22/2021 at 2:43 pm, ADM stated he received notification of the missing narcotic bubble packs on 10/21/2021 at 3:30 pm. ADM stated he initiated his investigation immediately and reviewed the video footage located in the facility's hallway. RD was identified in the video footage accessing Medication Cart two. ADM stated he retrieved from RD a bubble pack of Oxycodone-Acetaminophen 5/325 belonging to Resident 1 with nine tablets missing and a bubble pack of [MEDICATION(S)]-Acetaminophen 5/325 belonging to Resident 2 with 3 tablets missing on 10/21/2021 at 6:30 pm. ADM stated RD admitted taking the keys, opening the medication cart, and taking the bubble packs but denied taking the missing medications. During an interview on 10/22/2021 at 2:43 pm, and a review of the facility's video footage with the ADM and the DON dated 10/21/2021, and timed at 11:12 am, DON stated RD went in the nurse's station and stood beside LVN 1. ADM stated RD bent down, reached out to pick up something (unidentified) and left. DON stated RD went straight to Medication Cart two. ADM stated RD opened Medication Cart two using LVN 1's controlled medication key and took two bubble packs of medication from the narcotic drawer on 10/21/2021 at 11:17 am. RD left the narcotic keys on top of Medication Cart two and left. During a review of Resident 1's bubble pack of Oxycodone-Acetaminophen 5/325 on 10/22/2021 at 2:55 pm, indicated 16 tablets remaining. During a review of Resident 2's bubble pack of [MEDICATION(S)]-Acetaminophen 5/325 on 10/22/2021 at 3pm, indicated nine tablets remaining. On 10/22/2021 at 5:17 pm and 5:25pm, the Surveyor tried to contact the RD by telephone, but the RD did not answer the call. During an interview on 10/23/2021 at 11:01 am, LVN 3 stated she recounted the narcotics in Medication Cart two with LVN 1 on 10/21/2021 around 2:15 pm. LVN 3 stated the medication count sheets for Oxycodone-Acetaminophen for Resident 1 and [MEDICATION(S)]-Acetaminophen for Resident 2 were present but the bubble packs of the medications were missing. LVN 3 stated she (LVN 3) always kept the narcotic keys with her because she was responsible to keep her medication cart and the narcotics in it safe and not accessible to others. A review of the facility's policy and procedure titled Controlled Medications dated 7/2020, indicated it was the policy of the facility to provide separately locked, permanently affixed compartments for storage of controlled drugs and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored was minimal and a missing dose could be readily detected. The policy indicated the DON, and the consultant pharmacist maintained the facility's compliance with federal and state laws and regulations in the handling of controlled medications. The policy indicated only authorized licensed nursing and pharmacy personnel had access to controlled medications. The policy indicated access key to controlled medications was not the same key giving access to other medications. The policy indicated the licensed nurse maintained possession of the key to controlled medication storage areas, and the DON kept the back-up keys to all medication storage areas, including those for controlled medications.

Based on observation, interview, and record review the skilled nursing facility failed to provide cardiopulmonary resuscitation (CPR) (manual application of chest compressions and ventilation to a person in [MEDICAL CONDITION] (heart stops beating)) correctly to one of one sample residents (Resident 1). This deficient practice resulted in Resident 1 being in prolonged respiratory distress (difficulty breathing) due to the facility's staff incorrect use of two emergency respiratory equipment while providing CPR. Findings: A review of Resident 1 Admission Record indicated Resident 1 was admitted to the facility on [DATE] after being discharged from the general acute care hospital (GACH). Resident 1's [DIAGNOSES REDACTED]. According to Resident 1's order summary report for emergency response, dated [DATE], Resident 1 indicated she wanted CPR and full treatment. A review of Resident 1's Physicians Orders for Life Sustaining Treatment (POLST), a physician order [REDACTED]. On [DATE] at 2:20 p.m. CODE BLUE (facility's code that resident requires emergency assistance) was heard over the facility's overhead speakers. The Code Blue was observed to be for Resident 1. At 2:20 p.m. Resident 1 was observed lying in bed, pale, mouth open, gasping for air. Resident 1's abdomen was observed retracting (sinking in) with every breath. Resident 1's neck veins were bulging. She was hard to arouse and unable to speak. Resident 1 was observed with a non-rebreather mask (NRB) (This is a device used to deliver high concentration 10 - 15 liters per minute (L/min) of oxygen. It includes a face mask which is attached to a plastic reservoir bag and they are connected to an oxygen supply source. The reservoir bag needs to be inflated with oxygen prior to use and the resident inhales (breathes in) the oxygen in the reservoir bag, which refills again from the oxygen source. When the resident exhales( breathes out), it exits the mask through a one-way valve to outside the mask unit. If the reservoir bag is not filled with oxygen prior to use the resident has no source of air/oxygen to breathe in and may inhale their exhaled carbon [MEDICATION NAME]. The NRB requires an oxygen flow rate of ,[DATE] L/min to replace the oxygen inhaled and keep the bag inflated.). Resident 1's NRB reservoir bag was observed to be deflated. The NRB's oxygen tubing was connected to Resident 1's bedside oxygen concentrator (a portable device which produces oxygen, used for daily oxygen therapy to treat chronic respiratory diseases, not severe respiratory distress. Resident 1's vital sign monitor indicated: Oxygen saturation (percentage of oxygen in the body where 94% to 100% is normal range) of 84%. Pulse rate (heart beats per minute where ,[DATE] is normal range per minute) of 128. Resident 1's appearance remained the same. Resident 1's physician, Registered Nurse (RN) 1 and 2, and Licensed Vocational Nurses 1 and 2, were observed at Resident 1's bedside. At 2:25 p.m. LVN 1 was directly in front of Resident 1 and was handed an adult manual resuscitator, also known as a bag valve mask (BVM) also known as Ambu Bag (Consists of a mask, a self-inflating bag, which is compressed (squeezed) to supply oxygen to the resident, who is not breathing or having difficulty breathing, and an opening to connect to an oxygen supply and a reservoir bag.) LVN 1 was observed to apply the BVM to Resident 1's face, the self-inflating bag was observed to be collapsed. LVN 2 connected the oxygen tubing to the oxygen tank. LVN 1 was observed holding the BVM to Resident 1's face and trying to squeeze the main bag while the reservoir bag at the other end was deflated (not filled with oxygen). Resident 1 continued to be observed in respiratory distress, pale, open mouth breathing, gasping for air, abdomen retracting with every breath, neck veins bulging, and unable to speak. On [DATE] at 2:30 p.m. Resident 1 was observed to be in continued respiratory distress, when the Fire Department arrived and provided care to Resident 1. A Fire Department Crew Member was observed opening the BVM bag and allowed the deflated reservoir bag to fill with air and then reapplied it to Resident 1. The Fire Department Crew Member stated the BVM was on wrong. After the BVM was reapplied Resident 1 became more alert and responsive. Resident 1's oxygen saturation increased from 84% to 91% and was transported out of the facility to the GACH emergency department. From 2:20 p.m. to 2:30 p.m. Resident 1 was observed with the NRB mask and BVM being incorrectly applied and operated. On [DATE] at 3:05 p.m. during an interview, LVN 1 stated Resident 1's NRB and BVM's reservoir bags would not inflate (fill with oxygen). LVN 1 stated the BVM bag was collapsed when she tried to squeeze it. LVN 1 did not know why Resident 1 continued in respiratory distress from 2:20 p.m. to 2:40 p.m. During an interview on [DATE] at 3:50 p.m. RN 1 stated Resident 1 was found non-responsive and called a CODE BLUE for Resident 1. RN 1 stated Resident 1's doctor happened to be in the facility and came to her room and saw her non-responsive and the doctor began giving Resident 1 CPR. RN I stated multiple staff arrived to help. RN I stated she saw LVN 1 had applied the NRB and BVM incorrectly. RN 1 stated she realized it was wrong but was busy trying to coordinate things for the paramedics. On [DATE] at 4:45 p.m. LVN 3 stated Resident 1 initially had low oxygen saturation levels while on the NRB because it was connected to the oxygen concentrator which was set at 15 L/min with a deflated bag reservoir. LVN 3 stated Resident 1 continued in respiratory distress while on the non-rebreather and was switched to a bag valve mask and continued in respiratory distress. LVN 3 stated both the main bag was collapsed in and the reservoir bag would not inflate. During an interview with the facility Director of Nursing (DON), on [DATE] at 8: 45 a.m. DON indicated every nurse during a CODE BLUE plays an active role in patient care: charting, chest compression, providing oxygen, and charge nurse makes calls and assists the nurses at the bedside. The nurse charting should be observing if the patient is responding to treatment and charge nurse is assigning staff tasks. DON stated side effects of continued ineffective oxygen administration during a respiratory distress emergency response is detrimental (causes harm), increases the time of respiratory distress, can cause brain damage, and cause the heart to work harder. An article in Nursing Times. [DATE], titled Respiratory Procedures: Use of a non-rebreathing oxygen mask (www.nursingtimes.net), lists the proper way to use a NRB mask, which included the following: 1. Attach the oxygen tubing to the oxygen source. 2. Set the oxygen flow rate to ,[DATE] L/min. 3. Occlude (cover) the valve between the mask and the oxygen reservoir bag. 4. Check the reservoir bag is filling up. 5. Remove the finger. 6. Squeeze the oxygen reservoir bag to check the patency (open, unobstructed) of the valve between the mask and the reservoir bag. 7. Place the mask with a filled oxygen reservoir bag on the patient's face ensuring a tight fit. 8. Adjust the oxygen flow rate until it is sufficient. 9. Ensure the reservoir bag deflates by approximately one-third with each breath. According to the MEDLINE Adult Manual Resuscitator (device used in CPR) manufacturer instructions it states the following: The Adult Manual Resuscitator is designed for the use in various clinical situations to provide respiratory support in the presence of reversible apnea (to restore breathing) commonly associated with respiratory arrest. WARNINGS: This device should only be used by personnel trained in adult CPR procedures. PREPARATIONS FOR USE: 1. Test the resuscitator for proper functioning: With patient port completely occluded (closed off), squeeze bag body to assure resistance is present. 2. Before using the mask, inspect for adequate inflation. DIRECTIONS FOR USE: 1. Place the patient in a supine (lying on back) position. Establish an open airway. 2. Grasp bag body with one hand. 3. Ventilate the patient by compressing (squeezing) the bag body for inhalation and releasing the bag body for patient's passive exhalation and bag body re-expansion. Continue this cycle as directed by medical authority. 4. Using supplemental oxygen: Connect oxygen supply tubing to oxygen source at appropriate flow rate. Fixed carbon [MEDICATION NAME] (the fixed amount of toxic gas with in a person's body) values may be compromised (lower than expected) if oxygen flow is not sufficient. Oxygen flows equal or greater than 15 liters per minute may be necessary. A review of the facility policies provided indicated there was no present procedure for emergency medical response to respiratory distressed residents or policies on how to use a non-breather mask or BVM. This was confirmed by the DON during an interview on [DATE] at 8: 45 a.m.