Every finding on record at Mission Carmichael Healthcare Center

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two of 27 sampled residents (Resident 126 and Resident 51) when:1. Follow-up appointments were cancelled and delayed for Resident 51; and,2. There was no monitoring and care plan for Resident 126's use of offloading boot (a specialized medical device designed to reduce pressure, friction, and weight on specific areas of the foot or heel).These failures resulted in delays in care for Resident 51 and increased Resident 126's risk to develop skin breakdown.Findings:During a review of Resident 51's admission records, the records indicated Resident 51 was admitted in February 2026 with diagnoses that included displaced comminuted fracture of shaft of left tibia and left fibula (both lower leg bones are broken into three or more fragments), fracture of part of neck of left femur (broken hip), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Resident 51's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/8/26, indicated Resident 51 had moderate cognitive impairment.During a review of Resident 51's physician order, dated 2/3/26, the order indicated, .[Resident 51] has capacity to make health care decisions.During a review of Resident 51's hospital records, dated 2/3/26, the records indicated, .F/u [follow-up] ortho [orthopedic - a specialty focused on diagnosing, treating and preventing disorders of muscles and bones] [name of physician] on 03/17/2026 at 10:15 AM.one hour early for Xray [an imaging test used to create images of bones and internal organs].During a review of Resident 51's nurses progress note, dated 3/17/26, the note indicated, .Called [name of physician] office to re schedule resident appt [appointment].Follow up Appt: March 24, 2026 @ 8:15.Communicated with SSD [Social Services Director] and resident informed of her schedule.During a review of Resident 51's nurses progress note, dated 3/24/26, the note indicated, .[Resident 51's] F/U DOCTOR APPOINTMENT WAS RESCHEDULED. [Resident 51] DOES NOT HAVE CAPACITY TO MAKE HEALTH CARE DECISION AND HAS TO HAVE FAMILY/STAFF TO ACCOMPANIED HER TO THE APPOINTMENT.During a review of Resident 51's nurses progress note, dated 4/7/26, the note indicated, .[physician] ordered to have Xrays done in facility if AP [anteroposterior - from front to back] lateral knee [outside of knee] 2 views and images forwarded to their clinic for review.During a review of Resident 51's social services progress note, dated 4/9/26, the note indicated, .Called [physician] office. They are still waiting for the X-rays of left knee before they can schedule appointment.During a review of Resident 51's nurses progress note, dated 4/10/26, the note indicated, NP [nurse practitioner].reviewed left knee x-ray, done on 4/8/26. No new order was received. [NP] noted, admitted for this (fracture), a follow-up x-ray for ortho.During a review of Resident 51's social services progress note, dated 4/10/26, the note indicated, .Appointment: 5/19/2026 9:30am.During an interview on 5/19/26 at 9:56 a.m. with Resident 51, Resident 51 stated she was not feeling good because her appointment for x-ray and left leg brace was cancelled. Resident 51 stated the appointment was scheduled in the morning of 5/19/26 and stated she did not know the reason for the cancellation.During a concurrent interview and record review on 5/22/26 at 8:47 a.m. with the SSD, the SSD reviewed Resident 51's progress notes and confirmed Resident 51 was scheduled to have her orthopedic appointment on 3/17/26 and was rescheduled on 3/24/26. The SSD stated she was not aware of the reason why the appointment was rescheduled. The SSD further confirmed that Resident 51's appointment was cancelled again on 3/24/26 because Resident 51 did not have the capacity to make healthcare decisions and required a family member or staff to accompany Resident 51 to the appointment. Contrary to the reason why Resident 51's appointment was cancelled, the SSD confirmed that Resident 51's physician order indicated that Resident 51 had the capacity to make healthcare decisions. The SSD stated that if there was a cancellation of appointment, there should be a reason why and it should be documented. The SSD confirmed that there was no documented evidence on why Resident 51's appointment was cancelled on 3/17/26 and the SSD stated that she did not understand the situation on Resident 51's capacity to make healthcare decisions. The SSD stated that there was a break in communication between the team.During a concurrent interview and record review on 5/22/26 at 11 a.m. with the Director of Nursing (DON), the DON confirmed Resident 51 had an orthopedic follow-up appointment scheduled for 3/17/26. The DON stated that the transportation company wanted the facility to give notification about the appointment at least a week prior to the appointment. The DON further stated the facility could not book the transportation on time to meet the appointment, so the appointment needed to be rescheduled. The DON confirmed that there was no documented evidence on why the appointment was cancelled and rescheduled and stated, .they [staff] probably forgot to document. The DON also confirmed that Resident 51's appointment was rescheduled for 3/24/26 but got cancelled again because Resident 51 did not have the capacity to make healthcare decisions and Resident 51's family member was unable to go with Resident 51 to the appointment. The DON confirmed that Resident 51's physician order indicated that Resident 51 had the capacity to make healthcare decisions. The DON further stated that the facility was not informed that Resident 5's family member was not able to make it to the appointment, and it was hard for the facility to provide the staff to go to the appointment. The DON confirmed that there was no documented evidence that the family member or staff member was not available for the appointment. The DON stated, .nurses communicate but sometimes, things get forgotten.During a review of the facility's policy and procedure (P&P) titled Provision of Physician Ordered Services, revised 5/15/23, the P&P indicated, .The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician services according to professional standards of quality.1. Diagnostic tests: a. Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders.b. Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity.d. Documentation of consultations, diagnostic tests.will be maintained in the resident's clinical record.5. Follow-up appointments: Facility staff will assist residents in scheduling and attending follow-up appointments as ordered by the physician.Necessary documentation of scheduled appointments and resident attendance may be maintained.2. During a review of Resident 126's admission records, the records indicated Resident 126 was admitted in April 2026 with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), necrotizing fasciitis (severe bacterial infection that destroys the body's soft tissue), polyneuropathy (occurs when multiple peripheral nerves become damaged), and major depressive disorder. Resident 126's MDS indicated Resident 126 had intact cognition.During a review of Resident 126's care plan, initiated on 4/30/26 and revised on 5/8/26, the care plan indicated, .[Resident 126] has potential/actual impairment to skin integrity and is at continued risk for skin breakdown r/t [related to] fragile skin.During a concurrent observation and interview on 5/19/26 at 10:42 a.m. with Resident 126 in his room, Resident 126 was observed alert and calm, lying in bed, with offloading boots on both feet. Resident 126 stated he wears the offloading boot most of the time.During an interview on 5/21/26 at 9:05 a.m. with Licensed Nurse 10 (LN 10), LN 10 stated that residents that use offloading boots needed to have a physician order to monitor the skin integrity. LN 10 further stated, .We want to know how long it's [offloading boots] been there. LN 10 added that the use of offloading boots should be included in the care plan. LN 10 stated it was important for the staff to be aware that a resident is wearing offloading boots to make sure they were properly placed and to monitor the condition of the skin.During an interview on 5/21/26 at 11:51 a.m. with Treatment Nurse 2 (TN 2), TN 2 stated the use of offloading boots should be checked and assessed every shift and the assessment is documented under the skin assessment. TN 2 further stated that there is usually an order for the use of the offloading boots and the nurses document that they did the assessment. TN 2 stated that there should be a physician order for the use of the offloading boots and it should be included in the care plan. TN 2 also stated that if the use of offloading boots was not monitored, it could give the residents more pressure on the skin and high risk for skin breakdown. TN 2 further stated it was important to include the use of the offloading boots in the care plan because the care plan was the guide on what care to provide for the residents.During a follow-up interview on 5/21/26 at 3:10 p.m. with TN 2, TN 2 confirmed that Resident 126 was using offloading boots on both feet since admission. TN 2 confirmed that there was no physician order or Treatment Administration Record (TAR) for Resident 126's use of the boots. TN 2 also confirmed that Resident 126's use of offloading boots was not included in the care plan. TN 2 confirmed that she just entered the order and the care plan today, 5/21/26, for Resident 126's use of the offloading boots because she remembered that Resident 126 uses offloading boots.During a concurrent interview and record review on 5/21/26 at 3:16 p.m. with the DON, the DON stated that for residents wearing offloading boots, the nurses check the use of the boots every shift to make sure they were on. The DON further stated that if a resident had a high risk for skin breakdown, the use of offloading boots should be part of the interventions in the care plan. The DON confirmed that Resident 126 had a high risk for skin breakdown because he was bedbound and had a history of open wound. The DON stated that there should have been monitoring on Resident 126's use of the boots and it should have been added to the care plan. The DON confirmed there was no documented evidence that Resident 126's use of the boots was being monitored.During a review of the facility's P&P titled Pressure Injury Prevention and Management, revised 9/12/23, the P&P indicated, .2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate.4. Interventions for Prevention and to Promote Healing.a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions.c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc).f. Interventions will be documented in the care plan and communicated to all relevant staff.g. Compliance with interventions will be documented in the weekly summary charting.

Based on observation, interview, and record review, the facility failed to provide the care and services necessary to ensure appropriate treatment and services to prevent urinary tract infections were provided for two of 27 sampled residents (Resident 126 and Resident 144) when:There was no physician order for suprapubic catheter (a tube inserted directly into the bladder to drain urine) and there was no output monitoring for Resident 126; andThere was no output monitoring for Resident 144 while the resident had suprapubic catheter in place.These failures decreased the facility's potential to monitor Resident 126's use of catheter and had the potential to place Resident 126 and Resident 144 at risk for complications, including urinary tract infections.During a review of Resident 126's admission records, the records indicated Resident 126 was admitted in 4/29/26 with diagnoses that included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), neuromuscular dysfunction of bladder (Neurogenic bladder - happens when an injury or disease interrupts the electrical signals between the nervous system and the bladder), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Resident 126's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/1/26, indicated Resident 126 had intact cognition.During a review of Resident 126's MDS Section H - Bladder and Bowel, dated 5/1/26, the MDS indicated Resident 126 had an indwelling catheter.During a review of Resident 126's care plan, revised on 4/30/26, the care plan indicated, [Resident 126] has Suprapubic Catheter r/t [ related to]: Neurogenic bladder.Monitor and document intake and output as per facility policy.During a concurrent observation and interview on 5/19/26 at 10:42 a.m. with Resident 126 in his room, Resident 126 was observed alert and calm, lying in bed, catheter bag observed on left side of bed, draining clear yellow urine. When asked about the catheter, Resident 126 stated he had a suprapubic catheter in place and had the catheter upon admission.A review of Resident 126's physician orders indicated the following:- Suprapubic Catheter Size: 16FR [French size - used to measure the outer diameter of the catheter] .Notify health care provider for blockage, leaking, pulled out, excessive sedimentation for further advice., ordered 5/19/26; and,- Monitor urine output related to suprapubic catheter, ordered 5/19/26.During an interview on 5/21/26 at 9:24 a.m. with Licensed Nurse 10 (LN 10), LN 10 stated urinary catheters were monitored for patency and that there should be an order for the use of catheter. LN 10 further stated it was important to monitor the output because residents sometimes do not have enough output and that needed to be reported to the physician because of the possibility of blockage. LN 10 stated the physician order and the output monitoring should be entered and done upon admission.During a concurrent interview and record review on 5/21/26 at 3:16 p.m. with the Director of Nursing (DON), the DON confirmed that Resident 126 had a suprapubic upon admission. The DON stated that there should be a physician order for residents that have catheters to make sure that nurses were aware that a resident has a catheter to monitor if there were blockages or if there was output or if the catheter was working. The DON also stated staff need to monitor the output to check if the catheter is working or if there is blood. The DON confirmed there were no physician orders for Resident 126's suprapubic catheter and output monitoring before 5/19/26 and stated the facility would not be able to find out if Resident 126 was having output or if the catheter was still working.2. During a review of Resident 144's admission records, the records indicated Resident 144 was admitted to the facility on [DATE] with diagnoses that included retention of urine. Resident 144's MDS, dated [DATE], indicated Resident 144 had severe cognitive impairment.During a review of Resident144's care plan, initiated on 5/18/26, the care plan indicated, [Resident 144] has Indwelling Suprapubic Catheter.Monitor and document intake and output as per facility policy.During an observation on 5/19/26 at 9:53 a.m. in Resident 144's room, Resident 144 was observed alert and calm, lying in bed, catheter tubing observed on right side of bed, connected to catheter bag.During a concurrent interview and record review on 5/21/26 at 3:48 p.m. with the DON, the DON confirmed that Resident 144 had a catheter upon admission. The DON also confirmed that Resident 144 did not have a physician order to monitor output before 5/20/26. The DON stated there was no documented evidence that Resident 144's output was monitored and recorded.During a review of the facility's policy and procedure (P&P) titled Appropriate Use of Indwelling Catheters, revised 12/19/22, the P&P indicated, .4. The use of an indwelling catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary.9. Indwelling urinary catheters (urethral or suprapubic) will be utilized in accordance with current standards of practice, with interventions to prevent complications to the extent possible. Possible complications include, but are not limited to: urinary tract infection, blockage of the catheter, expulsion of the catheter, pain, discomfort, and bleeding.

Based on interview and record review, three residents reviewed for weight loss (Resident 1, Resident 3 and Resident 56) did not maintain weight and no root cause analysis was done to determine best approach for reversing weight loss. This failure had the potential of leading to malnutrition and death.Findings:1a. Review of Resident 1's (Res 1) chart indicated Res 1 was admitted during the winter of 24/25 with diagnosis including pneumonitis, immunodeficiency, severe protein calorie malnutrition, and diabetes.Res 1 had gone from a weight of 155 lbs. (pounds) as of 5/3/25, to a weight of 135 lbs. in 5/3/26. This was a loss of 20 lbs. or 12.9% of body weight over a year. While not meeting the definition of significant weight loss, the gradual, unintentional weight loss placed Res 1 at risk for muscle loss, functional decline and decreased immune response. This insidious (gradual, without trying) weight loss is often a red flag for underlying health issues. As such, identifying and addressing the root cause early is critical to preventing complications.Review of interdisciplinary team (IDT) meeting notes indicated concern for the weight loss on 6/10/25, 7/9/25, 9/11/25, 10/7/25, 3/4/26, 4/7/26, and 5/7/26. Interventions were recommended such as increasing the frequency of weighing, fortifying (increasing the calorie content) of the diet, adding snacks, adding and/or changing nutrition supplements. No root cause was identified for the weight loss.During an interview with the Registered Dietitian (RD) on 5/20/26 at 2:34 p.m., the RD acknowledged that a root cause for the weight loss had not been identified in the notes. During an interview with the Assistant Director of Nursing (ADON) on 5/21/26 at 2:39 p.m., the ADON stated that weight loss often occurred when Res 1 had more difficulty breathing but agreed that information was not included in Res 1's notes used to determine interventions. 1b. Review of Resident 3's (Res 3) chart indicated Res 3 was admitted during the winter of 23/24 with diagnosis including diabetes, depression, dysphagia, and protein calorie malnutrition.Res 3 had gone from weighing 175 lbs. on 5/3/25, to 153 lbs. as of 5/4/26. Review of the RD note from 3/10/26 indicated under Weight Change -(minus) 12 lbs (7.1%) x1 mo (month). This indicated significant weight loss and a red flag that the weight loss should be evaluated.Review of interdisciplinary team (IDT) meeting notes indicated concern for the weight loss on 9/12/25, 3/4/26, 4/7/26, and 5/7/26. While interventions were recommended such as increasing the frequency of weighing, adding snacks, and having resident 3 undergo a swallow evaluation, no root cause was identified for the weight change. During an interview with the RD on 5/20/26 at 2:34 p.m., the RD acknowledged that a root cause for the weight loss had not been identified. During an interview with the ADON on 5/21/26 at 2:39 p.m., the ADON stated that Res 3's a wound (that was now healed) and being dependent for feedings may have contributed to the weight loss but agreed that information was not included in Res 3's notes and/or interventions.1c. Review of Resident 56's (Res 56) chart indicated Res 56 was admitted during the fall of 2015 with diagnosis including diabetes, dementia, and cerebrovascular accident (lack of oxygen causing brain cells to die).Res 56 had gone from weighing 132 lbs. on 7/2/25, to 109 lbs. as of 5/3/26. Review of the RD note from 5/7/26 indicated under Weight Change -(minus) 6 lbs (5.2%) x 2 wks (weeks), -11 lbs (9.2%) x 3 mo (months), -15 lbs (12.1%) x 6 mo. This indicated significant weight loss, a red flag that the weight losswhich should be evaluated.Review of interdisciplinary team (IDT) meeting notes indicated concern for the weight loss on 10/21/25, 2/20/26, 3/12/26, 4/7/26, and 5/7/26. While interventions were recommended such as increasing the frequency of weighing, fortifying the diet, adding snacks, and adding nutrition supplements, no root cause was identified for the weight change.During an interview with the RD on 5/20/26 at 2:34 p.m., the RD acknowledged that a root cause for the weight loss had not been identified. During an interview with the ADON on 5/21/26 at 2:39 p.m., the ADON stated Res 56 had a wound and was dependent for feedings which may have contributed to the weight loss though was not stated as the cause for weight loss in Res 56's notes and/or used for the determining the interventions.Review of facility provided Weight Management Policy (The Compliance Store, LLC., 2022) indicated that Weight may be a useful indicator of nutritional status. Significant changes in weight (loss or gain) or insidious weight changes (unintended loss or gain over a duration of time) may indicate a nutritional problem. It further indicated in bullet 4 that Interventions will be identified, implemented, monitored, and modified (as appropriate, consistent with the resident's assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. It further indicated in bullet 6 that a significant change in weight is defined as 5% change in weight in 1 month (30 days) or 10% change in weight in 6 months (180 days). Review of Setting Up Systems to Prevent Weight Loss ([NAME], MSN, RN 3/12/2026) at www.providermagazine.com indicated When a resident begins to lose weight, the root cause is often found in the daily routine-not the dietary order. Common contributors include:Inconsistent meal setup or feeding assistance.Missed snacks due to staffing patterns or competing priorities.Lack of meaningful observation about barriers (pain, fatigue, swallowing).Delayed escalation when intake declines.Care plan interventions that are not happening consistently at the bedside.Preventing weight loss depends on what staff notice and report early-not just what gets documented after the fact. CNAs are often the first to recognize barriers, but only if they are trained and empowered to report them.Nutrition-related observations that should trigger follow-up include:Refusing favorite foods.Fatigue and falling asleep mid-meal.Coughing, throat clearing, or pocketing food.Chewing difficulty, denture problems, or mouth pain.Mood changes, withdrawal, or loss of interest in meals.Constipation or abdominal discomfort affecting appetite.Weight-loss prevention becomes significantly more effective when teams view observation as part of clinical surveillance .

Based on observation, interview and record review, the facility failed to provide substitutions when the given meal was refused for three residents (Resident 1, Resident 26 and Resident 82) for a census of 129. This had the potential to result in hunger, weight loss, and malnutrition. Findings:During the initial resident interviews on 5/19/26 at 10:10 a.m., Resident 82 stated that he did not like the facility provided meals at times. Resident 82 further stated I'll just say I pass but complained that no meal substitute would be offered, leading to hunger. During the lunch meal observation 5/19/26 at 12:10 p.m., Resident 26 looked at her meal and wheeled out of the lower dining room. When asked, Resident 26 stated that she did not like the look of the meal. Observations were made of Resident 26 at 12:30 p.m. and 12:50 p.m. Resident appeared to be asleep in bed; no meal tray was on the bedside table. During a breakfast meal observation on 5/20/26 at 8:32 a.m., Resident 26 was interviewed in the hallway outside of her room. Resident 26 indicated that she did not receive a substitute meal for lunch the previous day.During the lunch meal observation on 5/19/26 at 12:47 p.m., Resident 1 was in bed, with his meal tray on his bedside table. Resident 1 had most of the meal uneaten. No substitute was offered when meal tray was removed. Resident 1 further stated he had lost weight during the stay at the facility. During an interview on 5/20/26 at 2:34 p.m. with the Registered Dietitian (RD), the RD stated that when a meal was refused, nursing should be offering a meal substitute.During an interview on 5/21/26 at 4:07 p.m. with the Dietary Supervisor (DS), the DS stated the nursing staff should go to kitchen to let us know when a meal was refused so that they could replace it with something else.Review of facility provided Food Preparation Guidelines (The Compliance Store, LLC, 2022) indicated in bullet 6 that Staff shall offer residents appropriate alternatives when they choose not to consume food/drink that is initially served .

Based on interview and posted mealtimes, the facility failed to keep the amount of time between dinner and breakfast to 14 hours or less for census of 129. This had the potential to result in residents' hunger and unstable blood sugar levels.Findings:During a concurrent interview and record review on 5/19/26 at 8:55 a.m. with the Dietary Supervisor (DS), the DS showed a copy of the meal schedule. Meals were noted to start with breakfast at 7 a.m., lunch at 11:30 a.m., and dinner at 4:30 p.m. This represented 14 1/2 hours between dinner and breakfast. The DS denied that the facility provided all residents with a substantial nighttime snack.

Based on observation, interview and record review, the facility failed to meet the standards for food service safety for a census of 129 when:The water curtain/splash shield of the ice machine revealed calcium buildup,The floor in front of the ice machine had two large breaks of approximately 3 by 10,Food labeling in the dry storage was inconsistent with the storage guidelines, A box of beef patties was not securely covered in the freezer, andThe middle dining room was being used for haircuts as residents were set up for the lunch meal.These failures had the potential of leading to cross-contamination and food borne illness.1. During the initial kitchen tour on 5/19/26 at 8:40 a.m. with the Director of Maintenance (DOM), the Manitowoc ice machine was opened to view the internal components. The plastic screen (water curtain/splash shield) covering the ice grid was observed with calcium buildup on the inside of approximately 2 inches by 4 inches though it had been approximately 10 days since it was last serviced. Review of easyice.com on Complete Manitowoc Ice Machine Cleaning Instructions it indicated that Limescale is the white buildup that can develop on commercial ice makers. It's also called calcium carbonate, calcium deposit, or scale for short. When this builds up, it requires descaling to remove. Descaling should be completed as the first step in the deep cleaning, followed by disinfecting and sanitizing. Take parts to the sink and do a thorough clean by spraying them off with a spray bottle filled with a 50/50 solution of descaler and water, scrubbing them with a brush, and rinsing them. 2. During the initial kitchen tour on 5/19/26 at 8:48 a.m., the floor in front of the ice machine was observed with 2 large breaks of approximately 3 inches by 10 inches. Subsequent interview of the Dietary Supervisor (DS) on 5/19/26 at 9:39 a.m., the DS stated that the floor had been like that for 5 to 6 years. Review of the facility provided policy Preventative Maintenance Program (The Compliance Store, LLC., 2022) indicated The Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. In bullet 1 it further indicated that The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Review of the US Food and Drug Administration's 2022 Food Code section 4-202.16 on Nonfood-Contact Surfaces indicated that Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and to allow easy cleaning and to facilitate maintenance. Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. Well designed equipment enhances the ability to keep nonfood-contact surfaces clean. 3. During an observation of the dry food storage on 5/19/26 starting at 9:10 a.m., a bag of pasta had a prep date of 5/15/26, and a used by date of 12/15/26 (7 months). A second opened bag of pasta had a prep date of 5/6/26 and a use by date of 12/6/26. A third bag of pasta had a prep date of 5/19/26 and a use by date of 12/19/26. Review of storage guidelines on door to storeroom indicated pasta was good for 2 years when unopened, and 1 year once opened. [NAME] 1 confirmed the pasta labels and food storage instructions. A large, opened bottle of vinegar was observed with a prep date of 4/24/26 and a use by date of 4/24/26. Per storage guidelines, vinegar is safe for 2 years when unopened, and 12 months once opened. [NAME] 1 confirmed the label and food storage instructions. Review of facility provided policy Food Storage ([NAME] Corporate Dietitians, 2024) indicated that All products should be . dated upon receipt, when open, and when prepared. Use-By dates on all food stored . according to the timetable in the Dry, Refrigerated and Freezer Storage Charts. Review of the US Food and Drug Administration's 2022 Food Code section 3-501.17 on Ready-to-Eat, Time/Temperature Control for Safety indicated that Food, Date Marking. shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded . 4. During the initial kitchen tour on 5/19/26 at 9:39 a.m. in the walk-in freezer, a box of beef patties was observed to have been opened. The bag containing the beef patties had been left open, exposing the beef patties to the air. During a subsequent interview with the DS on 5/21/26 at 4:40 p.m., the DS stated that the open bag could lead to cross-contamination of the beef patties. Review of facility provided policy Food Storage ([NAME] Corporate Dietitians, 2024) indicated that the Frozen Meat/Poultry and Foods section in bullet 3 on storage that Foods . should be stored in airtight containers or wrapped in heavy-duty aluminum or special laminated papers. 5. During an observation of the lunch meal service on 5/19/26 at 11:32 a.m., in the lower dining room., the middle dining room was observed through the glass windows. While waiting to see which dining room received the first meal cart, a male resident was observed in the middle dining room having his hair trimmed with an electric clipper. During an interview on 5/19/26 at 11:40 a.m. in the lower dining room, the hair stylist finished the haircut. The hair stylist stated that during her tenure she provided haircuts for the residents at the facility in a dedicated beauty shop until a year ago when hair cutting was moved into the dining room. During a subsequent interview with the Registered Dietitian (RD) on 5/19/26 at 11:47 a.m., the RD stated that cutting hair prior to a meal was a risk for cross contamination. During an interview on 5/21/26 at 2:39 p.m. with the Assistant Director of Nursing (ADON), the ADON stated that haircutting in the dining room prior to lunch would be an infection control issue. Review of the US Food and Drug Administration's 2022 Food Code section 2-402.11 indicated that Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination.

Based on observation, interview, and record review, the facility failed to follow infection control prevention practices for 6 of 27 sampled residents (Resident 15, Resident 115, Resident 16, Resident 93, Resident 44, and Resident 128) when: 1. Staff did not use required personal protective equipment (PPE- clothing and equipment worn or used to provide protection against hazardous substances and/or environment) while providing care to Resident 15 on enhanced barrier precaution (EBP- an infection control method); 2. Staff did not perform hand hygiene in between glove use during wound care for Resident 115;3.Resident 16's Oxygen tubing was not stored properly;4. A glucometer for Resident 93 not cleaned per manufacture recommendations; 5. Resident 44's nebulizer machine (device that turns liquid medicine into mist that can be inhaled) was on the floor; and 6. Resident 128's oxygen tubing was on the floor. These failures put Resident 15, Resident 115, Resident 16, Resident 93, Resident 44, and Resident 128 at increased risk for infection and adverse health outcomes. Findings: 1. A review of the admission Record indicated Resident 15 was admitted [DATE] with diagnoses including dysphagia (difficulty swallowing) and encounter for attention to gastrostomy (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). A review of Resident 15's physician order dated 2/24/26 indicated, Enhanced Barrier Precaution r/t [related to] G-tube .to prevent the spread of infections for specific care activities such as .toileting and changing incontinence briefs . During an observation on 5/19/26 at 10:44 a.m., there was an EBP signage by Resident 15's door and there was a yellow dot beside resident's name. During a follow up observation on 5/20/26 at 10:09 a.m., a female staff was inside Resident 15's room with face mask and gloves on. The staff had no gown and there was no observation of staff removing a gown after providing care for the resident. During an interview on 5/20/26 at 10: 11 a.m. with Certified Nursing Assistant 3 (CNA 3), the CNA 3 stated she changed Resident 15's brief. The CNA 3 further stated if Resident was on EBP then she was supposed to use a gown. The CNA 3 further stated she did not know if she was supposed to use a gown and what the yellow dot means. During a follow up interview on 5/20/26 at 10:18 a.m. with CNA 3, the CNA 3 stated she asked a co-worker regarding the yellow dot, and she was informed the yellow dot indicated Resident 15 was on EBP. During an interview on 5/21/26 at 3:30 p.m., with the Infection Preventionist (IP), the IP stated Resident 15 was on EBP due to presence of G-tube. The IP further stated her expectation when staff are caring for residents with the yellow dot identifier is to use gown and gloves (PPE) when doing high contact resident care including brief change. A review of the facility's policy and procedure revised 3/10/2025 and titled Enhanced Barrier Precautions indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms [MDRO- bacteria that developed resistance to multiple classes of antimicrobial drugs] .The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities .High-contact resident care activities include .Changing briefs . 2. A review of the admission Record indicated Resident 115 was admitted [DATE] with diagnoses including type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and pressure ulcer of right buttock, stage 3 (full- thickness loss of skin, dead and black tissue may be visible). During an observation on 5/21/26 starting at 11:27 a.m., with the Treatment Nurse 1 (TN 1) and a female Certified Nursing Assistant (CNA) inside Resident 115's room. There were two instances wherein the TN 1 did not perform hand hygiene in between glove use: - when TN 1 removed the old dressing on Resident 115's right buttock, TN 1 removed her gloves and put on a new pair of gloves; and - when TN 1 applied a barrier cream on the surrounding area of the wound and a skin preparation wipe to improve adhesion, TN 1 removed her gloves and put on new pair of gloves. During an interview on 5/21/26 at 11:35 a.m., with the TN 1 outside Resident 115's room, TN 1 stated she performs hand hygiene prior to glove use and before and after handling clean or soiled dressing. During an interview on 5/21/26 at 3:30 p.m. with the IP, the IP stated her expectation during wound care would be for staff to wear a gown and gloves during treatment. The IP further stated hand hygiene should be practiced before and after removing gloves, and hand hygiene will include the use of alcohol-based sanitizer. The IP added the facility go by the Centers for Disease Control and Prevention (CDC) guidelines and the facility policy. A review of the facility's policy and procedure revised 12/19/2022 and titled, Hand Hygiene indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Staff will perform hand hygiene when indicated .Alcohol- based hand rub with 60 to 95% alcohol is the preferred method of cleaning hands in most clinical situations .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. The CDC guidelines for wound care in SNFs emphasize using clean technique for chronic wound care to prevent infection, relying on strict hand hygiene, appropriate PPE (gloves and gown), and maintaining a clean field. Key CDC- aligned recommendations for wound care in SNFs include to perform hand hygiene before and after all wound care, and before putting on and after taking off gloves. (https://www.cdc.gov) 3.Review of Resident 16's AR, indicated Resident 16 was admitted in September 2023 with several diagnoses including chronic obstructive pulmonary disease (COPD-a condition that causes obstruction of airflow and ca make it difficult to breath) and chronic respiratory failure with hypoxia (long term condition that causes reduced oxygen to body). Review of Resident 16's Order Set Summary indicated an order for Oxygen (O2) at 3 liters per Nasal Cannula (an oxygen delivery device consisting of tubing to deliver oxygen through the nose) O2 supplement every shift. Review of Resident 16's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 4/23/26 indicated Resident 16 was cognitively intact. During a concurrent observation and interview on 5/19/26 at 9:48 a.m. with Certified Nursing Assistant (CNA) 5. Oxygen nasal cannula was observed on Resident 16's wheelchair. It was not in a bag and was lying on top of Resident 16's personal items including a sweatshirt and a towel. CNA 5 confirmed the above finding and stated that when not in use the oxygen tubing should be in a bag on the wheelchair. During an interview on 5/21/26 at 12:16 a.m. with the IP. The IP stated that her expectation for oxygen tubing is not in use it should be placed in the plastic bag on the resident's wheelchair. If it is left out of the bag it could be an infection control issue and cause cross contamination to other residents. Review of the facility's policy titled, Infection Prevention and Control, dated 12/19/22, the policy indicated. This facility has established and maintained an affection policy and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . 4.Review of Resident 93's AR indicated Resident 93 was admitted in May 2025, with several diagnosis including Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Review of Resident 93's Order Summary Set order date 2/28/26 indicated an order for Insulin Lispro Injection Solution (a rapid acting liquid solution that helps control a person's blood sugars) 100 units/ml (units/ml-units per milliliter a form a measurement). Inject per sliding scale (an insulin dose based on a person's current blood sugar) .subcutaneous (under the skin) with meals for Type 2 Diabetes. Review of Resident 93's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 3/26/26 indicated Resident 93 was cognitively intact. During a concurrent observation and interview on 5/20/26 at 8:05 a.m. with Licensed Nurse (LN) 9, LN 9 was observed using a glucometer to check Resident 93's blood glucose level. After LN 9 used the glucometer, she wiped the glucometer of with an alcohol pad. LN 9 stated that this is not the proper way to clean the glucometer and further stated she should have used a disinfectant wipe after using the glucometer, especially since Resident 93 is in contact isolation. During an interview on 5/21/26 at 12:21 p.m. with the infection Preventionist (IP), the IP stated her expectation for cleaning the glucometer would be to use a disinfectant wipe for two minutes per manufacture guidelines. The IP stated that if the glucometer is not cleaned properly there is a chance for cross contamination from one resident to another. Review of facility's policy titled, Glucometer Disinfection, dated 12/29/22, the policy indicated, The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi resident use. Review of the glucometer manufacture instructions dated 12/14, the instructions indicated that The blood glucose meters need to be clean and disinfected after each use . Disinfecting can be accomplished with a EPA-registered disinfectant detergent or germicide that is approved for health care settings or a solution of 1 to 10 concentration of sodium hypochlorite (bleach).' 5. A review of Resident 44's admission Record indicated Resident 44 was admitted to the facility in February 2020 with multiple diagnoses including chronic obstructive pulmonary disease (COPD-damage to the airways or lungs that blocks airflow and makes it difficult to breathe), asthma (lung disease caused by inflammation and muscle tightening around airways making it difficult to breathe), respiratory failure with hypoxia (respiratory system does not maintain enough oxygen in the blood), morbid obesity (body mass index of 40 or over- comparison of weight to height), and pulmonary fibrosis (lung tissue scarring causing difficulty breathing). A review of Resident 44's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 2/18/26, indicated Resident 44 had a BIMS score of 12 out of 15 that indicated Resident 44 had moderate cognitive impairment. A review of Resident 44's order dated 10/10/22, indicated .Albuterol Sulfate Nebulization Solution [medication used in nebulizer to treat respiratory conditions] (2.5MG [milligrams]/3ML [milliliters] 0.083%[concentration] 3 ml inhale orally via nebulizer every 4 hours as needed for SOB [shortness of breath] and/or wheezing . A review of Resident 44's Medication Administration Record (MAR), for 5/1/26 to 5/21/26, indicated .Albuterol Sulfate Nebulization Solution (2.5MG /3ML 0.083% 3 ml inhale orally via nebulizer every 4 hours as needed for SOB and/or wheezing- Start Date-10/10/2022 . -D/C [discontinue] Date-05/20/2026 . During a concurrent observation and interview on 5/19/26 at 8:45 a.m. with Resident 44, observed nebulizer machine on floor next to bed. Observed nebulizer tubing in nightstand drawer with drawer closed on tubing. Resident 44 stated they put the nebulizer on the floor because she was not using it. During a concurrent observation and interview on 5/19/26 at 9:53 a.m. with Certified Nursing Assistant (CNA) 6, CNA 6 confirmed Resident 44's nebulizer machine was on the floor and acknowledged it should not be on the floor. CNA 6 placed the nebulizer machine on Resident 44's nightstand. During an interview on 5/19/26 at 9:56 a.m. with Licensed Nurse (LN) 8, LN 8 stated Resident 44's nebulizer machine should not have been on the floor. LN 8 stated the nebulizer tubing should be in a bag and dated when changed. Resident 44 did not consent to view tubing in drawer to see if was in bag. LN 8 stated the nebulizer machine on the floor is an infection control issue. During an interview on 5/21/26 at 1:40 p.m. with the Infection Preventionist (IP), reviewed observation of Resident 44's nebulizer machine on the floor. The IP stated the nebulizer should not have been on the floor. The IP stated if the nebulizer is no longer being used it should be removed along with the tubing to prevent cross contamination. A review of the facility's Policy and Procedure (P&P) titled Nebulizer Therapy, revised 12/22/25, indicated .It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions .store the nebulizer cup and mouthpiece in a storage bag . A review of the facility's P&P titled Oxygen Administration, revised 5/20/24, indicated .If applicable, change nebulizer tubing and delivery devices weekly and PRN .per facility policy and if they become soiled or contaminated .Keep delivery devices covered in plastic bag when not in use .Cleaning and care of equipment shall be in accordance with facilities policies for such equipment . A review of the facility's P&P titled Infection Prevention and Control Program, dated 12/19/22, indicated .All reusable items and equipment requiring special cleaning. disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment . 6. A review of Resident 128's admission Record indicated Resident 128 was admitted to the facility in March 2025 with multiple diagnoses including chronic obstructive pulmonary disease (COPD-damage to the airways or lungs that blocks airflow and makes it difficult to breathe), heart failure (heart does not pump blood as well as it should), respiratory failure with hypoxia (respiratory system does not maintain enough oxygen in the blood), obstructive sleep apnea (OSA- sleep disorder where the walls of the throat close during sleep causing abnormal breathing), morbid obesity (body mass index of 40 or over- comparison of weight to height), and asthma (lung disease caused by inflammation and muscle tightening around airways making it difficult to breathe). A review of Resident 128's MDS, Cognitive Patterns, dated 3/3/26, indicated Resident 128 had a BIMS score of 0 out of 15 that indicated Resident 128 had severe cognitive impairment. A review of Resident 128's physician's order dated 11/6/25 indicated .Supplemental 02 [oxygen] @ 2-4 L/min [flow rate of oxygen delivered in liters per minute] via nasal cannula [thin flexible tube to deliver oxygen into the nose] AS NEEDED, may titrate 02 to maintain SPO2 [oxygen saturation- measurement of how much oxygen your blood is carrying in percent] greater or equal to 90 %. as needed for SPO2 < 90 % or SOB [shortness of breath]/wheezing . A review of Resident 128's Care Plan . [Resident 128] has COPD exacerbation, acute hypoxic respiratory failure ., initiated 03/03/2025, indicated .Interventions .Educate resident on importance of using oxygen. Monitor resident for compliance of using oxygen .initiated 03/03/2025 . During a concurrent observation and interview on 5/19/26 at 8:45 a.m. with Resident 128, observed 02 set at 2 liters/minute but tubing was on floor. Resident 128 stated she had been wearing the oxygen, but it fell on the floor. During a concurrent observation and interview on 5/20/26 at 3;20 p.m. with Licensed Nurse (LN) 5, observed Resident 128 with 02 set at 2 liters/ minute but oxygen tubing was on the floor. LN 5 confirmed the oxygen tubing was on the floor and stated oxygen tubing should be in a bag when not in use. LN 5 stated if the oxygen tubing was not in a bag, it was an infection control issue. LN 5 stated if the tubing was on the floor, it was contaminated and needed to be changed. During an interview on 5/20/26 at 4:15 p.m. with the Director of Nursing (DON), the DON stated oxygen tubing should not be on the floor and when not being used should be kept in a bag. During an interview on 4/21/26 at 1:40 p.m. with the IP, the IP stated oxygen tubing should not be on the ground. The IP stated oxygen tubing should be in a bag when not in use and if on the ground would provide new tubing due to contamination. A review of the facility's Policy and Procedure titled Oxygen Administration, revised 5/20/24, indicated .If applicable, change nebulizer tubing and delivery devices weekly and PRN .per facility policy and if they become soiled or contaminated .Keep delivery devices covered in plastic bag when not in use .Cleaning and care of equipment shall be in accordance with facilities policies for such equipment .

Based on observation, interview and record review, the facility failed to provide care consistent with professional standards for two of twenty-seven sampled Residents (Residents 78 and 93) when:1. Physician inhaler order for Resident 78 was not followed and 2. Resident 93's blood glucose was not obtained prior to mealtime insulin administration.These failures had the potential to result in provision of inappropriate treatment for both residents. Findings:1. A review of Resident 78's admission Record (AR) indicated Resident 78 was admitted in February 2026, with several diagnosis including chronic obstructive pulmonary disease (COPD-a condition that causes obstruction of airflow and can make it difficult to breath) and asthma (a condition that causes narrowing of airways and can cause shortness of breath).Review of Resident 78's Order Summary Report with an order date 2/27/26, indicated Inhaler with Fluticasone Furoate-Vilanterol (a medication that decreases inflammation). Aerosol Powder Breath Activated 100-25 mcg (mcg-microgram a unit of measurement), 1 puff inhale orally one time a day for COPD. Rinse mouth after use.Review of Resident 78's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 5/13/26 indicated Resident 78 was cognitively intact. Review of Resident 78's Care Plan (CP) dated 2/9/26, the CP indicated, Focus-Resident has COPD with an intervention that indicated give aerosol/inhalers (a handheld device that delivers medication to the lungs) or bronchodilators (medication that helps improve a person's breathing) as ordered.During a concurrent observation and interview on 5/20/26 at 8:21 a.m. with Licensed Nurse (LN 9), LN 9 was observed handing Resident 78 the Fluticasone Furoate-Vilanterol Inhaler and the medication was administered. LN 9 did not give instructions to Resident 78 to rinse his mouth after use as per the physician order. LN 9 stated she forgot to instruct Resident 78 to rinse his mouth and she should have told him to do so.During an interview on 5/21/26 at 1:32 p.m. with the Director of Nursing (DON), the DON stated that her expectation would be that the physician orders were followed and that LN should have instructed Resident 78 to rinse his mouth after using the inhaler.Review of the facility policy titled, Medication Administration, dated 12/19/22, the policy indicated, Medications are administered by licensed nurses.as ordered by the physician and in accordance with professional standards of practice .2. Review of Resident 93's AR indicated Resident 93 was admitted in May 2025, with several diagnosis including Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).Review of Resident 93's Order Summary Set order date 2/28/26 indicated an order for Insulin Lispro Injection Solution (a rapid acting injectable medication that helps control a person's blood sugar) 100 units/ml (units/ml-units per milliliter a form a measurement). Inject per sliding scale (an insulin dose based on a person's current blood sugar) .subcutaneous (under the skin) with meals for diabetes.Review of Resident 93's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 3/26/26 indicated Resident 93 was cognitively intact. During a concurrent observation and interview on 5/20/26 at 8:05 a.m. with LN 9, LN 9 was going to perform a blood glucose check on Resident 93 to determine what dose of Insulin Lispro he would require before breakfast. Upon entering the room Resident 93 was eating his breakfast. LN 9 confirmed the observation and stated Resident 93's blood glucose check should have been done about thirty minutes before he began eating breakfast.During an interview on 5/21/26 at 1:31 p.m. with the DON, the DON stated her expectation would be that blood glucose check should be done thirty minutes before a resident's meal to determine the dose of insulin needed. The DON further stated you would not get an accurate blood glucose result if it was tested while a resident was eating.Review of the American Diabetes Association, Section 7.11, titled, Diabetes Technology: Standards of Care in Diabetes-2026, it indicated that, People who are taking insulin and using a blood glucose monitoring should be encouraged to check their blood glucose levels based on their insulin therapy. This includes checking when fasting, prior to meals.

Based on observation, interview, and record review, the facility failed to provide proper foot care for 2 of 27 sampled residents (Resident 15, Resident 63) when: Resident 15 had thick and long toenails; and,Resident 63 had long, thickened toenails and the toenail on first toe of left foot was curving into second toe. These failures had the potential to cause foot infection, pain, and to decrease mobility.Findings: 1. A review of the admission Record indicated Resident 15 was admitted [DATE] with diagnoses including hereditary ataxia (gradual loss of muscle control, poor balance and uncoordinated movements) and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (CVA- stroke, loss of blood flow to a part of the brain) affecting the right dominant side. A review of Resident 15's Minimum Data Set (MDS- a federally mandated resident assessment tool) indicated Resident 15 had short and long-term memory problem and dependent on staff for personal hygiene. A review of Resident 15's physician order dated 2/24/26 indicated, May see podiatrist [medical specialists who treats foot related conditions]. During an observation on 5/19/26 at 10:44 a.m., Resident 15 was nonverbal and toenails were long. During a concurrent observation and interview on 5/20/26 at 10:21 a.m. with Licensed Nurse 1 (LN 1) inside Resident 15's room, LN 1 checked Resident 15's toenails. The LN 1 stated Resident 15's toenails were thick and long and needed to be trimmed. LN 1 further stated she did not receive a report regarding Resident 15's toenails. During an interview on 5/21/26 at 9:30 a.m. with the Medical Records Assistant (MRA), the MRA stated there was no documentation from Social Services regarding podiatry care for Resident 15. The MRA further stated there was no podiatry care provided for Resident 15. During an interview on 5/22/26 at 8:13 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated he was assigned to Resident 15 today. CNA 1 further stated during showers he checks the resident from head to toe, if fingernails or toenails are long, he will put a note in the shower sheet, and the shower sheet will be given to the nurse. CNA 1 stated when he worked with Resident 15 sometime ago, he noticed the toenails were slightly long and he put a note in the shower sheet and he handed the shower sheet to the nurse. CNA 1 further added CNAs were not allowed to trim the toenails, only the Registered Nurses (RNs). During an interview on 5/22/26 at 9:54 a.m. with the Director of Nursing (DON), the DON stated the admission nurse checks resident from head to toe and if toenails were long and thick this observation will be reported to Social Services. The DON further stated her expectation when CNAs are providing showers was to check the toenails and for CNAs to communicate observation with the nurse and the nurse to communicate with Social Services. 2. A review of Resident 63's admission Record indicated Resident 63 had been admitted to the facility in September 2025 with multiple diagnoses including fracture of left femur (a break in the thigh bone), chronic obstructive pulmonary disease (damage to the airways or lungs that blocks airflow that makes it difficult to breathe), chronic kidney disease (kidneys are damaged and cannot filter the blood the way they should), and chronic pain. A review of Resident 63's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 3/25/26, indicated Resident 63 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 12 out of 15 that indicated Resident 63 had moderate cognitive impairment. During a concurrent observation and interview on 5/19/26 at 8:45 a.m. with Resident 63, Resident 63 was in bed and removed her socks. Observed Resident 63's toenails were approximately one centimeter longer that the top of her toes and appeared thickened. The left first toenail was curved into her second toe on left foot. Resident 63 stated her left toenail was starting to cut into the second toe. Resident 63 stated she needed her toenails cut but they had not been cut since she was admitted . Resident 63 stated she had not been seen by a podiatrist while in the facility. During a concurrent interview and record review on 5/19/26 at 3:53 p.m. with the Social Services Director (SSD), the SSD stated a podiatrist comes to the facility every 60 to 90 days. After review of Resident 63's clinical record, the SSD acknowledged that Resident 63 had an order to be seen by podiatry dated 9/19/25 but had not been seen by podiatry. The SSD stated the nurses notify her who needs to be seen by podiatry. The SSD stated she did not receive a referral from nursing that Resident 63 needed to be seen by podiatry, so she was not added to the list for podiatry services. The SSD stated Resident 63 will be added to the list for podiatry to see in June 2026. A review of Resident 63's physician order, dated 9/19/25, indicated .May see podiatrist . A review of Resident 63's Care Plan . [Resident 63] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Activity Intolerance, Disease Processes: left femoral neck fx [fracture] ., initiated 9/19/25. indicated .Interventions/Tasks .Refer to podiatry for nail care as needed .initiated 05/20/2026 .PERSONAL HYGIENE: The resident requires partial assistance by 1 staff with personal hygiene .Initiated 09/24/2025 . Monitor /document/report PRN [as needed] any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function .initiated 09/19/2025 . A review of Resident 63's Progress Note, dated 5/20/26 at 8:35 a.m., indicated .Resident referred to podiatry . A review of Resident 63's Progress Note, dated 5/20/26 at 8:52 a.m., indicated SSA [Social Services Assistant] spoke with the treatment nurse about cutting the toenails of the resident. Informed the TN [treatment nurse] that resident is non-diabetic and has been referred to podiatry . During a concurrent interview and record review on 5/20/26 at 4:15 p.m. with the Director of Nursing (DON), the DON acknowledged that Resident 63 had not received podiatry services. The DON stated the Certified Nursing Assistants (CNAs) are able to perform nail care for non- diabetic residents, but if the nails are too long or thickened may not be able to trim the nails. During an interview on 5/22/26 at 1:21 p.m. with CNA 4, CNA 4 stated she checks fingernails every Sunday to see it they are dirty and then cleans and clips them for non-diabetic residents. CNA 4 stated CNAs do not clip toenails but notifies the LVN (Licensed Vocational Nurse) to clip the toenails if needed. CNA 4 stated if the resident is a diabetic they are referred to podiatry. A review of the facility's Policy and Procedure (P&P) titled Nail Care, dated 12/19/22, indicated .The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health .Assessments of resident nails will be conducted to determine the resident's nail condition, needs, and preferences for nail care .Obtain history and preferences regarding podiatrist .Identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke .Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis .Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled sessions as the need arises .If trimming is allowed, clip nails using nail clippers straight across and even with the tops of the fingers/toes .Document completion of task, any complications, or if resident refuses . A review of the facility's P&P titled Podiatry Services, revised 12/2/24, indicated .It is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health .Residents requiring foot care will be referred to qualified professionals such as podiatrist .Foot disorders which may require treatment include .nail disorders .Employees should refer any identified need for foot care to the social worker or designee .The social worker or designee will assist residents in making appointments . A review of the facility's P&P titled Activities of Daily Living (ADLs), dated 12/19/22, indicated .Care and services may consist of the following activities of daily living .Bathing, dressing, grooming and oral care .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain .grooming, and personal .hygiene .

Based on observation, interview, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standard of practice for two of 27 sampled residents (Resident 115 and Resident 128) when: Resident 115 had no oxygen signage and oxygen order in place; and, Resident 128 was not fitted with the correct BiPAP (Bilevel Positive Airway Pressure-noninvasive ventilation machine that helps with breathing) mask. These failures had the potential for Resident 115 and Resident 128 to experience respiratory distress and increased risk for fire hazard for Resident 115.Findings: 1. A review of the admission Record indicated Resident 115 was admitted [DATE] with diagnoses including myasthenia gravis (chronic autoimmune disorder [body's immune system attacks its own healthy tissues] which affects voluntary muscles controlling the eyes, chewing, swallowing, and breathing) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) with acute exacerbation (sudden, significant worsening). A review of Resident 115's Nurses Progress Notes dated 5/18/26 at 8:53 p.m. [20:53] indicated, .arrived to [sic] facility at 1900 [7 p.m.] .alert and oriented .on continuous O2 [oxygen] [NAME] nasal cannula [NC-a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen] at 2L [liter-unit of measurement] During a concurrent observation and interview on 5/19/26 at 10:08 a.m., there was no signage by the door. Resident 115 was observed with ongoing oxygen between 2-3 liters per minute via nasal cannula. Resident 115 opened her eyes when her name was called, and resident stated she did not feel good. During an interview on 5/19/26 at 1:30 p.m. with Licensed Nurse 2 (LN 2), the LN 2 stated yes the oxygen in use signage should be placed when a resident is using an oxygen concentrator (a medical device that pulls in room air, filters out nitrogen and delivers purified oxygen). During a follow up observation and interview on 5/19/26 at 1:33 p.m., there was no oxygen signage by Resident 115's door. Resident 115 with ongoing oxygen via NC. Resident 115 denied being short of breath. During a concurrent observation and interview on 5/19/26 at 1:35 p.m., with LN 3, the LN 3 confirmed there was no oxygen signage by Resident 115's door and resident was currently on oxygen. The LN 3 further stated there should be one when LN 3 was asked if there should be an oxygen signage by the door. During an interview and record review on 5/19/26 at 3:02 p.m. with LN 2, Resident 115's oxygen order and electronic Medication Administration Record (eMAR) were reviewed. The LN 2 stated Resident 115's oxygen order was put in today (5/19/26) at 3 p.m. The LN 3 further stated Resident 115 had oxygen this morning, resident was on oxygen prior to hospitalization on 5/6/26 and when she was readmitted to the facility on [DATE]. The LN 2 checked Resident 115's eMAR for May and Resident 115's oxygen order was discontinued on 5/12/26 and the new oxygen order was received today. The LN 2 added when she came in this morning, Resident 115's oxygen saturation was around 90% and LN 2 turned the oxygen concentrator on at 2 liters per minute. During an interview on 5/22/26 at 10:19 a.m. with the Director of Nursing (DON), the DON stated when a resident is using an oxygen concentrator there should be an oxygen signage by the resident's door. The DON further stated the nurse should have called the on-call physician or Nurse Practitioner if Resident 115 needed the oxygen since the resident did not have an oxygen order when she was readmitted on [DATE]. The DON added her expectation is for the nurse to get an order if a resident needs oxygen. A review of the facility's policy and procedure revised 5/20/2024 and titled, Oxygen Administration indicated, Oxygen is administered to residents who need it, consistent with professional standards of practice .Oxygen is administered under orders of a physician .Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use. 2. A review of Resident 128's admission Record indicated Resident 128 was admitted to the facility in March 2025 with multiple diagnoses including chronic obstructive pulmonary disease (COPD-damage to the airways or lungs that blocks airflow and makes it difficult to breathe), heart failure (heart does not pump blood as well as it should), respiratory failure with hypoxia (respiratory system does not maintain enough oxygen in the blood), obstructive sleep apnea (OSA- sleep disorder where the walls of the throat close during sleep causing abnormal breathing), morbid obesity (body mass index of 40 or over- comparison of weight to height), and asthma (lung disease caused by inflammation and muscle tightening around airways making it difficult to breathe). A review of Resident 128's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 3/3/26, indicated Resident 128 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 0 out of 15 that indicated Resident 128 had severe cognitive impairment. A review of Resident 128's physician order dated 4/29/25, indicated .BIPAP: Type of Mask: large nasal mask . A review of Resident 128's Medication Administration Record, for 4/1/26 to 4/30/26, indicated BIPAP was worn 7 out of 30 times on the night shift. MAR documentation indicated Resident 128 refused the BIPAP 2 times. A review of Resident 128's MAR, for 5/1/26 to 5/21/26, indicated BIPAP was worn 7 out of 21 times on the night shift. MAR documentation did not indicate Resident 128 refused the BIPAP. A review of Resident 128's Care Plan .Requires use of BIPAP therapy due to OSA ., initiated 11/16/2025, indicated .Interventions .BIPAP: Type of Mask: large nasal mask .date initiated 11/16/2025 .Call vendor for any problem with bipap or its accessories .date initiated 05/20/2026 .Encourage Resident's use of CPAP/BIPAP . date initiated 11/16/2025 . During a concurrent observation and interview on 5/19/26 at 8:46 a.m. with Resident 128, observed BIPAP machine on nightstand with mask in bag. Resident 128 stated she does not wear the BIPAP because the mask is too small. During a concurrent observation and interview on 5/20/26 at 3:08 p.m. with Resident 128, Resident 128 removed the mask from the bag and held up to her face and stated it was too small and she had not been wearing it. Resident 128 stated she had reported to staff the mask was too small. During an interview on 5/20/26 at 3:11 p.m. with Licensed Nurse (LN) 4, LN 4 stated Resident 128 does not wear the BIPAP on her shift, the evening shift 3 p.m. to 11 p.m. LN 4 stated she was not aware that Resident 128's BIPAP mask was too small. LN 4 stated the RN (Registered Nurse) applies the BIPAP. LN 4 stated if the mask was too small the RN needed to reassess the mask. LN 4 stated Resident 128 needs to wear the BIPAP when sleeping to help her breathing. During a concurrent observation and interview on 5/20/26 at 3:20 p.m. with LN 5, LN 5 stated she was the RN supervisor but was not aware that Resident 128's BIPAP mask was too small. LN 5 and this surveyor met with Resident 128. LN 5 examined the BIPAP mask and acknowledged it was too small for Resident 128 and will not work. LN 5 stated a new mask needed to be ordered. During a concurrent interview and record review on 5/20/26 at 4:15 p.m. with the Director of Nursing (DON), the DON stated Resident 128's BIPAP orders were from the hospital upon admission to the facility. The DON stated Resident 128 had episodes of removing the mask. The DON acknowledged the mask may not fit Resident 128. During an interview on 5/20/26 at 4:44 p.m. with the Director of Admissions (DOA), the DOA stated he was notified on 5/8/26 that Resident 128's BIPAP did not fit and needed a new mask. The DOA stated that was the first time he became aware that Resident 128's mask did not fit. The DOA stated he contacted the vendor on 5/8/26. The DOA acknowledged that Resident 128 had BIPAP order since 4/29/25 and may not have had the proper mask since 4/29/25. During a subsequent interview on 5/21/26 at 9:16 a.m. with the DOA, the DOA stated Resident 128 has a large nasal mask which is the largest size of the nasal mask. The DOA stated Resident 128 requested a full-face mask and will now order the full-face mask. The DOA acknowledged it has been over a year that Resident 128 did not have the correct face mask. A review of the facility's Policy and Procedure (P&P) titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy), dated 12/19/22, indicated .It is the policy of this facility to provide noninvasive ventilation as per physician's orders and current standard of practice .BiPap, or bi-level positive airway pressure .delivers an inhale pressure and an exhale pressure to provide a patent airway. It requires a machine that generates the separate pressures through a tube into a mask that fits over the nose or mouth . Document use of the machine, resident's tolerance, any skin, respiratory or other changes and response (s) Replace equipment routinely in accordance with manufacturers recommendations. General guidelines . Face mask and tubing - once every three months .

Based on interview and record review, the facility failed to ensure residents receiving dialysis (treatment to remove extra fluid and waste when kidneys fail) received care and services consistent with professional standards of practice for one of 27 sampled residents (Resident 5) when Resident 5's fluid restrictions (limits in the total daily intake of liquids) were not followed per physician's order.This failure placed Resident 5 at high risk for fluid overload (too much fluid in the body that could cause swelling, high blood pressure, breathing problems, and heart issues).During a review of Resident 5's admission records, the records indicated Resident 5 was admitted to the facility in March 2026 with diagnoses that included end stage renal disease (permanent kidney failure) and dependence on renal dialysis. Resident 5's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 4/6/26, indicated Resident had intact cognition and did not exhibit behaviors of rejection of care.During a review of Resident 5's physician order, dated 4/23/26, the order indicated, Fluid restriction 1000mL [milliliters, a unit of measurement]/24 hours.A review of Resident 5's Fluid Intake from 4/22/26 to 5/22/26 indicated the following dates with corresponding total fluid intake that exceeded 1000ml over 24 hours:- 4/25/26 - 1120 ml- 4/27/26 - 1460 ml- 4/28/26 - 1120 ml- 4/30/26 - 1290 ml- 5/2/26 - 1560 ml- 5/4/26 - 1220 ml- 5/5/26 - 2400 ml- 5/10/26 - 1390 ml- 5/11/26 - 1700 ml- 5/15/26 - 1580 ml- 5/16/26 - 1200 ml- 5/17/26 - 1560 ml- 5/20/26 - 1120 ml- 5/21/26 - 1560 mlDuring a concurrent interview and record review with the Director of Nursing (DON), the DON confirmed Resident 5 had an order for fluid restriction of 1000 ml for 24 hours. The DON also confirmed that Resident 5 received more than 1000 ml for multiple days in April and May 2026. The DON stated that Resident 5 was very non-compliant with fluid intake and that Resident 5 got angry when reminded of the fluid restriction. The DON confirmed there were no notes from staff that indicated Resident 5 was non-compliant with the fluid restriction. The DON further confirmed that Resident 5's non-compliance with the fluid restriction was not in the care plan. The DON stated that Resident 5 had the right to do what he wanted but the staff needed to make sure that the non-compliance was in the care plan and that everything was documented. The DON further stated that the lack of documentation and care planning would look like Resident 5 was not monitored for fluid intake and the order for fluid restriction was not followed.During a review of the facility's policy and procedure (P&P) titled Hemodialysis, revised 6/5/23, the P&P indicated, .This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan.The facility will assure that each resident receives care and services for the provision of hemodialysis.consistent with professional standards of practice. This will include:.Ongoing assessment and oversight of the resident before, during, and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions.During a review of the facility's P&P titled Fluid Restriction, revised 5/18/26, the P&P indicated, .It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to physician's orders.6. The resident has the right to refuse the fluid restriction, and if refused, documentation should support the reason for the refusal, the education of the risks and benefits, and any supporting documentation of the resident's continued refusal, assessment for any changes in condition related to the refusal, and the notification of the physician about the resident's refusal.

Based on interview and record review the facility failed to ensure Certified Nursing Assistants (CNAs) had an annual performance review for three of three sampled CNA staff (CNA 3, CNA 4, and CNA 7).This failure had the potential for CNA 3, CNA 4, and CNA 7 to provide inadequate care to residents. Findings: During an interview on 5/21/26 at 1:13 p.m. with the Director of Staff Development (DSD), the DSD stated he was responsible for conducting the performance evaluation for the CNAs. The DSD further stated he had not conducted a performance evaluation since he started last December. During a concurrent interview and record review on 5/21/26 at 5 p.m. with the DSD, the Payroll Action Form for the 3 CNAs was reviewed. The Payroll Action Form indicated CNA 3 was hired on 12/12/23, CNA 4 was hired on 10/17/23 and CNA 7 was hired on 8/1/21. The DSD further stated he cannot find the annual performance evaluation for the 3 CNAs. During an interview on 5/22/26 at 10:28 a.m., with the Director of Nursing (DON), the DON stated the performance evaluation for CNAs was done annually and the DSD is responsible for conducting the review. The DON further stated the importance of performance evaluation was for the facility to evaluate how an employee made progress in their knowledge and skills to make sure they provide the highest, practicable care for each resident, to evaluate attitude towards the residents/family, to evaluate resident care most specially resident's safety and completeness of documentation. A review of the facility's policy & procedure revised 12/19/2022 and titled, Evaluation Process indicated, It is the policy of our facility to review the work performance of employees with a formal written evaluation annually .The following procedures will be followed for employee performance evaluations .At the end of each month, the Human Resource department will notify the Department Manager of evaluations due for the following month .Evaluation forms should be returned to the manager/supervisor at least one (1) week prior to employee's appraisal date whenever possible .The Manager/Supervisor is to complete the Employee Evaluation Form .After the evaluation has been reviewed by the Administrator, the manager/supervisor will meet with the employee to review and discuss the evaluation .Once the evaluation review is complete, the employee and manager should sign the evaluation form .Original evaluation tools are to be forwarded to the Human Resources within the facility to be processed and placed in the appropriate personnel file.

Based on observation, interview, and record review, the facility failed to ensure dental services was provided for one of 27 sampled residents (Resident 113) when Resident 113's lower denture was missing. This failure increased the potential for Resident 113 to experience difficulty in chewing and weight loss. A review of the admission Record indicated Resident 113 was admitted [DATE] with diagnoses including hypothyroidism (the thyroid gland [small, butterfly -shaped gland in the neck] does not produce enough thyroid hormones leading to extreme fatigue, unintentional weight gain, and feeling cold all the time) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). A review of Resident 113's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 3/31/26 indicated Resident 113 was cognitively intact with a Brief Interview for Mental Status (BIMS- an assessment tool to screen and identify memory, orientation, and judgement status) of 15. The MDS further indicated Resident 113 required partial or moderate assistance with oral hygiene which included the ability to insert and remove dentures into and from the mouth. A review of Resident 113's Inventory of Personal Effects dated 3/29/26 indicated, Resident 113 had (1) upper and (1) lower dentures. A review of Resident 113's care plan dated 4/1/26 indicated Resident 113 has potential for oral/dental health problems related to full dentures. The interventions included to coordinate arrangements for dental care and monitor/document/report any signs & symptoms of oral/dental problems needing attention. During a concurrent observation and interview on 5/19/26 at 9:17 a.m., Resident 113 was edentulous, observed one denture in a cup. Resident 113 stated his lower denture was broken and he did not know where it was. Resident 113 added he is receiving soft food and had trouble chewing at times. During a follow up observation and interview on 5/20/26 at 12:37 p.m., Resident 113 was inside his room eating his lunch without dentures. Resident 113's meal ticket indicated Regular easy to chew. Resident stated no when he was asked if he found his lower denture. During a concurrent interview and record review on 5/20/26 at 2:31 p.m. with Licensed Nurse 6 (LN 6), Resident 113's Inventory of Personal Effects was reviewed. LN 6 stated Resident 113's inventory dated 3/29/26 indicated resident had 1 upper and 1 lower denture. LN 6 further stated he did not receive a report Resident 113 had a missing denture. During a subsequent observation and interview on 5/20/26 at 2:39 p.m., with LN 6 inside Resident 113's room. LN 6 saw one (1) denture in a cup. Resident 113 stated the denture in the cup was his upper denture. LN 6 looked inside Resident 113's drawer and [LN 6] could not find the other denture. Resident 113 further stated he told somebody when he did not have the other denture. LN 6 stated when a denture is missing, they notify Social Services Department and laundry and notify family as well. During an interview on 5/20/26 at 2:52 p.m. with Certified Nursing Assistant (CNA 8), CNA 8 stated she worked with Resident 113 beginning of the month. CNA 8 further stated she noticed Resident 113 had one denture, when she asked Resident 113, resident did not know where it was, resident told her the lower denture was missing. CNA 8 added she reported the missing denture to the charge nurse. CNA 8 further added she noticed the denture was missing the week before last week (two weeks ago). During a follow up interview on 5/20/26 at 3:25 p.m. with LN 6 inside the conference room, LN 6 stated he spoke with the two staff from Social Services. The staff from Social Services told LN 6 they did not receive a report regarding the missing denture for Resident 113. LN 6 further stated if a CNA reported to him a resident was missing dentures, he will put a note in the clinical records and notify Social Services. LN 6 added he did not see documented evidence of Resident 113's missing denture in the clinical records. During an interview on 5/22/26 at 10:05 a.m. with the Director of Nursing (DON), the DON stated for residents who are alert and able to take care of dentures, the expectation was for staff to check if a resident was wearing dentures before meals. The DON further stated if a CNA was made aware the dentures were missing, the CNA should report to the charge nurse, and the charge nurse should report to Social Services. The DON added there was no change in Resident 113's diet texture since 3/29/26. A review of the facility's policy & procedure revised 12/19/2022 and titled Theft and Loss Program indicated, The facility has a Theft and Loss program to ensure that resident's property is safeguarded .When a personal property item is reported missing, the staff should immediately begin a search for the missing property .If the property is not found, a Theft and Loss report is to be completed .The completed Theft and Loss report should be given to the Social Services staff for further investigation and resolution.

Based on observation, interview, and record review, the facility failed to ensure the call light device was accessible for 1 of 27 sampled residents (Resident 142) when Resident 142 was not able to reach his call light device to call for assistance. This failure placed Resident 142 at risk for his care needs to be unmet and at increased risk for falls. A review of Resident 142's admission Record indicated Resident 142 was admitted to the facility in May 2026 with multiple diagnoses including gangrene and necrosis of lung (complication of pneumonia causing death of lung tissue), chronic obstructive pulmonary disease (COPD-damage to the airways or lungs that blocks airflow that makes it difficult to breathe), diabetes (too much sugar in the blood), vascular dementia (inadequate blood flow to the brain causing changes in thinking skills and memory), and protein-calorie malnutrition (inadequate intake of protein and calories). A review of Resident 142's Minimum Data Set (MDS- federally mandated assessment tool), Cognitive Patterns, dated 5/11/26, indicated Resident 142 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 10 out of 15 that indicated Resident 142 had moderate cognitive impairment. A review of Resident 142's MDS, Functional Abilities, dated 5/11/26, indicated Resident 142 needed moderate to substantial assistance with eating, oral hygiene, dressing, and personal hygiene and was dependent for toileting, bathing, bed mobility, and transfers. A review of Resident 142's Care Plan . [Resident 142] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Activity Intolerance, Disease Processes: gangrene and necrosis of lung, Type 2 DM [diabetes mellitus], COPD, vascular dementia ., initiated 05/08/2026, indicated .Interventions .Encourage the resident to use bell to call for assistance .Date Initiated: 05/08/2026 . During a concurrent observation and interview on 5/19/26 at 8:45 a.m. with Resident 148, observed Resident 148's call light device hanging from the left side of the bed rail almost to the floor. When asked if he could reach it, Resident 148 stated he was not able to reach the call light device. During a concurrent observation and interview on 5/19/26 at 10:53 a.m. with Licensed Nurse (LN) 1, LN 1 acknowledged that Resident 148 was not able to reach his call light device on his left side. LN 1 stated the call light device needs to be close to the resident. LN 1 handed Resident 148 his call light device and asked him to demonstrate if he could use it. Observed Resident 148 was not able to use the call light device with his left hand. LN 1 acknowledged that Resident 148 was not able to use the call light with his left hand and stated it needed to be moved to Resident 148's right side where he was able to press the button on the call light device. During an interview on 5/22/26 at 1:21 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated call light devices should be close to the resident, and she usually clips it to the top of their clothing. CNA 4 stated the call light device needs to be within reach of the resident. CNA 4 stated it needs to be assessed if resident able to use the call light device and it should be placed on the resident's stronger side to be able to use. CNA 4 stated if resident not able to use their call light device they may yell out or may try to get out of bed on their own and fall. A review of the facility's Policy and Procedure (P&P) titled Call Lights: Accessibility and Timely Response, dated 12/19/22, indicated .The purpose of this policy is to ensure the facility is adequately equipped with a call light .Staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light .Each resident shall, as much as possible, be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system .Staff will ensure the call light is within reach of the resident and secured, as needed . The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room .

Based on observation, interview, and record review the facility failed to ensure 2 of 5 sampled residents (Resident 1 and Resident 2) were properly positioned during feeding assistance as per care plan and facility's meal assistance policy and procedure. This failure placed Resident 1 and Resident 2 at risk for aspiration and possible discomfort when eating. Findings: 1a. A review of Resident 1's admission record indicated Resident 1 was admitted in March 2025 with multiple diagnoses including COPD (a lung disease that makes it difficult to breathe) and GERD (Gastroesophageal reflux disease- a condition where stomach acid and food can flow backward from the stomach into the throat). A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 3/28/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 6 out of 15 that indicated Resident 1 had severe cognitive impairment. A review of Resident 1's MDS, Functional Abilities and Goals, indicated Resident 1 required maximum assistance for rolling left to right and eating. A review of Resident 1's care plan titled, The resident has GERD dated 3/24/2025, indicated .Avoid lying down for at least 1 hour after meals. Keep HOB elevated. Encourage to stand/sit upright after meals . A review of Resident 1's care plan titled, The resident has nutritional problem . , dated 3/25/2025, indicated, .Maintain the HOB [Head of Bed] at 30-45 degrees during feeding . During an observation on 4/9/25 at 12:25 p.m. with CNA 1 at Resident 1's bedside, Resident 1 was observed in a left side lying position. No assistive devices for positioning were observed. CNA 1 was observed as she fed a spoon of yellow jello to Resident 1 without repositioning the resident. During an interview on 4/9/25 at 12:35 p.m. with CNA 1 outside of Resident 1's room, CNA 1 stated Residents should be sitting upright when eating meals. CNA 1 confirmed yellow jello was fed to Resident 1 while lying on his left side. During a follow up observation on 4/9/25 at 12:37 p.m. outside of Resident 1's room, Resident 1 was observed lying with head of bed lower than 30 degrees and lying on his left side. 1b. A review of Resident 2's admission record indicated, Resident 2 was admitted in March 2025 with multiple diagnoses including Need for assistance with personal care and dysphagia (difficulty swallowing). During a review of Resident 2's MDS, Cognitive Patterns, dated 4/2/25, indicated Resident 2 had a BIMS score of 99 out of 15 that indicated Resident 1 could not complete the interview. A review of Resident 2's MDS, Functional Abilities and Goals, indicated Resident 2 was dependent on staff for rolling left to right and eating. A review of Resident 2's care plan, titled the Resident has nutritional problem . , dated 4/4/25, indicated, .Maintain the HOB at 30-45 degrees . During an observation on 4/9/25 at 12:41 p.m., in Resident 2's room with CNA 2 present, Resident 2 was observed in supine position with head of bed lower than 30 degrees. CNA 2 was observed offering resident a spoon of yellow pudding while resident was in supine lying position. During a concurrent observation and interview on 4/9/25 at 12:41 p.m. with CNA 2 at Resident 2's bedside, CNA 2 confirmed that she attempted to give Resident 2 a spoon of yellow pudding while Resident 2 was in a lying position. CNA 2 stated staff should always put the head of bed up when feeding residents. During review of facility policy and procedure (P&P) titled Activities of Daily Living (ADLs) , dated 12/19/2022, the P&P indicated . a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition . During a review of facility P&P titled, Meal Supervision and Assistance , dated 12/19/2022, the P&P indicated .the resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped.

Based on interviews and record reviews, the facility failed to ensure that discontinued non-controlled medications (pharmaceutical preparations that can only be obtained through a medical practitioner's prescription and dispensed by a pharmacist but are not considered controlled substances under the Controlled Substance Act) and those which remained in the facility after discharge of the patient were destroyed in the presence of two licensed nurses. This failure had the potential risk for diversion (deflection of prescription drugs from medical sources into the illegal market) and/or misuse of non-controlled medications. Findings: During a concurrent interview and record review on [DATE] at 4:22 p.m. with the Infection Preventionist (IP), the non-controlled medication disposition logbook was reviewed. The IP confirmed that the destruction of non-controlled medications was not being signed consistently by two licensed nurses on multiple dates and with multiple medications. Some of the documents reviewed had only one licensed nurse signature, and some did not have any signature at all. The IP stated that non-controlled medications should be destroyed and signed by two (2) licensed nurses. During a phone interview on [DATE] at 3:21 p.m. with the Pharmacy Consultant (PC), the PC stated that for non-controlled drug destruction, there should always be two license nurses signing the sheets when the medications are being destroyed. The PC further stated that there would be a potential for drug diversion if the non-controlled drug destructions were not done and signed by two licensed nurses. During an interview on [DATE] at 10:26 a.m. with the Director of Nursing (DON), the DON stated that the non-controlled medications should be destroyed and signed consistently by two licensed nurses. The DON further stated that there would be possible misuse of the medications if the destructions were not done and signed by two licensed nurses. A review of the facility's policy and procedure titled, Destruction of Unused Drugs, revised [DATE], indicated, All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations .4. The actual destruction oof drugs conducted by our staff must be witnessed by: .Non-controlled Medication: i. Consultant pharmacist; or ii. Licensed nurse. 5. A destruction record must be maintained for all drugs destroyed. The actual destruction of drugs conducted by our facility must be witnessed by facility staff as per state requirements .The following information shall be included on this record: .g. The signature of the consultant pharmacist or licensed nurse destroying the non-controlled medications.

Based on observation, interview, and record review the facility failed to ensure safe medication administration practices when the facility's medication error rate was more than 5% (percentage- number or ratio that expressed as a fraction of 100) for a resident census of 125. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of two errors out of 30 opportunities which resulted in a facility wide medication error rate of 6.67% in two out of eight residents (Resident 96 and Resident 132) observed for medication administration. These failures had the potential for unsafe and ineffective medication use of Resident 96 and Resident 132 and had the potential to affect the residents' medical conditions. Findings: 1. During a concurrent medication administration observation and interview which started on 3/24/25 at 11:48 a.m. with Licensed Nurse (LN) 3, LN 3 stated she already checked Resident 96's blood sugar level, and it was 217. LN 3 then administered a total of seven units of Insulin Lispro (a fast- acting medication used to manage blood sugar levels) to Resident 96 on her right upper outer arm. There was no observed meal tray in Resident 96's room. LN 3 stated lunch was scheduled at 11:30 a.m. but it was running late on that day. A review of Resident 96's active physician's order, dated 2/10/25, indicated, Insulin Lispro Injection Solution 100 UNIT/ML (unit per milliliters- unit of measurement) .Inject 5 unit subcutaneously (under the skin) two times a day related to TYPE 1 DIABETES MELLITUS (a chronic condition where the body doesn't produce insulin, causing too much sugar in the blood) . A review of Resident 96's active physician's order, dated 2/10/25, indicated, Insulin Lispro Injection Solution 100 UNIT/ML .Inject as per sliding scale: .201-250= 2 units .subcutaneously before meals related to TYPE 1 DIABETES MELLITUS . During an observation on 3/24/25 at 12:23 p.m. in Resident 96's room, there was still no observed meal tray in Resident 96's room. During a concurrent observation and interview on 3/24/25 at 12:37 p.m. with Certified Nurse Assistant (CNA) 8 in Resident 96's room, CNA 8 confirmed that Resident 96 did not receive her lunch meal tray yet. CNA 8 stated the kitchen has just started bringing out food carts. During an observation on 3/24/25 at 12:41 p.m. in Resident 96's room, Resident 96 was observed eating her lunch meal. A review of Resident 96's, Weights and Vitals Summary, indicated Resident 96 had blood sugar levels as follows: 3/24/25 at 4:41 p.m.- 86 mg/dl (milligrams per deciliter- unit of measurement) 3/24/25 at 23:01 p.m.- 119 mg/dl A further review of Resident 96's, Weights and Vitals Summary, indicated Resident 96's previous blood sugar levels usually ranges from 217 - 398 mg/dl. During a phone interview on 3/26/25 at 3:21 p.m. with the Pharmacy Consultant (PC), the PC stated Insulin lispro should be administered before meals, if not, it could cause hypoglycemia (low blood sugar). The PC further stated nurses should follow the doctor's order when administering Insulin Lispro. A review of an online publication, Drugs.com, titled, When does insulin lispro peak / how long does it last?, dated 6/17/24, indicated, Insulin Lispro .Starts working within 0 to 15 minutes after administration .Peaks in 30 to 90 minutes .Keeps working for less than five hours (usually two to four hours . (https://www.drugs.com/medical-answers/insulin-lispro-peak-long-3544836/) 2. During a medication administration observation which started on 3/25/25 at 9:20 a.m. with LN 5, LN 5 administered a total of 10 medications to Resident 132 which included 1 tablet of Pantoprazole (a medication that reduces the amount of acid the stomach) 40 mg (milligrams- unit of measurement). A review of Resident 132's active physician's order, dated 3/18/25, indicated, Pantoprazole Sodium Oral tablet Delayed Release 40 MG .Give 1 tablet by mouth one time a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE (a condition where stomach contents flow back up into the food pipe, causing inflammation and discomfort) . A review of Resident 132's Medication Administration Record (MAR- a legal document used to record medications given to the residents), for the month of March 2025, indicated Resident 132's pantoprazole was scheduled to be administered every 7:30 a.m. During a phone interview on 3/26/25 at 3:21 p.m. with the PC, the PC stated that Resident 132's pantoprazole should be administered 1 hour before or 1 hour after the scheduled time. The PC further stated that the medications efficacy (ability to produce a desired or intended result) would be affected if the pantoprazole was not administered within the scheduled time of administration. During an interview on 3/27/25 at 10:26 a.m. with the Director of Nursing (DON), the DON stated that she would expect staff to follow the physician's order when administering prescribed administering medications. A review of the facility's policy and procedure (P&P) titled, Medication Administration, dated 12/19/22, indicated, Medications are administered .as ordered by the physician and in accordance with professional standards of practice .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician .

Based on observation, interview, and record review, the facility failed to ensure medications and supplies were properly labeled and stored in accordance with manufacturer's guidelines, the facility's policies and procedures, and accepted professional standards for a census of 125 residents when: 1. An unlabeled, opened glucose gel tube (a medication administered for low blood sugars) was found in medication cart North 3; 2. A discharged resident's medications were found loose in a bag in the medication room; and 3. The refrigerator in the North Medication Room was not within the correct temperature range. These failures had the potential to result in unsafe medication administration and drug diversion. Findings: 1. During a concurrent observation and interview on [DATE] at 10:03 a.m. with Licensed Nurse (LN) 2, a glucose gel tube was found in the top drawer of medication cart North-3. LN 2 confirmed the gel had been opened and there was no label which indicated the date it had been opened, or when it expired. During a concurrent interview and record review on [DATE] at 9:40 a.m. with LN 8, LN 8 reviewed the manufacturer's instructions for use and confirmed the gel was a single use medication. During an interview on [DATE] at 11:50 am with LN 2, LN 2 confirmed the gel was a single use medication and there was a risk it could have been already administered to another resident. 2. During a concurrent observation and interview on [DATE] at 3:30 p.m. with the Infection Preventionist (IP), a plastic bag with resident belongings was on the counter of the North medication room. The IP confirmed the bag contained a resident's medications and there was an opened pill bottle with loose pills in the bag. The IP stated when a resident was discharged , they kept their medications in the medication room, if they don't return within 7 days, they disposed of them. The IP stated an open medication bottle was a risk for drug diversion and would not be appropriate to return to the resident should they return to the facility. 3. During a concurrent observation and interview on [DATE] at 4:01 p.m. with the IP, the IP confirmed the temperature of the North medication room refrigerator was 51 degrees Fahrenheit (F a unit of measurement.) The refrigerator contained insulin vials, emergency medication kits, and vials for vaccination. During a concurrent observation and interview on [DATE] at 4:14 p.m. with the IP, the temperature of the medication refrigerator was rechecked and the IP confirmed it was still at 51 F . The IP stated if the refrigerator temperature was out of range, it could compromise the efficacy of the medication and make them unsafe for resident use. During an interview on [DATE] at 4:07 p.m. with Pharmacy Consultant (PC), the PC concurred the glucose gel was for individual use. The PC stated an unlabeled, opened tube should not have been in the medication cart, should have been disposed of immediately after resident administration, was a risk of cross-contamination and had the potential for it to be administered to another resident. The PC said all medications at the facility need to be monitored, recorded and accounted for. The PC confirmed medications stored in a refrigerator at the incorrect temperatures could compromise their efficacy and make them unsafe for use. During an interview on [DATE] 10:26 a.m. with the Director of Nursing (DON), the DON confirmed that nurses needed to label, dispose of and store all medications appropriately. During a review of a facility policy titled, Labeling of Medications and Biologicals, revised [DATE], the policy indicated, All medications and biologicals will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. During a review of the product insert for the glucose gel it indicated, Do not use if tube has been previously opened or punctured and, Use before the expiry date printed on the carton. During a review of the facility policy titled, Storage of Medication Requiring Refrigeration, revised [DATE], the policy indicated, Refrigerators used for storage of biologicals .Temperature should be maintained between ,d+[DATE] F . During a review of the facility policy titled, Destruction of Unused Drugs, revised [DATE], the policy indicated, Unused, unwanted and non-returnable medications should be removed from their storage area.

Based on observation, interview and record review, the facility failed to store and ensure food safety in accordance with professional standards for food service safety to prevent an outbreak of foodborne illness for the census of 125 residents when: 1. Food items found in the freezer were unlabeled with the open and the use by dates. a. opened bag of garlic bread; b. opened box of pork sausage links with net weight of 10 lb.; and c. opened box of fish fillet with net weight of 15 lb. 2. Food items found in the walk-in refrigerator unlabeled with the open and use by dates. a. mustard (condiments) with net weight of 48 oz; and b. honey mustard (dressing) with net weight of 1 gal. 3. Food items found in the dry storage room were unlabeled and had lapsed use by dates. a. corn meal with use by date of 2/17/25; b. cake mix with use by date of 2/30/25; c. soy sauce with net weight of 1 gal, unlabeled with the open and the use by date; and d. white powder with unreadable name label, the open date and the use by date. 4. four (4) dented cans were found in the dry storage room: a. artichoke in can with net weight of 5 lb.; b. beef ravioli in can with net weight of 6 lb. 12oz; c. pinto beans in can with net weight of 6lb 15oz; d. tomato soup in can with net weight of 50 oz; and e. tomato soup in can with net weight of 7.52 oz. These failures had the potential to cause foodborne illness to highly susceptible residents. Findings: During a concurrent observation and interview in the kitchen with the Dietary Manager (DM), on 3/24/25 at 8:40 a.m., the DM confirmed and agreed on all findings listed above. The DM stated, the perishable food should be legibly labeled with the name of the product, date it was opened, use by date and monitored to ensure the food is safe to eat by the residents. The DM emphasized that food items with lapsed use by dates should have been thrown out as well as food items with unreadable labels as it's not safe and may cause possible foodborne illness. The DM confirmed there were 4 dented cans stored with the non-dented cans. The DM stated that dented cans should have been removed from the non-dented can shelves as it's not safe to use and may cause botulism (rare but serious bacterial infection) to the residents as a potential outcome. During an interview in the kitchen with [NAME] 1 on 3/24/25 at 9:30 a.m., [NAME] 1 stated they are not supposed to use dented cans as it may be compromise and not safe to cook. During a concurrent observation and interview in the kitchen with [NAME] 2 on 3/24/25 at 10:10 a.m., 1 (one) dented can of tomato soup was placed on the countertop prep table beside the microwave and [NAME] 3 stated that he was going to use the dented can and make tomato soup. [NAME] 3 acknowledged he's not supposed to use dented cans as they may cause botulism. During an interview with the Registered Dietician (RD) on 3/27/25 at 10:19 a.m., the RD stated opened food items should be labeled with the name of the product, open date and use by date to avoid possible foodborne illness. A review of the facility's policy and procedure, titled, Date Marking for Food Safety, date implemented 12/19/22, indicated, The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall include the date of opening, and the date the item must be consumed or discarded . 6. The Head Cook, or designee, shall be responsible for checking the refrigerators daily for food items that are expiring, and shall discard accordingly. 7. The Dietary Supervisor (Manager), or designee, shall spot check the refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed . A review of the facility's policy and procedure, titled, Dented or Damaged Cans, dated 10/19, indicated, Upon delivery, all canned food products should be inspected for safe transport and quality upon receipt . A review of the Food and Drug Administration (FDA) Document titled, Food Code 2022, dated 1/18/23, indicated, 3-201.11 Compliance with Food Law. Refer to the public health reason for S 3-401.11. Source A primary line of defense in ensuring that food meets the requirements of S 3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting and processing, they do not fall victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard.

Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 125 when: 1. Residents' non-pharmaceutical (not medicinal drug related) personal belongings were found stored in four out of four sampled medication carts with pharmaceutical products; 2. Two facility staff did not wear required personal protective equipment (PPE) when performing resident care on Resident 70 who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use); and, 3. A facility staff, Nurse Practitioner (NP) was not wearing a facemask as required by the facility. These failures had the potential to spread germs and cause infection among residents, staff, and visitors. Findings: 1. During a concurrent observation and interview on 3/25/25 at 9:47 a.m. with Licensed Nurse (LN) 7 of medication cart 1, three rings and a white phone charger labelled with residents' name and room numbers were found stored next to the controlled medications (medications with high potential for abuse or addiction). LN 7 confirmed the observation. LN 7 stated the phone charger was owned by a discharged patient. LN 7 further stated they would store resident's personal items in medication carts to keep it safe. During a concurrent observation and interview on 3/25/25 at 10:03 a.m. with LN 2 of medication cart north-3, a hearing aid stored in a black container with its packaging box, a cellular phone [NAME] kit with its packaging card, two compact discs both stored in white paper sleeves, a black phone charger tied up with a rubber band, and a black key all labelled with residents' name and room numbers were all found stored next to the controlled medications. LN 2 confirmed the observation. During a concurrent observation and interview on 3/25/25 at 10:25 a.m. with LN 8 of medication cart south-3, a hearing aid stored in a black container was found stored next to the controlled medications. LN 8 confirmed the observation. During a concurrent observation and interview on 3/25/25 at 10:37 a.m. with LN 6 of medication cart south-5, a hearing aid with its packaging box, and a pair of eyeglasses labelled with residents' name and room number were found stored next to the controlled medications. LN 6 confirmed the observation. During an interview on 3/25/25 at 10:42 a.m. with the IP, the IP stated she did not feel that there was an issue with residents' personal items being stored in medication carts next to the controlled medications. The IP also stated that residents' personal items were stored in medication carts so the items would not be lost, and the nurses could keep on eye on the personal items. During a phone interview on 3/26/25 at 3:21 p.m. with the Pharmacy Consultant (PC), the PC stated that medications carts should only contain pharmacological products and equipment's necessary for medication administration, and it should not contain personal items. The PC also stated that the facility should have a different area to keep resident's personal items safe. The PC further stated that it would be a risk for cross contamination (movement or transfer of harmful bacteria from one person, object or place to another) if personal items are stored next to controlled medications because the items would still be in the same drawer. During an interview on 3/27/25 at 10:26 a.m., with the Director of Nursing (DON), the DON stated she would not expect to have resident's personal items stored in medication carts. The DON further stated having personal items in the medication cart could result in contamination or spread of germs which could cause infection to other residents. A review of the facility's policy and procedure (P&P) titled, Medication Storage, dated 12/19/22, indicated, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation . 51483 2. Resident 70 was admitted in Summer of 2023 with multiple diagnosis which included Resistance to multiple antibiotics (bacterial that do not respond to several types of antibiotics) and stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During a concurrent interview and observation on 3/26/25 at 4:06 p.m., Certified Nursing Assistant (CNA) providing bed bath to Resident 70 without a ppe gown on. CNA 5 stated We should wear PPE for precaution. During a concurrent interview and observation on 3/26/25 at 4:07 p.m., CNA 6 providing bed bath to Resident 70 without PPE gown on. CNA 6 stated We should wear enhanced barrier precautions because she has a tube and wound. If we don't wear it we are at risk of fluids going on us. During an interview on 3/26/25 at 4:13 p.m. with LN (Licensed Nurse) 10, LN 10, stated For [Resident 70] bed bath I would wear gown, and gloves. I will look at the EHB (Enhanced Barrier Precaution, safety steps used to help stop the spread of germs) sign or care plan to guide me . all patients with g-tubes are on enhanced barrier precautions An adverse outcome could be risk for infection. During an interview on 3/26/25 at 4:15 p.m. with DON (Director of Nursing), the DON confirmed it was the expectation for all staff to wear gowns, masks, and gloves, when providing direct patient care for residents on EBP. The DON stated wearing proper PPE while providing care to residents on EBP due to risk of infection. During an interview on 3/27/25, at 9:34 a.m., with the IP (Infection Preventionist), the IP confirmed it was the expectation for all staff to wear gowns, masks, and gloves, when providing direct patient care for residents on EBP. The IP stated wearing proper PPE while providing care to residents on EBP was needed to prevent the spread of infection to staff and residents. During a review of Resident 70's Care Plan Report, dated 6/24/2024, indicated, Resident is placed on Enhanced Barrier Precautions related to unhealed wounds. During a review of the facilities Policy and Procedure (P & P) titled Enhanced Barrier Precautions, dated 3/10/25, PPE for enhanced barrier precautions is only necessary when performing high-contact care activities High-contact resident care activities include bathing/showering .device care . feeding tubes. 39489 3. Upon the Team's entrance on 3/24/25 at 8 a.m., the DON instructed all surveyors to wear masks as they have current residents with an active respiratory infection in the facility. The DON emphasized that all employees are required to wear masks to promote infection control and decrease transmission of respiratory infection. During a concurrent observation and interview at the North Station hallway with the NP on 3/25/25 at 11:25 a.m., the NP was not wearing a mask, stood across from the North Nurses Station while reading documents. The NP acknowledged she should wear a mask as required by the facility to promote infection control. In a review of the facility's P&P titled, Management of Respiratory Syncytial Virus (RSV, respiratory virus that infects the lungs and respiratory tract), date implemented 12/19/22, indicated, .3. Infection control principles will be followed to decrease the risk of transmission based on federal, state or local guidance. These principles include .d. Appropriate personal protective equipment (PPE, [equipment used to prevent or minimize exposure to hazards].)