Every finding on record at Mission Valley Post Acute

Based on observation, interview and record review, the facility failed to ensure the administrator who supervised and directed the facility operations was licensed according to state regulation when the unlicensed Operations Manager (OM) had the role of administrator for more than two years and five months.This failure resulted residents and staff being supervised and directed by unqualified administrative leadership.During an observation on 7/23/25 at 11:19 a.m. a facility post board near the nurses station was inspected. The post board had a nursing home administrator (NHA) license holder (NHAH) which indicated OM was not the licensed administrator of the facility. The post board also had a letter to residents and families which was signed Sincerely, ADMINISTRATOR [OM]'s signature. NHAH was not at the facility.During a record review of two facility financial reports submitted to the state agency titled, Long Term Care Facility Integrated Disclosure and Medi-Cal Cost Report, dated 12/31/23 and 12/31/24, the report listed OM as the administrator. The two reports did not list the facility's Reported Administrator (RA) in 2023 or 2024 in any part of the document.A review of state agency database indicated RA was reported to the state agency as the facility's administrator from 3/2023 to 5/2025.A review of state nursing home administrator license database, accessed on 7/23/25, indicated OM did not have a NHA license.During a record review of the facility staff sign in sheet titled, [Facility] Screening Log, dated 7/23/25, the sheet indicated a printed assignment of OM as the administrator. The sheet did not indicate NHAH was part of the staff sign in sheet.During a concurrent observation, interview and record review on 7/23/25 at 1:15 p.m. with OM outside of the Administrator office, OM's business card was reviewed. OM introduced himself as the administrator. Surveyor received a business card with OM's name and the title Administrator under OM's name. OM stated the office which said Administrator was his office.A review of Resident 9's admission record indicated Resident 9 was admitted for heart failure, kidney disease and respiratory failure.During a record review of Resident 9's minimum data set (MDS, an assessment tool to guide resident care), dated 4/4/25, the MDS indicated Resident 9 had Brief Interview for Mental Status score of 15 (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.)A record review of Resident 9's nursing note titled, Nursing Weekly Summary, dated 7/21/25, was reviewed, the nursing note indicated Resident 9 did not have any memory deficits and was alert and oriented.During an interview on 7/23/25 at 1:53 p.m. with Resident 9, Resident 9 stated they were the resident council president. Resident 9 stated he spoke with OM frequently and stated OM was the administrator of the facility.During an interview on 7/23/25 at 2:05 p.m. with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), the DON and ADON both stated OM was the administrator for almost three years since the facility's operating organization purchased the facility.During a concurrent interview and record review on 7/23/25 at 2:35 p.m. with Director of Social Work (DSW), six resident grievance logs, dated 1/4/25 through 5/15/25, were reviewed. DSW stated the grievance logs were reviewed and signed by the administrator. DSW stated OM's signature was on the administrator line for all six logs.During an interview on 7/23/25 at 3:25 p.m. with OM, OM stated they were responsible for following up on grievances and signing off as completed. OM stated they started as the administrator in 3/2023.During an interview on 7/23/25 at 3:55 p.m. with the DON, the DON stated OM was the administrator at quality assurance and performance improvement (QAPI) meetings.During a concurrent interview and record review at 7/23/25 at 4:08 p.m. with OM, the facility monthly QAPI documents titled, QAA Committee Agenda/Minutes/Sign in Sheet, dated from 1/2025 to 6/2025 were reviewed. OM stated they worked with other department leaders to make and execute action plans. The QAPI documents indicated OM had signed in as the administrator for all six months.During concurrent interview and record review on 7/23/25 at 4:10 p.m. with OM, the facility's job description for operations manager and administrator titled, Operations Manager, dated 2/2024, and Administrator, dated 12/2018, were reviewed. OM stated he was not a licensed nursing home administrator and had not taken recent steps to have the license completed. OM stated NHAH was the administrator of the building. OM stated the NHAH was also the Regional Operations Manager of the facility's operating corporation since March 2025 and OM reported to NHAH. A review of both job descriptions indicated both operations manager and administrator reported to the Regional Director of Operations. Both job descriptions indicated an operations manager and administrator needed licenses.must maintain licensing credentials for an Administrator.During a phone interview on 5/11/26 at 2:00 p.m. with the NHAH, NHAH stated they were the reported administrator for the facility from 4/2025 to 8/2025, and they were the facility's operation corporation's regional operations manager. NHAH stated Reported Administrator (RA) was the facility administrator prior to them. NHAH stated the operations manager can perform duties delegated to them by the administrator but should not be calling themselves the administrator. NHAH stated they were unaware of OM acting as the facility administrator.During a review of facility policy and procedure (P&P) titled, Grievances/Complaints, Filing, dated 04/2017, the P&P indicated the administrator has delegated responsibility of grievance and/or complaint investigation to the Social Service.the grievance officer will.submit a written report of the findings to the administrator within five (5) working days.the administrator will review the findings.During a review of state health and safety code titled, California Code, Health and Safety Code 1416.6 (a), the code indicated it shall be a misdemeanor for any person to act or serve in the capacity of a nursing home administrator, unless he or she is the hold of an active nursing home administrator's license.During a review of state regulation titled, Title 22, Chapter 3. Skilled Nursing Facilities, 72007 Administrator, the regulation defined an administrator as a person licensed as a nursing home administrator by the California Board of Examiners of Nursing Home Administrators.

Based on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for Residents 1-8, the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered).2. The facility failed to ensure, between 5/1/23-8/31/23, the Consultant Pharmacist identified the scheduled (controlled medication, narcotic) medication system was incomplete (all documents available) and inaccurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered).Findings:1. During an interview, on 4/16/26 at 9:40 a.m., Director of Nursing (DON) and Medical Record Director (MRD) were asked to describe the scheduled medication process. Their description included that scheduled medications were delivered by the pharmacy with a corresponding Shipping Manifest. The Shipping Manifest was the documentation that the scheduled medication was delivered to the facility. They further described that the Shipping Manifests and CDRs were retained by the facility. They were requested to provide all the scheduled medication Shipping Manifests and CDRs from 5/1/23 through 8/31/23. During a concurrent observation and interview, on 4/16/26 at 9:50 a.m., at nursing station 1, Registered Nurse (RN 1) identified medication cart (stores medication) #1. RN 1 was asked to describe the scheduled medication record system. Her description included scheduled medications were delivered with a Shipping Manifest and a corresponding CDR. The nurse reviewed the scheduled medication and Shipping Manifest for errors. The nurse signed the Shipping Manifest. The Shipping Manifest was sent for retention. The medication was locked in the medication cart. The CDR was filed at the medication cart. The CDR was used to document removal of patient medications. Administration of the medication was documented on the MAR. Completed CDRs were sent for retention. If there were scheduled medications remaining upon discontinuation, the remaining medication and the CDR were sent to the DON.During a concurrent interview and record review, on 4/17/26 at 10:17 a.m., DON and MRD identified the following CDRs. Resident 1 5879782 Oxycodone (narcotic pain reliever)/APAP (acetaminophen, non-narcotic pain reliever) 5/325 mg tab (tablet) #38 8/27/23Resident 1 5914390 Oxycodone/APAP 5/325 mg tab #30 9/4/23Resident 2 5807376 Oxycodone 5 mg tablet #8 8/8/23Resident 2 5781740 Oxycodone 5 mg tablet #2 8/1/23Resident 3 5638821 Oxycodone 5 mg tablet #10 8/25/23Resident 4 5520097 Hydrocodone (narcotic pain reliever)/APAP 5/325 mg tab #32 5/27/23Resident 5 5437319 Hydrocodone/APAP 10/325 mg tab #38 5/9/23Resident 6 5604363 Hydrocodone/APAP 10/325 mg tab #17 6/16/23Resident 7 5709661 Hydrocodone/APAP 10/325 mg tab #12 7/13/23Resident 8 5479374 Oxycodone 5 mg tablet #36 5/18/23They stated the facility could not locate the corresponding Shipping Manifests. During a concurrent interview and record review, on 4/17/26 at 10:30 a.m., DON, Assistant Director of Nursing (ADON) and MRD identified the resident's CDRs listed below. They compared the CDR medication removal against the MAR. They acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below. Resident 6 5604363 Hydrocodone/APAP 10/325 mg tab #17 6/16/236/23/23 23407/4/23 1110Resident 7 5709661 Hydrocodone/APAP 10/325 mg tab #12 7/13/237/14/23 21007/15/23 21007/16/23 0657, 1101Resident 1 5914390 Oxycodone/APAP 5/325 mg tab #30 9/4/239/10/23 0601, 20009/12/23 05079/17/23 3 removed from CDR, 2 documented on MARResident 8 5479374 Oxycodone 5 mg tablet #36 5/18/235/22/23 2300Resident 2 5781740 Oxycodone 5 mg tablet #2 8/1/238/2/23 1110, 11108/3/23 1400, 1400During a concurrent interview and record review, on 4/17/26 at 10:59 a.m., DON, ADON and MRD identified the policy for Controlled Substances (Revision Date November 2022). They reviewed the policy and acknowledged it required the documentation (Shipping Manifests, CDRs and MARs) to be complete (all documents available) and accurate (monitored and reconciled). An administrative record review, of the policy for Controlled Substances (Revision Date November 2022) showed, Dispensing and Reconciling Controlled Substances,1. Controlled substance inventory is monitored and reconciled (complete and accurate) to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records.2. During an interview, on 4/16/26 at 9:40 a.m., DON and MRD were asked to describe the scheduled medication process. Their description included that scheduled medications were delivered by the pharmacy with a corresponding Shipping Manifest. The Shipping Manifest was the documentation that the scheduled medication was delivered to the facility. They further described that the Shipping Manifests and CDRs were retained by the facility. They were requested to provide all the scheduled medication Shipping Manifests and CDRs from 5/1/23 through 8/31/23. During a concurrent observation and interview, on 4/16/26 at 9:50 a.m., at nursing station 1, RN 1 identified medication cart (stores medication) #1. RN 1 was asked to describe the scheduled medication record system. Her description included scheduled medications were delivered with a Shipping Manifest and a corresponding CDR. The nurse reviewed the scheduled medication and Shipping Manifest for errors. The nurse signed the Shipping Manifest. The Shipping Manifest was sent for retention. The medication was locked in the medication cart. The CDR was filed at the medication cart. The CDR was used to document removal of patient medications. Administration of the medication was documented on the MAR. Completed CDRs were sent for retention. If there were scheduled medications remaining upon discontinuation, the remaining medication and the CDR were sent to the DON.During a concurrent interview and record review, on 4/17/26 at 10:17 a.m., DON and MRD identified the following CDRs. Resident 1 5879782 Oxycodone (narcotic pain reliever)/APAP (acetaminophen, non-narcotic pain reliever) 5/325 mg tab (tablet) #38 8/27/23Resident 1 5914390 Oxycodone/APAP 5/325 mg tab #30 9/4/23Resident 2 5807376 Oxycodone 5 mg tablet #8 8/8/23Resident 2 5781740 Oxycodone 5 mg tablet #2 8/1/23Resident 3 5638821 Oxycodone 5 mg tablet #10 8/25/23Resident 4 5520097 Hydrocodone (narcotic pain reliever)/APAP 5/325 mg tab #32 5/27/23Resident 5 5437319 Hydrocodone/APAP 10/325 mg tab #38 5/9/23Resident 6 5604363 Hydrocodone/APAP 10/325 mg tab #17 6/16/23Resident 7 5709661 Hydrocodone/APAP 10/325 mg tab #12 7/13/23Resident 8 5479374 Oxycodone 5 mg tablet #36 5/18/23They stated the facility could not locate the corresponding Shipping Manifests. During a concurrent interview and record review, on 4/17/26 at 10:30 a.m., DON, ADON and MRD identified the resident's CDRs listed below. They compared the CDR medication removal against the MAR. They acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below. Resident 6 5604363 Hydrocodone/APAP 10/325 mg tab #17 6/16/236/23/23 23407/4/23 1110Resident 7 5709661 Hydrocodone/APAP 10/325 mg tab #12 7/13/237/14/23 21007/15/23 21007/16/23 0657, 1101Resident 1 5914390 Oxycodone/APAP 5/325 mg tab #30 9/4/239/10/23 0601, 20009/12/23 05079/17/23 3 removed from CDR, 2 documented on MARResident 8 5479374 Oxycodone 5 mg tablet #36 5/18/235/22/23 2300Resident 2 5781740 Oxycodone 5 mg tablet #2 8/1/238/2/23 1110, 11108/3/23 1400, 1400Continuing the interview and record review, on 4/17/26 at 10:30 a.m., DON, ADON and MRD, were requested to provide the Pharmacist inspection reports for 5/1/23-8/31/23. They identified the Executive Summary of Consultant Pharmacist's Medication Regimen Review, for dates 6/1-6/30/23, 7/1-7/31/23 and 8/1-8/31/23. DON and ADON inspected the reports and stated there was no documentation of issues of incomplete or inaccurate scheduled medication records. During a concurrent interview and record review, on 4/17/26 at 10:59 am, DON, ADON and MRD identified the policy for Controlled Substances (Revision Date November 2022). They reviewed the policy and acknowledged it required the documentation (Shipping Manifests, CDRs and MARs) to be complete (all documents available) and accurate (monitored and reconciled). During a concurrent interview and record review, on 4/17/26 at 11:07 a.m., DON, ADON and MRD, identified the policy for Pharmacy Services-Role of the Consultant Pharmacist (Revision Date April 2019). They reviewed the policy and stated that it was the facility's expectation that issues with scheduled medications should have been evaluated and identified.An administrative record review, of the Executive Summary of Consultant Pharmacist's Medication Regimen Review, for dates 6/1-6/30/23, 7/1-7/31/23 and 8/1-8/31/23, showed random narcotic audits were completed in 6/2023 and 8/2023. There were no documented findings from the narcotic audits.An administrative record review, of the policy for Controlled Substances (Revision Date November 2022) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled (complete and accurate) to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records.An administrative record review, of the Policy for Pharmacy Services-Role of the Consultant Pharmacist (Revision Date April 2019) showed, Policy Interpretation and Implementation, 3. The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to:, a. develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services.

Based on observations, interviews, and record reviews, the facility failed to provide safe, clean, and homelike environment for five of six sampled residents (Residents 21, 23, 54, 73, and 75) when: 1. Resident 21 and 75's shared room had wet floor surfaces without a caution signage.2. Resident 54 and 73's shared room had wet floor surfaces without a caution signage and multiple items on the floor, including spilled white liquid, a yogurt cup, plastic spoon, toothbrush and plastic cup.3. Resident 23's oxygen concentrator (a medical device used to provide supplemental oxygen) had scattered white powder-like speckles on the top surface. These failures had the potential to result in slips, trips, falls, injury, exposure to unsanitary conditions and decreased resident comfort and well-being due to unsafe environmental hazards.1. During a record review of Resident 75's admission record (AR) printed on [DATE], the AR indicated Resident 75 as was admitted to the facility in [DATE] with diagnoses including lack of coordination and muscle weakness.During a record review of Resident 21's AR printed on [DATE], the AR indicated Resident 21 was admitted to the facility in [DATE] with diagnosis including type II diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood).During an observation on [DATE] at 10:02 a.m. in Resident 21 and Resident 75's shared room, the floor area between the left side of Resident 75's bed and the edge of resident 21's bed had a wet floor surface area. Resident 21's responsible party was present at the time of observation and was advised to proceed with caution due to the wet floor surface; however, no caution or wet-floor signage had been placed to alert Resident 21 and Resident 75, staff, or visitors of the wet floor condition.2. During a record review of Resident 73's AR printed on [DATE], the AR indicated Resident 73 was admitted to the facility in [DATE] with diagnoses including cerebral infarction (death of brain tissue caused by a prolonged lack of blood flow and oxygen) and Alzheimer's disease (an irreversible, progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks).During a record review of Resident 54's AR printed on [DATE], the AR indicated Resident 54 was admitted in [DATE] with diagnoses including muscle weakness, visual hallucinations (perceptual experiences of seeing things that do not actually exist in the physical environment), and delirium (a sudden, severe change in mental function that causes extreme confusion, disorientation, and fluctuating alertness) due to known physiological (physical body and its internal biological function) condition.During an observation and interview on [DATE] at 10:26 a.m. with Resident 73, Resident 73 was unattended while seated in a wheelchair and attempting to rise up from the wheelchair. Under Resident 73's bed, a plastic spoon, spilled white liquid, and a cup of yogurt were on the floor. Between Resident 73 and Resident 54's bed, a clear plastic cup was on the floor mat, adjacent to a wet floor surface area located under Resident 54's bed. No caution or wet-floor signage had been placed. Additionally, a white toothbrush and visible white particles were on the floor near the edge of Resident 54's bed. Resident 73 stated the room's condition was not good and stated they did not like the items on the floor.During an interview on [DATE] at 10:38 a.m. with Registered Nurse (RN) 1, RN 1 stated the staff should have been checking on Resident 73 and addressing their needs, including maintaining cleanliness of the room. RN 1 stated Resident 73 and Resident 54's floor should not have had a wet floor because it had the potential to cause injury including falls. RN 1 further stated, she would not have liked to have trash underneath her bed.3. During a record review of Resident 23's AR printed on [DATE], the AR indicated Resident 23 was admitted to the facility in [DATE] with diagnoses including Alzheimer's disease and asthma (a chronic lung disease that causes your airways to swell, narrow, and produce extra mucus).During an observation on [DATE] at 10:46 a.m. in Resident 23's room, Resident 23's nasal cannula (flexible plastic device used to deliver supplemental oxygen) was connected to an oxygen concentrator. The oxygen concentrator had white powder-like particles on the top surface area. During an observation and interview on [DATE] at 10:41 a.m. with CNA 3, the oxygen concentrator still had the white powder-like particles scattered on the top surface. CNA 3 was observed wiping the white particles with her pointer finger and stated the white powder-like particles were dust. CNA 1 stated the Central Supply (CS) staff were responsible for maintaining the oxygen concentrators.During an observation and interview on [DATE] at 10:54 a.m. with CS, CS also wiped the visible white particles from the oxygen concentrator with her finger and confirmed the particles were dust. CS stated she was responsible in maintaining the cleanliness of the oxygen at least weekly; however, she had not yet cleaned it. CS further stated the oxygen concentrator should have been kept clean so Resident 23 could breathe clean air. During an interview on [DATE] at 3:53 p.m. with the Director of Nursing (DON), DON stated the rooms should be kept tidied and cleaned every day. DON stated the facility should have provided home-like environment to Residents 21, 23, 54, 73, and 75 because the facility was their home. DON stated, if it was her room, she would have complained about the room condition. DON further stated the floors should not have been wet because the residents could have experienced falls or slips, particularly residents who were at high risk for falls. During a record review of the facility's policy and procedure (P&P), titled, Homelike Environment revised in February 2021, the P&P indicated, Residents are provided with a safe, clean, comfortable, and homelike environment.2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include.a. clean, sanitary and orderly environment.During a record review of the facility's P&P, titled, Floors revised in [DATE], the P&P indicated, Floors shall be maintained in clean, safe, and sanitary manner.1. All floors shall be mopped/cleaned/vacuumed daily in accordance with our established procedures.

Based on observations, interviews, and record reviews, the facility failed to provide ongoing assessment, monitoring, and implementation of physician orders for three of five sampled residents (Residents 1, 10, and 95) when: 1. Resident 1, who experienced a change in condition, did not receive timely nursing assessment and evaluation after Resident 1 was observed very sleepy and unresponsive despite multiple attempts by the licensed nurse to awaken Resident 1. 2. Resident 10, who had physician orders for daily weights, did not receive weight monitoring as ordered, and the physician was not notified of the refusals. 3. Resident 95, who had physician orders for daily weights due to a diagnosis of congestive cardiac failure, had incorrect weights recorded (congested heart failure or CHF means the heart is too weak to pump blood efficiently and daily weights is taken because sudden weight gain is often the very first sign that the heart is struggling). These failures had the potential to result in delayed identification of changes in condition, delayed nursing interventions and treatment, worsening conditions, hospitalization and decline in Residents 1, 10, and 95's health status. 1. During a review of Resident 1's admission Record (AR) dated on 5/20/26, the AR indicated Resident 1 was originally admitted to the facility in April 2020 and was readmitted in April 2026 with diagnoses including pneumonia due to methicillin resistant Staphylococcus aureus (an aggressive, potentially life-threatening lung infection caused by Staphylococcus aureus bacteria that resist many common antibiotics) and acute respiratory failure with hypoxia (a life-threatening medical emergency where the lungs cannot adequately oxygenate the blood). During a review of Resident 1's Progress Notes (PN) dated on 4/5/26 at 10:17 p.m., the PN indicated Resident came back from out on pass with sister at 4:15 p.m. Resident noticed to be very sleepy.Resident did not respond to LN until multiple attempts. During a review of Resident 1's record, titled, SBAR (Situation, Background, Assessment, and Recommendation) Communication Form dated on 4/5/26 at 11:00 p.m., the SBAR indicated Resident 1 had high levels of white blood cell count (indicating infection). However, the SBAR did not show Resident 1's change in mental status described in the PN dated 4/5/26. During a review of Resident 1's record, titled, Weights and Vitals Summary (WVS) dated from 4/1/26 to 4/30/26, the WVS did not show documentation of Resident 1's vital signs assessment including blood pressure, oxygen saturation levels, respirations, pulse rates, and temperature, on 4/5/26. During a review of Resident 1's record, titled, SBAR dated on 4/6/26 at 8:30 a.m., the SBAR indicated approximately at 7:50 a.m., a CNA attempted to awaken Resident 1; however, Resident 1 was unresponsive and was noted to have a large amount of mucus. SBAR further indicated Resident 1 had an elevated blood pressure of 189/110 mmHg (milli mercury), an elevated pulse rate of 125 beats per minute (bpm) and oxygen saturation level of 82% and, an altered level of consciousness. SBAR indicated Resident 1 was transferred to acute care hospital via 911. During a review of Resident 1's record, titled, After Visit Summary (AVS) printed on 4/12/26, the AVS indicated Resident 1 was admitted to acute care hospital from [DATE] to 4/12/26 with hospital problem list including acute respiratory failure, polysubstance abuse (consumption of two or more drugs or substances simultaneously or within a short period), seizure (a sudden, uncontrolled burst of abnormal electrical activity in the brain), pneumonia due to MRSA, and urinary tract infection (UTI, bacterial infection that affects any part of your urinary system) due to extended-spectrum beta lactamase (ESBL) producing Escherichia coli (antibiotic-resistant bacteria that create enzymes, destroying common antibiotics like penicillins and cephalosporins). During an interview on 5/18/26 at 11:10 a.m. with Resident 1, Resident 1 stated there was a recent incident in which the facility did not provide timely nursing interventions when she became ill. Resident 1 stated after returning from an out on pass to visit her sister, Resident 1 became very sleepy, and nursing staff were unable to wake her. Resident 1 stated she stopped breathing the following day and was transferred to the acute care hospital. Resident 1 further stated the facility should have acted sooner because she was not normally sleepy. Resident 1 stated she felt the delay in care contributed to her hospitalization for approximately one week due to her condition. During an interview on 5/20/26 at 9:46 a.m. with Licensed Vocational Nurse (LVN) 5, Resident 1's electronic health record (EHR) was reviewed. LVN 5 stated Resident 1's baseline status was alert and oriented to person, place, time, and situation, was usually out of bed, and was not normally sleepy. LVN 5 stated Resident 1 developed a cough on 4/3/26 and was placed on monitoring for three days. LVN 5 stated Resident 1 returned from an out on pass on 4/5/26 and was observed to be very sleepy. LVN 5 stated the licensed nurse who documented a progress note on 4/5/26 attempted to wake Resident 1 multiple times. LVN 5 confirmed no vital signs were recorded on 4/5/26 after Resident 1 had been placed on monitoring starting 4/3/26 for three consecutive days due to coughing and after Resident 1 was observed with a change in condition. LVN 5 stated an SBAR was created on 4/5/26 for Resident 1 regarding elevated WBC; however, the SBAR did not address Resident 1's sleepiness or decreased responsiveness. LVN 5 further stated the SBAR did not contain an accurate assessment because the documented vital signs were copied from 4/4/26 rather than obtained on 4/5/26. LVN 5 stated she was assigned to Resident 1 on 4/6/26 and, after completing her rounds, a certified nurse assistant (CNA) notified her that Resident 1 was unresponsive when staff attempted to wake the resident for breakfast. LVN 5 stated upon assessment, Resident 1 had a large amount of mucus coming from the mouth and Resident 1's oxygen saturation level was 82% (normal levels ranges between 95% and 100%). LVN 5 stated Resident 1's presentation of increased sleepiness and decreased responsiveness on 4/5/26 indicated a change in condition that warranted prompt nursing assessment, monitoring, and interventions to determine whether emergency medical services and transfer to an acute care hospital were indicated. LVN 5 further stated Resident 1 had the risk of deterioration and could have had a cardiac arrest (a life-threatening medical emergency where the heart suddenly stops beating). During a concurrent interview and record review on 5/20/26 at 12:50 p.m. with the Director of Nursing (DON), Resident 1's EHR including PN dated 4/5/26, SBAR dated 4/5/26, and WVS dated from 4/1/26 to 4/30/26 were reviewed. DON confirmed no assessment, including vital signs, was performed when Resident 1 exhibited a change in condition on 4/5/26 when Resident 1 was found very sleepy with decreased responsiveness. DON stated Resident 1 should have been assessed to identify the cause of change in condition. DON further stated licensed nursing staff should have completed and documented an assessment, including vital signs accurately, to evaluate Resident 1's condition and compare findings with Resident 1's baseline. During a record review of the facility's policy and procedures (P&P), titled, Change in a Resident's Condition or Status revised in February 2021, the P&P indicated, 2. A significant change of condition is a major decline or improvement in the resident's status that.a. will not normally resolve itself without intervention by staff or implementing standard disease-related clinical interventions.3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form.8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.9. If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of resident's condition will be conducted. 2. During a review of Resident 10's AR dated on 5/20/26, the AR indicated Resident 10 was originally admitted to the facility in September 2024 and was readmitted in May 2026 with diagnoses including acute kidney failure (rapid decline of kidney function) with tubular necrosis (a serious kidney disorder where the tiny, tube-like structures in your kidneys are damaged) and heart failure (progressive condition where the heart muscle is too weak or too stiff to pump enough oxygen-rich blood to meet the body's needs). During a review of Resident 10's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 5/14/26, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 3. A BIMS score of zero to seven is an indication of severe cognitive status. During a review of Resident 10's Order Summary (OS) dated 5/20/26, the OS indicated the resident had a physician's order with start date on 5/9/26 scheduled at 9:00 a.m. to Monitor weight daily in the morning at the same time, in the same clothing, and on the same scale. If weight variance is greater than or equal to 2 lbs. (pounds) in one day or greater than or equal to 5 lbs. in five days. During a review of Resident 10's Care Plan for Congestive (the buildup or congestion of fluid in the body's tissues and organs) Heart Failure initiated on 1/11/26, the care plan indicated weights as ordered. During a review of Resident 10's PN, the following Progress Notes indicated Resident 10 refused weight measurements on 5/9/26, 5/10/26, 5/13/26, 5/14/26, 5/17/26 and 5/19/26. The PN did not show documentation regarding the reason for refusals, physician and family notification of the repeated refusals. During an observation and interview on 5/20/26 at 10:41 a.m. with Resident 10 and CNA 3, Resident 10 was sleeping in bed. CNA 3 stated Resident 10 did not exhibit behaviors of refusing weight measurements. CNA 3 stated she had not yet obtained Resident 10's weight was and she was unsure if Resident 10's weight measurements were performed daily. During an interview on 5/20/26 at 10:45 a.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 stated Resident 10 did not refuse weight when she performed weekly weight measurement on 5/15/26. RNA 1 further stated the CNAs were responsible for residents who were ordered on daily weight monitoring. During an interview on 5/26/26 at 10:47 a.m. with LVN 6, LVN 6 stated Resident 10 had a physician order for daily weights monitoring due to a diagnosis of CHF. LVN 6 stated she reminded CNA 3 at the beginning of the shift to get Resident 10's daily weight; however, CNA 3 did not provide her with the weight measurement. LVN 6 stated Resident 10's daily weight should have been obtained consistently to morning for fluid retention and identify changes that could have placed Resident 10 at risk of worsening of CHF symptoms such as shortness of breath and increased swelling of the body. During a follow-up observation and interview on 5/20/26 at 11:53 a.m. with Resident 10 and CNA 3, Hoyer-lift scale (specialized weighing accessory on a person lift that allows staff to accurately measure an individual's weight while they are suspended in a sling) was present in the room. CNA 3 stated she was done measuring Resident 10's weight without difficulty and Resident 10 did not refuse the weight measurement. Resident 10 stated she was okay doing weight monitoring. Resident 10 stated she was agreeable to daily weight monitoring and had no preference regarding when nursing staff obtained weight measurements. During a concurrent interview and record review on 5/20/26 at 12:33 p.m. with the DON, Resident 10's EHR was reviewed. DON stated the CNAs were responsible for obtaining daily weights and notifying the nurse once completed. DON stated licensed nurses were responsible for following up when residents refused ordered weight measurements. DON stated two or more refusals of daily weight measurements should have required physician notification, especially for residents with CHF or on fluid restrictions. DON stated weight changes could have indicated the need for medication or treatment adjustments. DON stated daily weight monitoring should have been followed as ordered by the physician. DON confirmed Resident 10's EHR did not contain physician notification regarding Resident 10's refusals of daily weight measurements. DON further stated failure to obtain and document daily weight measurements could have a delayed identification of fluid retention and placed Resident 10 at risk for cardiac overload, breathing difficulties, and swelling. DON further stated Resident 10's refusals should have been addressed through care planning and interventions to address barriers to daily weight monitoring. During a review of the facility's P&P, titled, Change in a Resident's Condition or Status revised in February 2021, the P&P indicated, 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an).f. refusal of treatment or medications two or more consecutive times. During a review of the facility's P&P, titled, Heart Failure – Clinical Protocol revised in February 2026, the P&P indicated, Treatment/Management.The physician will review and make recommendations for relevant aspects of nursing care plan; for example, what symptoms to expect, how often, and what (weights, renal function .) to monitor, when to report findings to the physician, etc. 3. During a review of Resident 95's admission Record (AR), the AR indicated Resident 95 was admitted to the facility on [DATE] with diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life) and CHF. A review of the Minimum Data Set (MDS - standardized assessment and care screening tool), dated 4/22/26, indicated Resident 95's cognition was severely impaired. During a record review of Resident 95's Physician's Order (PO) dated 5/19/26 indicated an order with a start date of 4/17/26 to monitor the resident's weight daily in the morning at the same time, with the same clothing and same scale. The PO also indicated an order that if the weight variance was greater than or equal to two lbs. in one day or greater than or equal to five lbs. in five days, to immediately notify the physician (lbs., lb. or pounds is a form of measurement also used to measure body weight). Resident 95's daily weight disclosed the following weight trend: 5/11/26 93 lbs. 5/12/26: 92 lbs. 5/13/26: 93.6 lbs. 5/14/26: 93.5 lbs. 5/15/26: 93.4 lbs. 5/16/26: 93.3 lbs. 5/17/26: 93 lbs. 5/18/26: 88.8 lbs. (weight loss of 4.2 lbs.) 5/19/26: 79.8 lbs. (weight loss of 9 lbs.) During a record review of Resident 95's CHF care plan dated 6/10/25, the care plan indicated a goal that Resident 95, will not have signs and symptoms of respiratory distress, weight gain identified and managed daily. During a concurrent interview and record review on 5/21/26, at 10:04 a.m., with the Director of Nursing (DON), Resident 95's Medication Administration Record (MAR) was reviewed. The daily weights recorded in the MAR show a sudden weight drop for Resident 95. The resident's weight decreased from 93 lbs. on 5/17/26 to 88.8 lbs. on 5/18/26 (a 4.2 lb. loss) and fell further to 79.8 lbs. on 5/19/26 (a 9 lb. loss). The DON stated that the resident should have been reweighed on 5/18/26 and 5/19/26 to verify if the weight was accurate. Additionally, the DON stated, the physician should have been notified if a weight gain of more than 2 pounds or a rapid weight loss was confirmed and interventions could have been started. During a review of the facility's policy and procedure (P&P) titled, Heart Failure- Clinical Protocol dated 2001, the P&P indicated, . Treatment/Management: 1. The physician will review and make recommendations for relevant aspects of the nursing care plan; for example what symptoms to expect ,how often and what (weights.) to monitor, when to report findings to the physician . During a review of the facility's P&P titled, Weight Assessment and Intervention dated 2001, the P&P indicated, . 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietician in writing .

Based on observation, interview, and record review, the facility failed to ensure the provision of pharmaceutical services when: 1. A routine medication was not available for administration for 3 days for 1 out of 4 residents (Resident 67) observed during the medication pass. 2. Controlled substance (medications that can be easily abused and are under strict government control) medications were signed out of the Controlled Drug Record (CDR, an inventory document) but not documented on the Medication Administration Record (MAR) for 2 out of 6 sampled residents (Residents 49 and 95) 3. An as-needed pain medication was not administered as ordered by the physician for 1 out of 6 sampled residents (Resident 39) 4. A controlled medication was not accurately documented as given on two occasions for 1 out of 6 sampled residents (Resident 36). The failures had the potential for complications to the resident's medical conditions; and inaccurate accountability and potential for abuse and diversion (unlawful distribution or use) of controlled medications. 1 During a medication administration observation on 5/18/26 at 9:56 AM, Registered Nurse (RN) 3 was observed preparing and administering 9 medications to Resident 67. RN 3 looked in the medication cart and stated she did not have the resident's dapagliflozin (brand name: Farxiga, medication for diabetes or congestive heart failure, a long-term condition that happens when your heart cannot pump blood well enough to give your body a normal supply) to give at this time. On 5/18/26 at 10:09 AM, RN 3 placed a call to the physician informing him she did not have Resident 67's dapagliflozin to administer. A review of Resident 67's physician's orders indicated an order for dapagliflozin 5 milligrams (mg, unit of measurement), 1 tablet daily for OBESITY, dated 4/29/26. A review of the nursing progress notes indicated the following: - 5/15/2026 at 11:47 AM, dapagliflozin . not available. f/u [follow up] with pharmacy. - 5/16/2026 at 9:42 AM, dapagliflozin .Awaiting for delivery. - 5/17/2026 at 8:12 AM, dapagliflozin .Awaiting for delivery. During a follow-up interview and record review with RN 3 on 5/18/26 at 2:20 PM, she stated she just received the Dapagliflozin for Resident 67. She reviewed Resident 67's MAR and confirmed it was not administered for 3 days, from 5/15 - 5/17/26, and stated the resident was receiving it for congestive heart failure. During a concurrent interview and record review with the Director of Nursing (DON) and Assistant DON (ADON) on 5/19/26 at 10:08 AM, the DON verified the facility did not administer Resident 67's Dapagliflozin for 3 days, from 5/15 to 5/17/26. Both the DON and ADON could not find documented evidence the nursing staff called the pharmacy when they ran out of the Dapagliflozin on those days. 2. During a concurrent interview and record review the DON and ADON on 5/19/26 at 10:20 AM, the DON stated any time an as-needed controlled medication is requested from a resident, the nursing staff would assess the resident's pain, review the medication order, retrieve the medication from the medication cart, sign the medication out from the CDR, give the medication, and document the administration on the MAR. a. A review of Resident 49's physician's orders indicated an order for Norco (hydrocodone-acetaminophen, a potent narcotic for pain) 5-325 mg, 1 tablet every 4 hours as needed for moderate pain, dated 12/23/25. On 5/19/2026 at 10:22 AM, a review of Resident 49's CDR for Norco 5/325 mg and the March 2026 MAR with the DON and ADON indicated the nursing staff signed 1 tablet out of the CDR but did not document the administration on the MAR on 2 occasions: on 5/23/25 at 9:35 AM and 3/29/26 at 9:54 AM. After reviewing the resident's clinical record including the MAR and the nursing progress notes, the ADON stated, I don't see it. She stated it should have been documented on the MAR to show it was administered to the resident. b. A review of Resident 95's physician's orders included the following orders:Roxicodone (a potent narcotic for pain) 5 mg, give 1 tablet one time daily, dated 4/24/26. Roxicodone 5 mg, give 1 tablet every 4 hours as needed for severe pain, dated 4/24/26.On 5/21/26 at 11:39 AM, a review of Resident 95's CDR for Roxicodone 5 mg and the May 2026 MAR with the ADON indicated the nursing staff signed 1 tablet out of the CDR but did not document the administration on the MAR on 2 occasions: on 5/8/26 at 6:36 PM and 5/13/26 at 8:04 PM. The ADON reviewed the MAR and the corresponding nursing progress notes and confirmed there was no documentation to show they were administered to the resident. 3. A review of Resident 39's physician's orders indicated an order, dated 5/2/26, for hydrocodone-acetaminophen (Norco) 5-325 mg, 1 tablet every 12 hours as needed for moderate pain (score 4-5) (numeric rating scale, scoring range, 0-10; 0 = no pain, 10 = worst pain possible). A review of Resident 39's May 2026 MAR indicated the nursing staff administered 1 tablet on 5/14/26 at 11:13 AM and another on 5/17/26 at 12:53 PM while the resident's pain score was zero (no pain). During a concurrent interview and record review with the DON and ADON on 5/19/26 at 10:28 AM, they both reviewed Resident 39's MAR and confirmed the finding. The ADON stated she could not find any reason why the Norco was administered while the pain score was zero. 4. A review of Resident 36's physician's orders indicated an order, dated 5/2/26, for Roxicodone 5 mg, give 1 tablet every 6 hours as needed for moderate pain. On 5/19/26 at 10:40 AM, a review of Resident 36's CDR for Roxicodone and May 2026 MAR indicated the nursing staff documented they administered 1 tablet on 5/8/26 at 6:36 PM and another on 5/13/26 at 8:04 p.m. but there was no removal of medications from the CDR. In other words, it was unknown where the Roxicodone came from. The DON stated she will get back to the surveyor. During a follow-up interview on 5/20/26 at 9:40 AM, the DON stated she spoke with the nurse who said she did not remember. The DON acknowledged documentation without giving the medication has the potential for medication not able to be given should the resident require a dose during this time because it would be too soon in the computer system. A review of the facility's policy and procedures (P&P) titled Administering Medications, dated 4/2019, indicated, Medications are administered in accordance with prescriber orders ., The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication . and As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered. A review of the facility's undated P&P titled Controlled Substance indicated, The facility complies with all laws, regulations, and other requirements related to . documentation of controlled medications, and the system for reconciling controlled substances includes the medication administration records.

Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: Three boxes of 4-fluid-ounce milkshakes (74 pieces per box) were stored in Freezer chest 4, which was not kept at the required temperature (fluid-ounce is a form of measurement).A box of blueberry muffins and two unopened bags of frozen potato wedges were stored in the emergency storage room.Clean water pitchers were kept next to the dirty coffee drainpipes. These failures had the potential for contamination of food resulting in food borne illness for 84 residents who received food from the kitchen. An observation and interview with the Dietary Manager (DM) during the kitchen's initial tour, on 5/18/26, at 9:44 a.m., showed three boxes of 4-fluid-ounce milkshakes (74 pieces per box). The boxes indicated to keep frozen at 0 degrees Fahrenheit or below (Fahrenheit or F is a form of temperature measurement). Although freezer chest 4's temperature registered at negative 4 degrees F, the freezer felt warm. At 2:45 p.m., the freezer's temperature was rechecked, and the temperature was 20 degrees F. DM stated the freezer's temperature should be at 0 degrees F or below. DM acknowledged that freezer 4 was broken. DM stated storing milkshakes in Freezer Chest 4 at an improper temperature placed residents at risk of stomach distress.During interview on 5/20/26 at 8:29 a.m., with the Maintenance Director (MD), MD stated that he only did visual checks on freezer chest 4 and stated he had no documentation of freezer chest 4 maintenance. Review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, revised November 2022, the P&P indicated, . 1. Refrigerators and/or freezers are maintained in good working condition.5. The supervisor takes immediate action if temperatures are out of range . 2. An observation and interview in the emergency storage room on 5/18/26, at 2:06 p.m., showed an unopened box of blueberry muffins and two unopened bags of frozen potato wedges placed on top of freezer chest 5. On observation, the emergency storage room felt warm. When DM was asked if the temperature of the room was being monitored, DM stated it was not. DM took the temperature of the blueberry muffins and was noted to be 48.9 degrees F. DM stated the temperature of the muffins should be at 41 degrees F. DM further stated that storing the blueberry muffins and potato wedges at room temperature created a risk of food spoilage. Stated if residents consumed spoiled food, they could experience stomach distress. Review of the facility's policy and procedure (P&P) titled, Food receiving and storage, revised November 2022, indicated, . Foods shall be received and stored in a manner that complies with safe food handling practices.2. Danger zone means temperatures above 41 F and below 135 F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Foods held in danger zone for more than four hours. may cause foodborne illness outbreak if consumed. 3. An observation and interview in the kitchen on 5/18/26, at 2:37 p.m., showed water pitchers stored next to the dirty coffee drainpipe.There were brown and black residue imbedded in different areas of the outer part of the coffee drainpipe. When DM wiped the drainpipe with a clean moist paper towel, it picked up brown residue. The DM acknowledged that the brown residue in the paper towel was dirt. The DM stated that the water pitchers were used to store clean drinking water for residents. Furthermore, the DM acknowledged that these pitchers should not have been stored next to the dirty drainpipe due to the risk of cross contamination (unintentional transfer of germs from one surface, object, or food to another). Review of the facility's policy and procedure (P&P) titled, Sanitation, revised November 2022, indicated, . The food service area is maintained in a clean and sanitary manner.1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris .

Based on observations, interviews, and record reviews, the facility failed to implement their infection prevention and control policies and procedures for five out of ten residents (Resident 9, 13, 16, 86, and 70) and a facility census of 84 when:For one of three sampled residents (Resident 9), Resident 9's clothing was on the floor and was returned to the closet without being laundered or cleaned prior to storage.For one of two sampled residents (Resident 86), Resident 86's urinal was stored directly on top of the trash receptacle without a lid and not placed in a protective bag.Laundry Personnel (LP) transported soiled linens in an uncovered laundry barrel through the hallway while wearing contaminated personal protective equipment (PPE, is equipment worn to minimize exposure to hazards) and entered the clean area of the laundry room without removing the contaminated PPE, exposing clean linens to contamination.Overflow (a secondary, dedicated storage unit in nursing facilities or hospitals used to store backup or overflow prescription medications) medication cart #1's sharps container was filled beyond capacity, with sharps extending above the manufacturer's designated fill line.For one sampled resident (Resident 13), Licensed Vocational Nurse (LVN) 3 did not perform proper hand hygiene during a wound care treatment.For one of two sampled residents (Resident 70), Resident 70's feeding bag tubing (a medical device used to deliver liquid nutrition, hydration, and medications directly into a patient's stomach or small intestine) was left uncapped and exposed.For one of three sampled residents (Resident 16), Resident 16's nebulizer (used to deliver medication in a fine mist over the nose and mouth) mask was left without a protective bag and exposed to air.One of three licensed nurses observed during the medication pass did not use the appropriate disinfectant to disinfect shared glucometers (medical device used to measure the approximate concentration of sugar in the blood) following a blood sugar monitoring procedure.These failures had the potential to increase the risk of transmission of infectious organisms, exposure to blood-borne pathogens (infectious microorganisms present in human blood), contamination of resident care items and development of healthcare-associated infections. 1. During a record review of Resident 9's admission Record (AR) printed on 5/20/26, the AR indicated Resident 9 was admitted to the facility in March 2023 with diagnoses of unstable angina (a type of chest pain that happens when your heart muscle isn't receiving enough oxygen) and personal history of Covid-19 (highly contagious infectious disease that primarily attacks the respiratory system). During an observation on 5/18/26 at 9:51 a.m. in Resident 9's room, a light gray pair of pants was on the floor directly in front of Resident 9's closet. During a subsequent observation on 5/18/26 at 10:00 a.m. in Resident 9's room, the same light gray pair of pants previously observed on the floor was returned to Resident 9's closet and stored together with Resident 9's clean clothing. During an interview and observation on 5/18/26 at 10:07 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 removed the light gray pair of pants from Resident 9's closet. CNA 1 stated the clothing should not have been returned to the closet after being on the floor because they it was considered dirty and could have contaminated Resident 9's clean clothing. CNA 1 further stated she would not want to wear clothing that had been on the floor. During an interview on 5/20/26 at 2:02 p.m. with the Infection Preventionist/Director of Staff Development (IP/DSD), the IP/DSD stated that clothing found on the floor should have been removed, placed in a plastic bag for laundering, and replaced with clean clothing. The IP/DSD further stated the clothing that had fallen onto the floor should not have been returned to Resident 9's closet because germs on the floor could have transferred to Resident 9's clean clothing, creating a risk for transfer of infection. During a review of the facility's policy and procedures (P&P) titled, Departmental (Environment Services) – Laundry and Linen, revised in January 2014, the P&P indicated, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing and storage of linen.Standard Precautions.1. Separate soiled and clean linen at all times.3. Considered all soiled linen to be potentially infectious and handle with standard precautions.Bagging and Handling Soiled Linen.1. All soiled linen must be placed directly into a covered laundry hamper. 2. During a record review of Resident 86's AR printed on 5/20/26, the AR indicated Resident 86 was admitted in the facility October 2024 with diagnosis of dysphagia (difficulty swallowing food, liquids, or saliva) following nontraumatic intracerebral hemorrhage (bleeding directly into the brain tissue without a history of head injury). During an observation and interview on 5/18/26 at 11:25 a.m. with Resident 86, Resident 86 was sleeping in bed. Resident 86's urinal, without a lid and not stored in a protective bag, was observed hanging on the side of the trash receptacle containing used purple gloves was located adjacent to the bathroom entrance. During an observation and interview on 5/18/26 at 11:34 a.m. with CNA 4, CNA 4 was observed removing Resident 86's urinal from the trash receptacle. CNA 4 stated the urinal should have been stored in a plastic bag and kept near Resident 86's bedside to prevent contamination and infection. During an interview on 5/20/26 at 2:02 p.m. with IP/DSD, IP/DSD stated urinals not in use should have been stored in a plastic bag with a lid and kept near the bedside drawer. The IP/DSD stated placing or hanging the urinal on the trash receptacle may contaminate the urinal from the waste or contaminated items inside the trash receptacle. The IP/DSD stated the contaminated urinal placed Resident 9's at risk for infection, including urinary tract infection (UTI, an infection in any part of your urinary system including kidneys, ureters, bladder, and urethra). During a review of the facility's P&P titled, Standard Precautions revised in September 2022, the P&P indicated, Standard precautions are used in care of all residents.Standard precautions presumed that all blood, body fluids, secretions, and excretions (except sweat).may contain transmissible infectious agents.Standard precautions include the following practices.5. Resident-Care Equipment.a. Resident-care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucous membrane exposure.and transfer of microorganism. 3. During an observation on 5/19/26 at 11:04 a.m. outside the laundry room, in the hallway, Housekeeping/Laundry Personnel (HK/LP), HK/LP was in the hallway transporting an uncovered gray laundry barrel containing soiled linens while wearing personal protective equipment (PPE, equipment worn to minimize exposure to hazards) including mask gloves, and gown. HK/LP entered the laundry room and placed the soiled laundry barrel in front of the washer and transferred the soiled linens into Washer #2. After transferring the soiled linens, HK/LP moved the laundry barrel across the demarcation line separating the dirty area from the clean area in order to close Washer #2's door. While still wearing the same PPE used to transport and handle the soiled linens, HK/LP entered the clean area and disposed of the gloves. Resident clothing was observed on top of the table in the clean area. HK/LP then returned to the dirty area, removed and hung the same gown on the wall. HK/LP stated she forgot to remove the soiled PPE prior to entering the clean area and stated she should have removed the PPE and performed hand hygiene before entering the clean area to prevent transmission of infection. During an interview on 5/19/26 at 11:20 a.m. with Housekeeping Manager (HKM), HKM stated laundry barrels containing soiled linens should have remained closed when handling and transporting to prevent contamination exposure in the hallway. HKM stated soiled linen barrel should not have crossed the demarcation line into the clean area. HKM further stated HK/LP should have removed the contaminated PPE and performed hand hygiene prior to entering the clean area to prevent contamination of clean linens and residents' clothing. HKM stated not following infection prevention practices had the risk for cross contamination and transmission of infectious organisms. During an interview on 5/20/26 at 3:35 p.m. with Director of Nursing (DON), DON stated HK/LP should not have worn contaminated PPE while transporting the soiled linens and should have removed the contaminated PPE used to transfer soiled laundry items from the hampers to the gray laundry barrel prior to entering the clean areas of the building. DON further stated contaminated PPE worn in the hallway could have come into contact with surrounding surfaces or individuals, creating a risk for cross-contamination. DON further stated HK/LP should have avoided crossing into the clean areas of laundry room without removing the contaminated PPE and should have not moved the soiled laundry barrel into the clean area of the laundry room due to the risk of contaminating clean laundry items. During a review of the facility's P&P titled, Laundry and Bedding, Soiled revised in January 2026, the P&P indicated, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control.Handling.1. All used laundry is handled as potentially contaminated using standard precautions.d. Staff handle soiled textiles/linens with minimum agitation to avoid contamination of air, surfaces, and persons.Storage.3. Clean linen is stored separately from contaminated linen. The use of separate rooms, closet or other designated spaces with a closing door are used to reduce the risk of accidental contamination. During a review of the facility's P&P titled, Standard Precautions revised in September 2022, the P&P indicated, 4. Gowns.Soiled gowns are removed as promptly as possible and hands washed to avoid transfer of microorganisms to other residents or environments. 4. During an observation in the hallway on 5/19/2026 at 2:59 p.m., a medication cart with a sharps container mounted on the side was observed to be filled beyond the manufacturer's indicated fill line and contained sharps and other metal objects not intended for sharps disposal. During an interview with Licensed Vocational Nurse (LVN) 4 on 05/19/2026 at 3:05 p.m., LVN 4 stated the cart was used as an overflow cart for storing residents' extra medications and confirmed the sharps container should have been replaced when full to prevent items from sticking out and reduce the risk of contamination and infections, including sepsis. During an interview with IP/DSD on 5/20/2026 at 2:02 p.m., the IP/DSD stated sharps containers must never exceed the fill line due to the risk of needle stick injury and that only needles, lancets, and test strips should be placed inside During an interview with DON on 5/20/2026 at 3:35 p.m., DON stated sharps containers must be replaced once they reach the fill line and that overfilled containers are dangerous because patients or staff could be poked by contaminated sharps. During a review of facility's P&P titled, Sharps Disposal, dated January 2012, the P&P indicated, designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from puncture and/or needlesticks when attempting to push sharps into the container. 5. During an observation on 5/19/2026 at 10:39 a.m., Licensed Vocational Nurse (LVN) 3, accompanied by the Director of Rehabilitation (DOR) who served as translator, entered the room to perform wound care for Resident 13. LVN 3 verified Resident 13's identity, disinfected the tray table, allowed the surface to dry for four minutes, donned personal protective equipment (PPE, mask, gowns, gloves, face shields, etc.), and prepared multiple wound care supplies, and performed hand hygiene between preparation steps. Certified Nursing Assistant (CNA) 2 was present in full PPE. During an observation on 5/19/26 at 10:51 a.m., LVN 3 removed a soiled dressing from Resident 13's coccyx (commonly known as the tailbone); however, she did not perform hand hygiene after removing the soiled dressing. LVN 3 put on new gloves without washing or sanitizing her hands. LVN 3 then cleansed the coccyx wound with saline moistened gauze, performed two wipes, and patted the area dry; all without changing gloves during wound cleansing. LVN 3 removed her gloves, did not perform hand hygiene again, and applied the ordered treatment for Resident 13. During an interview with LVN 3 on 5/19/2026 at 10:56 a.m., LVN 3 stated she was supposed to wash or sanitize her hands between glove changes and after removing a soiled dressing, acknowledging that failure to do so placed Resident 13 at risk for infection. During an interview with IP/DSD, on 5/20/2026 at 2:02 p.m., the IP/DSD stated that staff must wash hands with soap and water after removing a soiled dressing, before applying a new one, explaining that not washing hands can contaminate the wound and cause infections, including UTIs or wound infections. During an interview with Director of Nursing (DON) on 5/20/2026 at 3:35 p.m., DON stated staff were expected to perform hand hygiene every time they touched something dirty and specifically after removing a soiled dressing to prevent contaminating the wound. During a review of the facility's P&P titled Wound Care, dated October 2010, the P&P indicated steps in the procedure, .remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. During a review of the facility's P&P titled Handwashing/Hand Hygiene, dated October 2024, the P&P indicated for Hand Hygiene, f. before moving from work on a soiled body site to a clean body site on the same resident, and g. immediately after glove removal. 6. During an observation on 5/18/26 at 10:41 a.m., Resident 70's feeding formula was running 55 ml/hour. The tube feeding tip was uncapped and exposed, with dried formula on the machine. During an interview on 5/19/26 at 2:30 p.m. with DON, DON stated, after formula is completed, the tubing should be disconnected and capped to prevent contamination. 7. During an observation on 5/18/26 at 10:45 a.m., Resident 16's nebulizer mask was uncovered and not bagged, resting on the nightstand. A review of the National Institute of Health publication titled, How to Use a Nebulizer dated October 2021, indicated, after each treatment, wash the mask and other parts except the tubing with mild soap and warm water, rinse well and air dry on a paper towel, and store in a dry clean plastic storage. [Reference:https://www.nhlbi.nih.gov/sites/default/files/publications/How-to-Use-a-Nebulizer-21-HL-8163.pdf]. 8. During an observation on 5/18/26 at 11:59 AM, Registered Nurse (RN) 2 was observed at her medication cart with two Assure Platinum glucometers in hand. RN 2 was observed wiping each glucometer with an alcohol swab. She stated she had just finished testing the blood sugar (BS) for 5 residents using these two glucometers. She explained that she alternated them between residents by using one glucometer to measure the BS for a resident, wiping it and letting it dry after use while using the other glucometer to take the BS for another resident. RN 2 stated she used the alcohol swabs to wipe down the glucometer after each resident use. During an interview on 5/18/26 at 12:26 p.m., with the IP/DSD and DON, the IP/DSD stated glucometers are shared among residents, and nurses are to alternate them with wiping and drying them between resident uses. Both the IP/DSD and the DON stated they are to use the SaniCloth Bleach (a disinfectant wipe that contains bleach, to kill many organisms such as bacteria and viruses) wipe to disinfect the glucometers after each use. Both also stated it is not okay to use alcohol wipe to disinfect the glucometers as alcohol does not kill many organisms. During a follow-up interview with RN 2, on 5/18/26 at 2:16 p.m., she stated she was to use a bleach wipe, not the alcohol wipe, to disinfect the glucometer after each use. During an interview on 5/19/26 at 12:58 p.m. the DON stated the facility did not have a policy and procedure addressing glucometer disinfection but we follow the manufacturer's guidelines. The DON provided the undated guidelines from the manufacturer for Assure Platinum, which indicated the following under Cleaning and Disinfecting Guidelines, page 47: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant [chemical product vetted and approved by the Environmental Protection Agency to kill specific pathogens like bacteria, viruses, and fungi on surfaces] detergent or germicide [germ-killing] wipe. A review of the Center for Disease Control and Prevention's (CDC's) online publication titled Considerations for Blood Glucose Monitoring and Insulin Administration, dated 8/7/24, indicated: If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents.

Based on observation, staff interview, and review of facility documents, the facility failed to ensure Freezer 3 was maintained in proper working condition, as evidenced by:1. The freezer's louvered panel was missing (a louvered panel is a cover located at the bottom of a freezer. It allows air to circulate freely for cooling, while keeping out direct light, dust, and debris).2. The freezer's right handle was missing. 1. During a concurrent observation and interview on 5/20/26 at 8:23 a.m., with Dietary Manager (DM), DM showed freezer 3's louvered panel was missing. As a result, the wiring, coils, and mechanical parts underneath were exposed. In addition, the mechanical components and wiring were coated in scattered black sticky dust and the DM described the area as dirty. DM stated the louvered panel had been missing for one year.During an interview on 5/20/26 at 8:29 a.m., with the Maintenance Director (MD), MD stated that freezer 3's louvered panel was missing and was unsure when it was damaged. MD stated the risk was food contamination if the freezer stopped working due to the missing part that protected the freezer's mechanical parts.2. During a concurrent observation and interview on 5/20/26 at 8:30 a.m., with the DM, the DM showed freezer 3's right side handle was missing. DM stated it had been broken for a long time, and it was not reported to the MD.During an interview on 5/20/26 at 8:35 a.m., with the MD, MD stated that he was unsure when the freezer's handle was damaged and it should have been fixed.A review of the facility's P&P titled, Refrigerators and Freezers, revised November 2022, the P&P indicated, . 1. Refrigerators and/or freezers are maintained in good working condition.10. Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately .

Based on observation, interview and record review, for one of one sampled resident (Resident 70) reviewed for positioning and mobility, the facility failed to ensure Resident 70's reasonable accommodation of needs and preferences when the call light was left out of reach. This failure had the potential to impair the resident's ability to request help, placing the resident at risk for unmet care needs.During a review of Resident 70's admission Record (AR) dated 5/19/26, the AR indicated Resident 70 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (the severe or complete loss of motor function (paralysis) on one side of the body) and hemiparesis (weakness or partial paralysis affecting only one side of the body) affecting left non-dominant side, difficulty in walking, weakness and aphasia (disorder that affects how you communicate, impacts speech and ability to understand written or spoken language). During a review of Resident 70's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/13/26, the MDS indicated Resident 70 had impairment on one side of the body, both upper and lower extremities. The MDS also indicated Resident 70 was usually understood, had difficulty communicating some words or finishing thoughts but is able if prompted or given time, and usually understands and comprehends most conversation. During a review of Resident 70's fall care plan dated 4/9/26, the care plan indicated to keep call light and personal items within reach. During an observation on 5/18/26 at 12 p.m., inside Resident 70's room, Resident 70 was in a wheelchair positioned on the far-left side of the bed. Resident 70 had left side weakness, left side from shoulder down to hand slumped in wheelchair without support. Resident 70 was unable to lift left hand. Call light was placed on the right side of the bed, near Resident 70's left side. Resident 70 reported left side pain and requested repositioning.During an interview on 5/19/26 at 2:10 p.m. with Director of Nursing (DON), DON stated call light should be on the right within Resident 70's reach due to left side paralysis/weakness, as resident cannot access it if placed on the left (weak) side.

Based on interview and record review, the facility failed to ensure 1 out of 5 sampled residents (Resident 8) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior). Resident 8 has been receiving Olanzapine (an antipsychotic medication) without staff monitoring target behaviors quantitatively. Quantitative measure of target behaviors would be helpful in monitoring the patient's progress, assessing effects of treatment, and a factor in considering whether to conduct gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). A review of Resident 8's clinical record indicated she was admitted to the facility with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and depression. A review of Resident 8's physician's orders indicated the resident has been receiving Olanzapine 10 milligrams (unit of measurement), 1 tablet by mouth at bedtime for unspecified dementia manifested by angry outbursts since 4/3/25 (more than a year ago). There was also a physician's order to monitor specific behavior Anti-Psychotic m/b [manifested by]: Angry outburst every shift chart # [number] of episodes, dated 4/4/25. A review of Resident 8's medication administration records (where the nursing staff also documented behavior monitoring) for February, March, April, and May 2026 indicated the nursing staff has been placing a check mark in the entry for Monitor specific behavior Anti-Psychotic m/b: Angry outburst every shift chart # of episodes every shift. In other words, there was no quantitative measure or number of episodes (such as 0, 1, 2, 3, etc. episodes) entered into the MAR during the shift in these months. During a concurrent interview and record review with the Director of Nursing (DON) and the Assistant DON (ADON) on 5/20/26 at 3:05 PM, the ADON reviewed the MARs and stated, The order was put in that way without quantity since 4/4/25 (more than a year ago). Both staff confirmed the facility has not been monitoring the number of episodes of angry outbursts as response (or effectiveness) to Olanzapine treatment. They also confirmed that the number of target symptoms and behaviors would be used by the interdisciplinary team (team composed of members from different departments involved in a resident's care) to assess whether or not to recommend a GDR during the quarterly psychotropic medication review. The American Psychiatric Association (APA) published the Guidelines Statements in an online publication, dated 5/1/16, titled The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia. A review of Statement 3 of the Guidelines indicated, APA recommends that in patients with dementia with agitation or psychosis, response to treatment be assessed with a quantitative measure. The publication further indicated Use of a quantitative measure to document information on symptoms in a systematic fashion can be helpful in monitoring the patient's progress and assessing effects of treatment. (https://doi.org/10.1176/appi.books.9780890426807.ap02, accessed 5/26/26) A review of the facility's policy and procedures titled Antipsychotic Medication Use, dated 8/2022, indicated, The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications.

Based on observation, interview, and record review, the facility failed to ensure that continued nutritional care and services were provided to one of 20 sampled residents (Resident 68) when Resident 68, who had a weight loss of 11.2 pounds which yielded 11.8% weight loss from 4/6/26 to 5/1/26, was not reweighed after 5/1/26 for a total of 20 days (pounds or lbs. is a form of measurement which is also used to measure body weight).This deficient practice had the potential to result in Resident 68's further unplanned weight loss. During a review of Resident 68's admission Record (AR) dated 5/21/26, the AR indicated Resident 68 was admitted to the facility on [DATE] with diagnoses that included depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in daily activities) and malignant neoplasm of stomach (cancer of the stomach).A review of the Minimum Data Set (MDS - standardized assessment and care screening tool), dated 3/27/26, indicated Resident 68 's brief interview of mental status (BIMS, an assessment for mental status) score was 12 (a score of 12 represents moderate cognitive impairment).During an observation on 5/18/26 at 1:00 p.m., Resident 68 was lying in bed asleep, and her meal tray was at the bedside untouched.During an interview on 5/21/26 at 8:45 a.m., Certified Nursing Assistant (CNA) 5, CNA 5 stated she had been taking care of Resident 68 in the past two months for dayshift (work hours from 7:00 am to 3:30 p.m.). CNA 5 stated that Resident 68 only ate around 25% most of the time and not more than 50% of her breakfast and lunch in the past two months.Resident 68 's weight disclosed the following weight trend: 5/1/26 83.4 lbs. (weight loss of 10.8 lbs. or 11.46 percent from 4/17/26)4/27/26 83.8 lbs. (weight loss of 10.4 lbs. or 11.04 percent from 4/17/26)4/17/26 94. 2 lbs.4/10/ 26 94 lbs.4/6/26 94.6 lbs.3/28/ 26 94.8 lbs.3/27/26 94. 2 lbs.There was no record found that Resident 68 was reweighed from 5/1/26 until 5/21/26.During a concurrent interview and record review on 5/21/26, at 10:16 a.m., with the Director of nursing (DON), Resident 68's weight record was reviewed. The recorded weight on 5/1/26 was 83.4 lbs. which was 10.8 lbs. less than 4/17/26's weight of 94.2 lbs. DON acknowledged that the resident should have been weighed weekly to monitor if there was further weight loss.During a concurrent interview and record review on 5/21/26, at 10:33 a.m., with the Registered Dietitian (RD.), Resident 68's weight record was reviewed. RD stated that Resident 68 had 11.46 % weight loss from 3/27/26 to 5/1/26. RD could not find a record of Resident 68's weight after 5/1/26. RD acknowledged that the resident should have been reweighed after 5/1/26 at least biweekly to closely monitor for further weight loss.During a review of the facility's P&P titled, Weight Assessment and Intervention dated 2001, the P&P indicated, . 3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. If the weight is verified, nursing will immediately notify the dietician in writing .

Based on observation, interview and record review, for two of three sampled residents reviewed for respiratory care (Resident 16 and 23), the facility failed to ensure residents received respiratory care in accordance with professional standards of practice when:1. Resident 16's BiPAP (machine is a non-invasive that helps people breathe easier, it delivers pressurized air through a mask, providing a higher pressure when you inhale and a lower pressure when you exhale) equipment was not applied and not maintained as ordered nor did the staff follow required procedures for equipment monitoring and troubleshooting.2. Resident 23's oxygen via nasal cannula was not positioned correctly.These failures had the potential to result in inadequate ventilation support and increased respiratory distress. 1.During a review of Resident 16's admission Record dated 5/19/26, the AR indicated Resident 16 on 5/3/26 with diagnoses that included chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems), bronchiectasis (a chronic lung disease where the airways (bronchi) become permanently damaged, widened, and scarred), and dependence on supplemental oxygen. During a review of Resident 16's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 5/10/26, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of 14. A BIMS score of 13-15 is an indication of intact cognitive status. During a concurrent observation and interview on 5/18/26 at 10:45 a.m., at Resident 16's bedside, Resident 16 stated the BiPAP machine did not function properly the previous night. Resident 16 stated that he needed more oxygen and was unable to breathe, which prevented him from sleeping. Resident 16 stated he notified the nurse and requested that the doctor be called to increase his oxygen, but his concern was not addressed. Resident 16 further stated, forty minutes after starting the BiPAP, Resident 16's oxygen saturation (the amount of oxygen you have circulating in your blood) had dropped to 85 % (normal 95-100%). During a review of the Order Summary Report (OSR) dated 5/19/26, the OSR indicated an order BiPAP at bedtime. During a concurrent observation and interview on 5/18/26 at 3:10 p.m. with Registered Nurse (RN) 4 at Resident 16's bedside, RN 4 stated the BiPAP was turned on typically at 10 p.m. before leaving for the day. RN 4 stated the physician's order did not specify the BiPAP settings but believed the device was already set up and did not require staff to adjust the settings. However, RN 4 was unable to identify the required settings or locate them on the machine. RN 4 explained that her responsibilities included filling the water reservoir and was unsure how to determine if the BiPAP was malfunctioning. During a concurrent interview and record review on 5/19/26 at 2:10 p.m. with Director of Nursing (DON), DON stated the physician's order lacked information about the BiPAP settings and that a review of the hospital discharge records also did not indicate the ordered settings. DON stated the process for obtaining BiPAP equipment that included the facility's marketer coordinating with the vendor following the hospital's prescription. The vendor would set up the machine; the charge would then review the settings to confirm consistency with the physician's order. DON emphasized the importance of having information about the BiPAP settings, as excessive airflow would not address the residents' needs. DON said if the BiPAP machine fails, the charge nurse should inform the physician and vendor. During an interview on 5/20/26 at 9:45 a.m. with Director of Staff Development (DSD). DSD described the training procedures for BiPAP use. DSD stated, if a machine is available, staff are shown how to operate it and adjust settings. Otherwise, they are instructed to check the mask fit, read the instruction manual, and follow its guidance. Expectations include ensuring that the machine settings and mask size match the prescription. Staff are advised to ask the physician if they are unsure, as improper fit or settings could lead to breathing difficulties or insufficient oxygen delivery. During a review of Resident 16's eInteract Change in Condition Evaluation (CIC) dated 5/19/26, the CIC indicated, on 5/19/26 at 10 p.m. Resident 16's BiPAP was turned on, after 30 minutes, Resident 16 complained of shortness of breath, oxygen saturation dropped to 65 % with four liters of oxygen via nasal cannula. Resident 16 was transferred to the hospital. During a review of the facility's policy and procedure (P&P) titled, CPAP/BiPAP Support, undated, the P&P indicated, before initiating therapy, staff should review the resident's medical record to determine baseline respiratory and circulatory status, as well as physician's orders for oxygen concentration, flow, and pressure settings. 2. During a review of Resident 23's AR printed on 5/21/26, the AR indicated Resident 23 was admitted to the facility in January 2021 with diagnoses including Alzheimer's disease (a progressive, irreversible neurological disorder that destroys brain cells, leading to severe memory loss, cognitive decline, and the loss of basic daily functioning) and asthma (a chronic lung disease that causes your airways to swell, narrow, and produce extra mucus). During a review of Resident 23's MDS dated [DATE], the MDS indicated a BIMS score of three. A BIMS score of zero-seven indicates a severe cognitive status. During a review of Resident 23's Order Summary dated 2/29/24, the Order Summary indicated Resident 23 had a physician's order for oxygen (O2) therapy at 3 liters per minute via nasal cannula for asthma. During a review of Resident 23's Care Plan Report initiated on 2/26/24 with revision date on 3/20/24, the care plan for oxygen therapy related to ineffective gas exchange indicated Oxygen Settings: The resident has O2 via nasal prongs at 3(L/liters) continuously. During an observation on 5/18/26 at 10:40 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 was inside Resident 23's room, assisting Resident 23's roommate. LVN 4 then exited the room and proceeded to the medication cart. During an observation on 5/18/26 at 10:46 a.m. with Resident 23, Resident 23 was asleep in bed while the oxygen concentrator remained powered on; however, the nasal cannula was not positioned correctly and was instead observed under Resident 23's chin. During an observation and interview on 5/18/26 at 10:49 a.m. with LVN 4, LVN 4 reapplied the nasal cannula to Resident 23's nostrils. LVN 4 stated they last observed Resident 23 approximately 30 minutes earlier and was unsure how long Resident 23 had been without oxygen delivery. LVN 4 stated Resident 23 frequently removed the nasal cannula and nursing staff should have performed frequent monitoring and observation to ensure the nasal cannula was properly in place. LVN 4 further stated Resident 23 could have experienced hypoxia (deprived of adequate oxygen supply) with symptoms including shortness of breath and may have required breathing treatment intervention. During an interview on 5/19/26 at 2:37 p.m. with the DON, DON stated the oxygen therapy should have been provided continuously as ordered by the physician. DON stated the nursing staff should have monitored the placement of the nasal cannula at least every two hours, or more frequently as needed for residents with confusion, to ensure oxygen therapy was being administered to maintain acceptable oxygen saturation levels (a measurement of the percentage of hemoglobin in your red blood cells that is carrying oxygen). During a review of the facility's P&P, titled, Oxygen Administration revised in October 2010, the P&P indicated, 1. Review the physician's orders or facility protocol for oxygen administration.2. Review the resident's care plan to assess for any special needs of the resident.Steps in the Procedure.11. Securely anchor the tubing so it does not rub or irritate resident's nose. Behind the resident's ears, etc.12. Check the mask, tank, humidifying jar, etc.to be sure they are in good working order and securely fastened.13. Observe resident upon set up and periodically thereafter to be sure oxygen is being tolerated.

Based on interview and record review, the facility failed to ensure 2 out of 5 sampled residents (Residents 5 and 95) were free from unnecessary medications. Residents 5 had no hold parameters for an antihypertensive medication (medication to lower blood pressure); and Resident 95 had no monitoring for thyroid stimulating hormone (TSH) while receiving levothyroxine (medication to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone). The failure resulted in inadequate monitoring and had the potential for complications related to these medications such as severely low blood pressure or too low/too high TSH without dose adjustment, for the respective residents. 1. A review of Resident 5's clinical record indicated she was admitted to the facility with diagnoses including atrial fibrillation (is an irregular and often very rapid heart rhythm) and hypertension (high blood pressure [BP]). A review of Resident 5's physician's orders indicated an order for metoprolol (an antihypertensive medication) 25 milligrams (unit of measurement), give 1 tablet by mouth in the morning for Hypertension, dated 2/24/26. The order did not include hold parameters, such as when to hold or not give the medication. A review of the Prescribing Information (PI; detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) from the manufacturer for metoprolol, revised 7/2023, indicated metoprolol's effects include lowering the blood pressure and reducing the heart rate (HR). During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 5/20/26 at 10:58 AM, she reviewed Resident 5's May 2026 medication administration record (MAR) and confirmed there should have been instructions for when to hold the medication such as when the BP or HR was below certain readings to avoid them being too low. 2. A review of Resident 95's clinical record indicated she was admitted to the facility with diagnoses including hypothyroidism. A review of physician's orders indicated Resident 95 has been receiving levothyroxine 150 micrograms (unit of measurement), 1 tablet every morning since a re-admission to the facility on 6/10/25 (almost a year ago). A review of Resident 95's laboratory results indicated no laboratory monitoring for TSH related to levothyroxine use. During a concurrent interview and record review with the ADON on 5/21/26 at 11:20 AM, she reviewed Resident 95's clinical record and stated she could not find any TSH laboratory values. During a concurrent interview and record review with the Director of Nursing (DON) and ADON on 5/21/26 at 12:52 PM, the ADON stated she identified a TSH level that was conducted on 9/8/25 by the hospital during the resident's hospital stay from 9/8/25 to 9/16/25. It was 0.03 (very low; normal value: 0.35 - 4.94 mIU/L [milli-international units per liter]). Both the DON and ADON confirmed Resident 95 has been receiving levothyroxine 150 mcg daily without TSH monitoring since 6/10/25, and the facility was not aware of the hospital's low TSH level while she was in the hospital; as a result, there has been no TSH monitoring since she returned on 9/16/25 to see if dose adjustment was needed. A review of the PI from the manufacturer for levothyroxine, revised 4/2019, indicated the following: In adult patients with primary hypothyroidism, monitor serum TSH levels after an interval of 6 to 8 weeks after any change in dose. In patients on a stable and appropriate replacement dose, evaluate clinical and biochemical response every 6 to 12 months and whenever there is a change in the patient's clinical status. A review of the facility's Medication Utilization and Prescribing- Clinical Protocol, revised 7/2016, indicated the following under Monitoring: The staff and physician will periodically re-evaluate the conditions and symptoms for which each resident is receiving medications to ensure that the medication and dosage are still relevant and are not causing undesired complications.

Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of a Level I preadmission screening resident review (PASARR) screening for 1 (Resident #74) of 1 sampled resident reviewed for PASARR screening. Findings included: An Admission Record indicated the facility admitted Resident #74 on 08/20/2024. According to the Admission Record, the resident had a medical history that included diagnoses of unspecified disorder of psychological development, unspecified psychosis, and depression. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/23/2024, revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had active diagnoses to include depression, psychotic disorder, and unspecified disorder of psychological development. Per the MDS, the resident received an antipsychotic medication during this assessment period. Resident #74's care plan included a focus area initiated 08/20/2024, revealed Resident #74 received Risperdal, an antipsychotic medication. Resident #74's Order Summary Report that contained active orders as of 10/09/2024, revealed an order dated 08/20/2024, for Risperdal oral tablet 1 milligram (mg), give one tablet by mouth at bedtime for unspecified psychosis and risperidone oral tablet 1 mg, give a half a tablet by mouth one time a day for unspecified psychosis. Resident #74's Preadmission Screening and Resident Review Level I Screening dated 08/20/2024, indicated Resident #72 did not have a serious diagnoses mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusion, and/or mood disturbance. During an interview on 10/10/2024 at 3:26 PM the MDS Coordinator (MDS) stated she was responsible for checking the PASARR for accuracy when residents admitted to the facility. The MDS Coordinator stated a diagnosis of psychosis would be considered a mental illness. The MDS Coordinator stated Resident #74 received an antipsychotic medication and had a diagnosis of psychosis and the resident's mental illness diagnosis should have been indicated on the Level I PASARR screening. During an interview on 10/10/2024 at 9:16 AM the Director of Nursing (DON) stated her expectation was that the PASARR screening was completed. According to the DON, the MDS Coordinator followed up after a resident's admission to ensure the PASARR was completed accurately. The DON stated she thought Resident #74 had a mental illness diagnosis. The DON stated if the Level I screening was not accurate, no one would complete a Level II review, and the facility would not know what services were available for Resident #74. In an interview on 10/10/2024 at 10:02 AM, the Administrator stated his expectation was that the PASARR was completed timely and the MDS Coordinator verified that the PASARR for accuracy. A facility policy titled Admission Criteria, revised 03/2023, indicated 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. The policy indicated b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process.

Based on observation and interview, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 8 (Rooms 27 - 34) of 13 residents' rooms on 1 (Station 3) of 3 units in the facility. Findings included: On 10/10/2024 at 8:28 AM, the Maintenance Director measured the following rooms and confirmed the following dimensions: - In room [ROOM NUMBER], there was 70 sq feet for resident. - In room [ROOM NUMBER], there was 70 sq ft for each resident. - In room [ROOM NUMBER], there was 70 sq ft for each resident. - In room [ROOM NUMBER], there was 70 sq ft for each resident. - In room [ROOM NUMBER], there was 70 sq ft for each resident. - In room [ROOM NUMBER], there was 70 sq ft for each resident. - In room [ROOM NUMBER], there was 78.75 sq ft for each resident. - In room [ROOM NUMBER], there was 75sq ft for each resident. During an interview on 10/10/2024 at 9:40 AM, Certified Nursing Assistant (CNA) #1, stated she had no problems with providing care due to a resident's room size. During an interview on 10/10/2024 at 9:42 AM, CNA #2 stated she had no issues with providing care due to a resident's room size. During an interview on 10/10/2024 at 9:45 AM, Licensed Vocational Nurse #3 stated she never had an issue providing care due to a resident's room size. During an interview on 10/10/2024 at 10:09 AM, the Administrator stated he was aware of the room size requirements. The Administrator stated it was important for resident rooms to be a certain size so staff could provide care for the resident and for the size of the room to not impede the care provided. During an interview on 10/10/2024 at 10:19 AM, the Director of Nursing (DON) stated she thought the minimum resident room size requirements were 80 to 100 sq ft. The DON stated she expected the facility to meet whatever the regulation was regarding resident room sizes.

Based on interview and record review the facility failed to provide services which met professional standards for one resident (Resident 1) of three sampled residents when nursing staff did not document physician's orders were carried out. This failure contributed to formation and worsening of Resident 1's sacrococcyx (the backside area between a person ' s hips and down to the tailbone) wound. Findings: A review of Resident 1's admission record indicated an initial admitted [DATE] with diagnoses which included mitral valve insufficiency (a condition in which the valve between two heard chambers does not close tightly, which allows blood to flow backward in the heart) and traumatic hemorrhage of the cerebrum (trauma to the head which results in blood intermixing with brain tissue). A review of Resident 1's Braden Scale (an assessment tool used for predicting pressure injury risk) assessment dated [DATE] at 6:22 p.m. indicated a score of 9 which indicated Resident 1 was at very high risk for developing a pressure injury. A review of Resident 1's history and physical written by a physician dated 2/16/23 at 1:13 p.m. indicated, SNF [Skilled Nursing Facility] Admission .Skin- SC [sacroccoccyx] Stage 1 [injury of the skin as a result of continuous pressure characterized by superficial reddening that when pressed does not turn white] redness .Assessment and Plan .Decubitus [laying down area] ulcer: recommendation(s) barrier cream, foam dressing, position changes . A review of a care plan which focused on Resident 1's Stage 1 pressure injury on the coccyx (tailbone), initiated on 2/21/23, indicated nursing staff would, provide proper skin care to assist Resident 1 to reach her goal of preventing further deterioration of skin integrity. A review of Resident 1's Treatment Administration Record (TAR) dated February 2023 indicated staff did not document the physician's order, Barrier cream with foam dressing to redness to coccyx .change every day with diaper change and/or .when soiled .every shift . was carried out on: the day and night shifts of 2/17/23, on the day and evening shifts of 2/19/23, day shift of 2/20/023, and the evening shift of 2/23/23. A review of Resident 1's TAR dated March 2023 indicated the following physician's orders: Cleanse coccyx area noted with redness with NS [normal saline, a solution used to cleanse wounds], pat dry and apply .paste .every shift . was not carried out on: night shift of 3/6/23, day shift of 3/12/23, night shifts of 3/15/23 and 3/16/23, day shift of 3/20/23, evening shift of 3/21/23, and night shifts of 3/23/23 to 3/27/23; Air mattress every shift was not carried out on: night shift of 3/6/23, day shifts of 3/10/23 and 3/11/23, night shifts of 3/15/23 and 3/16/23, day shift of 3/20/23, evening shift of 3/21/23, and night shifts of 3/24/23 to 3/27/23; and, Apply barrier cream with every diaper change and PRN [as needed] when soiled .every shift for peri-care . was not carried out on: night shift of 3/6/23, day shift of 3/12/23, night shifts of 3/15/23 and 3/16/23, day shift of 3/20/23, evening shift of 3/21/23, and night shifts of 3/24/23 to 3/27/23. A review of Resident 1's TAR dated April 2023 indicated the following physician's orders: Cleanse coccyx area noted with redness with NS, pat dry and apply .paste .every shift . was not carried out on: evening shift of 4/15/23, night shift of 4/16/23, evening shift of 4/19/23, evening shift of 4/21/23, day and evening shifts of 4/22/23, day shift of 4/24/23, day shift of 4/26/23, evening shift of 4/28/23, and day shift of 4/29/23; Air mattress every shift was not carried out on: evening shift of 4/15/23, night shift of 4/16/23, evening shift of 4/19/23, evening shift of 4/21/23, day and evening shifts of 4/22/23, day shift of 4/24/23, day shift of 4/26/23, evening shift of 4/28/23, and day shift of 4/29/23; and, Apply barrier cream with every diaper change and PRN when soiled .every shift for peri-care . was not carried out on: evening shift of 4/15/23, night shift of 4/16/23, evening shift of 4/19/23, evening shift of 4/21/23, day and evening shifts of 4/22/23, day shift of 4/24/23, day shift of 4/26/23, evening shift of 4/28/23, and day shift of 4/29/23. A review of Resident 1's TAR dated May 2023 indicated the following physician's orders: Cleanse coccyx area noted with redness with NS, pat dry and apply .paste .every shift . was not carried out on: day shift of 5/3/23, day and evening shifts of 5/6/23, night shift of 5/10/23, day shift of 5/12/23, evening shifts of 5/15/23 and 5/16/23, day shift of 5/17/23, evening shift of 5/18/23, evening shifts of 5/21/23 to 5/23/23, and day shift of 5/24/23; Air mattress every shift was not carried out on: day shift of 5/3/23, day and evening shifts of 5/6/23, night shift of 5/10/23, day shift of 5/12/23, evening shifts of 5/15/23 and 5/16/23, day shift of 5/17/23, evening shift of 5/18/23, evening shifts of 5/21/23 to 5/23/23, and day shift of 5/24/23; and, Apply barrier cream with every diaper change and PRN when soiled .every shift for peri-care . was not carried out on: day shift of 5/3/23, day and evening shifts of 5/6/23, night shift of 5/10/23, day shift of 5/12/23, evening shifts of 5/15/23 and 5/16/23, day shift of 5/17/23, evening shift of 5/18/23, evening shifts of 5/21/23 to 5/23/23, and day shift of 5/24/23. A review of Resident 1's TAR dated June 2023 indicated the following physician's orders: Cleanse coccyx area noted with redness with NS, pat dry and apply .paste .every shift . was not carried out on: evening shift of 6/1/23, day shift of 6/3/23, day shift of 6/5/23, day shift of 6/11/23, day shift of 6/13/23, day shift of 6/16/23, and day shift of 6/19/23; Air mattress every shift was not carried out on: evening shift of 6/1/23, day shift of 6/3/23, day shift of 6/5/23, day shift of 6/11/23, day shift of 6/13/23, day shift of 6/16/23, and day shift of 6/19/23; and, Apply barrier cream with every diaper change and PRN when soiled .every shift for peri-care . was not carried out on: evening shift of 6/1/23, day shift of 6/3/23, day shift of 6/5/23, day shift of 6/11/23, day shift of 6/13/23, day shift of 6/16/23, and day shift of 6/19/23. A review of a SNF rounding note written by a physician dated 6/20/23 at 9:50 a.m. indicated, .Patient noted to have blisters and open area on the back, noted by staff over the weekend .Assessment and Plan .Pressure [Injury] of buttock Stage 2 (partial thickness skin loss), unspecified side has blisters and open area, DTI [Deep Tissue Injury, a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure] most likely with stage 2 on the open area .Has blister filled with fluid .Will apply [foam dressing] for now, continue to monitor, Patient already on airflow mattress . A review of Resident 1's wound evaluation dated 7/21/23 at 3:33 p.m. indicated, Body Location .Sacrum .Pressure [ulcer]- Unstageable (slough and/or eschar) .Area .+133% .Length .+24% .Width .+37% .Deepest Point .+100% .Longest Tunnel .+100% .Negative percentage values indicate wound is getting smaller .[Resident] sacrum area has opened up with an unstageable wound . A review of Resident 1's wound evaluation dated 7/27/23 at 10:32 a.m. indicated, Body Location .Sacrum .Pressure [ulcer]- Stage 4 .[Resident] has open wound on sacrum stage 4 . In a concurrent interview and record review on 5/17/24 at 10:49 a.m. with the Director of Nursing (DON), Resident 1 ' s TARs dated February 2023 through June 2023 were reviewed. The TARs indicated innumerable dates with no licensed staff initials in the boxes to demonstrate wound treatment orders were administered. The DON confirmed and stated, .If you did not document, it did not happen .[It was] the LN ' s responsibility to ensure orders are carried out .Yes, LN should document .according to TAR ' s chart codes . The DON acknowledged it was a deficiency. A review of the facility ' s policy and procedure titled Medication and Treatment Orders, revised July 2016, indicated, Orders for . treatments . shall be administered . upon the written order of a person duly licensed and authorized to prescribe . A review of the facility ' s policy and procedure titled, Prevention of Pressure Injuries, revised April 2020, indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable . Prevention .Keep the skin clean and hydrated . Clean promptly after episodes of incontinence .Use a barrier product to protect skin from moisture .Select appropriate support surfaces based the resident's risk factors .

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1, Resident 2) received the necessary treatment/services of a pressure ulcer to promote healing, prevent infection, and prevent new ulcers from developing when: 1) a. There was no skin risk assessment for Resident 1 upon admission, weekly, and thereafter. b. There was no ongoing assessment of the status and progress of the Resident 1 ' s anke and leg wounds, and sacrococcygeal Moisture Associated Skin Damage (MASD- caused by prolonged exposure to various sources of moisture including urine, perspiration). c. The physician ' s treatment orders for Resident 1 ' s ankle and leg wounds, and sacral MASD such as daily wound treatment, preventive and weekly assessments were not implemented as ordered. d. The care plan for R ankle wound did not include individualized wound care and treatment as indicated on the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) a. There was no ongoing assessment for Resident 2 ' s unstageable sacral pressure injury /ulcer [unstageable pressure ulcer has full thickness tissue loss which is covered by slough (dead tissue) and/or eschar (necrotic tissue that dryer than slough)]; and care plan was not implemented. b. The physician ' s treatment orders for Resident 2 ' s sacral injury such as daily wound treatment care and weekly assessments were not implemented as ordered. These failures had the potential for further progression of the pressure injury and open wounds for Residents 1 and 2. Findings: 1. During a review of Resident 1's Face Sheet, the Face Sheet indicated, Resident 1 was admitted on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the Minimum Data Set (MDS, a resident assessment tool), for Resident 1, dated 6/8/22, the MDS indicated a Brief Interview Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 14 indicating no cognitive impairment. During a concurrent observation and interview on 8/8/22, at 11:25 AM, and 11:35AM with Resident 1, Resident 1 was observed in bed, lying on his back, alert and oriented. Resident 1 stated, he had skin infections on his legs which got healed up. Resident 1 stated, he had wounds in his legs and his buttocks were red. Resident stated, his bed was hard and had reported it to staff. Resident 1 had a suprapubic catheter ( tubing connected to the bladder) to gravity. Observed Resident 1repositioned by the CNA. Resident 1 ' s sacral/coccyx area was red, raw-like with two scrapes (open areas) on his left buttock with pinkish fluid sticking onto the sheet. Observed, there is a wound behind L leg. Resident 1 ' s wounds in his R leg and R lateral ankle had small pinkish fluid sticking onto the pillowcase. The wounds all appeared unclean. Resident 1 stated they do the treatment sporadically. Resident 1 stated, he cannot recall when last the nurse came to check and treat the wounds. During a review of Resident 1's Braden Scale Assessment (for predicting pressure sore risk), dated 3/2/22, the Braden scale indicated, a score of 15 indicating at risk for skin breakdown. No evidence that a Braden scale assessment was done upon admission (4/5/22), weekly for four weeks and quarterly. During a review of the MDS for Resident 1, dated 6/8/22, MDS indicated, Resident 1 required extensive assistance with two-person physical assist for bed mobility and transfer. Resident 1 was also determined to have impairment on both lower extremities and at risk for developing pressure ulcers. During a review of the MDS section M (Skin condition) dated 6/8/22, MDS indicated, under other ulcers, wounds and skin problems, Resident 1 had MASD (for example incontinence-associated [CONDITION(S)] etc.). During a concurrent observation, interview and record review of Treatment Administration Record (TAR) on 8/8/22, at 3:25 PM, with LVN 2, TAR indicated, solid pink color for multiple days for Resident 1 and Resident 2 for the months July 2022 and August. LVN 1stated, the pink color signified the treatment was not carried out. LVN 1 confirmed, she did not carry out the treatment. LVN 1 stated, the treatment nurse is responsible for doing residents ' wound care. LVN 1 stated, she is unsure if he carried out wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 8/8/22, at 3:35 PM, LVN 2 stated, he is no longer the treatment nurse. LVN 2 stated, he only helps to do the wound care for residents with major wound such as wound vac. LVN 2 stated, the charge nurses are responsible for doing the wound care/treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During a concurrent interview and record review on 8/8/22, at 3:40 PM, with Assistant Director of Nursing (ADON), ADON stated, they have an in-house medical doctor that does the wound assessment for Resident 1 and Resident 2. ADON could not provide any nursing wound and pressure injury monitoring assessments for Resident 1 and Resident 2. During an interview on 7/8/22, at 3:45 PM with ADON, ADON stated, the charge nurses were responsible for doing wound/treatment on the floor except for the major wounds (like wound vac). ADON confirmed treatment were not done for Residents1 and 2. During a review of the clinical record for Resident 1, titled, Surgical consult wound medical doctor (MD) evaluation, dated 7/29/22, 7/1/22 and 6/24/22, MD evaluation indicated, Resident 1 ' s wound is Right (R) lateral malleolus [with etiology (the cause) developed as result of pressure injury/ulcer because of inability to offload completely]; and a wound on R lateral leg. A review of the MD evaluation dated 6/24/22 indicated the R lateral malleolus wound measured 1.0 x 1.0 cm and to follow up at interval of 1 week. The clinical record dated 7/1/22 indicated the R lateral malleolus ulcer is 1.2 cm X 1.0 cm and to follow up at an interval of 1 week. The MD evaluation dated 7/29/22 indicated the R lateral malleolus wound is epithelialized (covered with epithelial tissue during the healing of a wound). MD evaluation indicated, the R lateral leg wound etiology (cause) is shear injury and measured 4.0 com X 1.0 cm and MD would follow at an interval of 1 week. During a review of Resident 1's Order Summary Report, the Order Summary Report for week of 8/8/22, for treatment orders indicated, Barrier cream to buttocks and sacral area every shift for skin prophylaxis with start date 7/13/2022; Buttocks MASD: Apply [MEDICATION(S)] every shift with start date 5/16/22; Complete weekly Skin Check under assessment every evening shift every Wednesday for weekly monitoring with start date 9/22/21; Left calf wound: apply zinc every day shift, Right calf wound: apply zinc every day shift with start date 5/26/22 ; [MEDICATION(S)] solution 10% ([MEDICATION(S)]- iodine) Apply to Right lateral ankle to topically every day shift for [MEDICATION(S)] and island dressing (a type of dressing that absorbs excess fluid) to right lateral ankle with start date 4/23/22; [MEDICATION(S)]- Triamcinolone cream 0-0.1 unit/GM % Apply to bottom of the legs topically two times a day for MASD with start date 1/21/22; Pressure relieving mattress low air loss (LAL) for treatment and prevention and pressure injury: Check for proper function of LAL mattress and setting every shift with start date 12/2/21. During a review of the TAR for Resident 1 indicated no wound treatment done at lateral ankle, L & R calf wounds and buttocks MASD, and bottoms of legs on 7/1, 7/3, 7/4, 7/5, 7/6, 7/7, 7/8, 7/19, 7/22, 7/24, 7/25, & 7/29/22, day shift. No wound treatment was done on 8/1, 8/2, 8/3, 8/4, 8/5, 8/7, & 8/8/22. Treatment was not done for Resident 1's bottom of legs on day shift 7/1, 7/3, 7/4, 7/5, 7/6, 7/7, 7/8, 7/19, 7/22, 7/24, 7/25, & 7/29/22. On 7/3, 7/7, 7/12, 715, 7/19, 7/26, 7/27/22, evening shift, no treatment done. Day shift in August 8/1 thru 8/5, 8/7, 8/8/22, no treatment done. Checks for proper function of the LAL mattress and setting every shift not done on 7/1, 7/3, 7/4, 7/5, 7/6, 7/8, 7/19, 7/22, 7/24, 7/25, 7/29/22, on day shift and on 7/3, 7/7, 7/12, 7/15, 7/19, 7/26, 7/27/22, and also not done on evening shift on 8/1thru 8/5, 8/8/22. During a review of the Resident 1 ' s care plan (undated) for right ankle wound indicated follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. During an observation and interview on 8/8/22, at 1:05 PM, with Resident 2, Resident 2 was lying on her back. Resident 2 had a foley catheter to gravity. Resident 2 stated, she does not want to move at this time and refused observation of her sacral injury. During a review of Resident 2 's Face Sheet, the Face Sheet indicated, Resident 2 was admitted on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2 ' s Minimum Data Set (MDS, a resident assessment tool), dated 6/8/22, the MDS indicated a Brief Interview Mental Status (BIMS, a brief scanner to help detect cognitive impairment) score of 12 indicating moderate cognitive impairment. During a review of Resident 's Braden Scale Assessment (for predicting pressure sore risk), dated 6/13/22, the Braden scale on admission indicated a score of 13 indicating moderate risk for skin breakdown. During a review of the MDS dated [DATE], MDS indicated Resident required extensive assistance with two-person physical assist for bed mobility and transfer. During a review of the MDS section M (Skin condition) dated 6/17/22, MDS indicated, Resident 2 was determined to be at risk for developing pressure ulcers; Resident 2 had 3 unstageable - deep tissue injury and 3 unstageable pressure ulcers present of admission. During a review of the clinical record of Resident 2, titled, Surgical consult wound medical doctor (MD) evaluation, dated 6/17/22, the MD wound evaluation indicated, first visit: Resident 2 had a left (L) buttock and right buttock pressure injury/ulcer which developed from the hospital. The 6/17/22 MD evaluation indicated the L buttock ulcer measured 2.0 cm X 1.5 cm with 100% slough undetermined depth (UTD - unstageable); R buttock pressure injury/ulcer measured 5.5 cm X 6.5cm (UTD) with 100% slough. During a review of Resident 2' s Order Summary Report, the Order Summary Report for week of 8/8/22, for wound treatment orders indicated Cleanse Sacrococcygeal extending to L and R buttock [unable to determine (UTD - indicating unstageable)] with normal saline, pat dry, apply Santyl, cover with bordered gauze as needed with start date 6/14/22; Wound treatment orders also indicated Cleanse Sacrococcygeal extending to L and R buttock unable to determine (UTD - indicating unstageable) with normal saline, pat dry, apply Santyl, cover with bordered gauze every day shift with start date 6/15/22; Complete Weekly Skin Check V3 under assessment every evening shift every Thurs for weekly monitoring with start date 6/16/22; Observe unstageable sacral pressure wound every shift, notify MD for any change every shift with start date 6/13/22. During a review of the TAR for Resident 2, TAR indicated, no wound treatment done for Resident 2 ' s sacral pressure injury for 7/1, 7/3, 7/4, 7/5, 7/7, 7/8, 7/19, 7/22, 7/24, 7/25, 7/29 on day shift.TAR also indicated, there was no observation of the sacral injury done as ordered for 10 days on day shift and for 7 days on evening shift in July 2022; the observation and wound/treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] & 8/8/22. During a review of Resident 2 ' s care plan (undated) for unstageable pressure ulcer, the care plan interventions indicated, Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing weekly .Assess and document status of wound perimeter, wound bed, and healing progress . During a review of the facility ' s policy and procedure (P & P) titled, Pressure injury Wound Guidelines, dated June 2018, the P & P: Risk assessment . Guidelines - Assess all residents for risk for skin breakdown upon admission and weekly for the first 4 weeks after admission, and quarterly thereafter to identify risk of skin breakdown and on any change of condition, including development of a new pressure injury 1. Nursing staff will observe skin during routine care to identify changes and implement and document preventative interventions as individual needs are identified 2. The plan of care will be updated and implemented, based on individual needs identified by a resident assessment, comprehensive skin assessment and score on the Braden Scale . During a review of the facility ' s P&P titled, Wound Management Guidelines, the P & P indicated, It is the philosophy of this facility to ensure that resident skin status is assessed, and appropriate interventions are implemented . The pressure injury wound treatment and prevention program will focus on the following strategies: Evaluate the resident for risk of pressure injuries and any existing pressure injuries .Local wound care and treatment, education and quality improvement .Treatment as ordered.

Based on observation, interview and record review, facility failed to protect residents by allowing CNA 1 to continue to work as a direct care giver before completion of an investigation of Resident 1's physical abuse allegation against CNA 1. The facility failed to thoroughly investigate physical abuse allegations by two of two sampled residents (Resident 1 and Resident 2) against Certified Nursing Assistant (CNA1). Theses failures had the potential to result in repeated physical abuse of Resident 1 and Resident 2 and placed other 56 residents residing at the facility at potential risk for abuse. An Immediate Jeopardy (IJ, a situation in which a facility's actions places one or more residents/patients in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected) situation was identified and called due to facility's failure to thoroughly investigate a physical abuse allegation and protect 58 residents from the potential for further abuse. The Administrator (ADM) was verbally notified of the IJ situation on 5/20/22 at 2:34 p.m. During an onsite visit to the facility on [DATE], the facility initiated a plan of action and the IJ was removed on 5/25/22 at 11:15 a.m. Findings: During a review of Resident 1's Admission Record dated 5/20/22, the record indicated Resident 1 was admitted to the facility on [DATE]. During a record review of Resident 1's Minimum Data Set (MDS- An assessment used to guide care) dated 4/13/22, MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- cognition assessment) score was 13 out of 15, indicating intact cognitive function. During an observation and interview with Resident 1 on 5/20/22, at 8:10 a.m., Resident 1 stated, on 4/24/22 at lunch time she was in bed and had lunch menu in her right hand. CNA 1 grabbed menu from her, squeezed her wrist hard and bandage came off of her right wrist. Resident 1 stated she had broken skin on her right wrist, and which started to bleed after the bandage came off. Resident 1 stated her skin tear hurt quite a bit after and it made her feel upset and angry. During an electronic record review of Resident 1's progress notes dated 4/24/22, at 1:07 p.m., completed by Licensed Vocational Nurse (LVN 1), the progress notes indicated, at 12:45pm [CNA 3] alerted that [Resident 1] had skin tear on right arm. [CNA 3] alerted nurse that another CNA was passing out food and that wound appeared. [FR 1] alerted nurse that she had talked to mother and [Resident 1] stated that when she was looking at food menu, [CNA 1] yanked the paper and scratched her arm. [Resident 1] also stated when she requested something from [CNA 1], [CNA 1] waived hand in air and walked away. Resident skin [tear] cleaned with [normal saline], triple antibiotic applied and bandaged. During an interview with LVN 1 on 5/20/22, at 9:05 a.m., LVN 1 stated, around 1:00 p.m., on 4/24/22, FR 1 informed her CNA 1 grabbed Resident 1's wrist and caused a skin tear to open. LVN 1 stated Resident 1's skin tear was a quarter sized skin flap and it was bleeding. LVN 1 stated she cleansed the skin tear with saline and applied anti-biotic ointment and bandage. LVN 1 stated that CNA 1 continued to stay in facility until end of shift around 2:00 p.m. [even after an abuse allegation was made against her]. LVN 1 stated that she completed a grievance form regarding the abuse allegation by Resident 1. During a record review Resident Grievance/Complaint Form dated 4/24/22, LVN 1 documented CNA 1 grabbed [Resident 1's] arm at 12:49 p.m. in Resident 1's room. Under actions or recommendations LVN 1 documented [CNA 1] should no longer work with [Resident 1]. During a phone interview with Family Representative 1 (FR1) on 5/23/22, at 11:03 a.m., FR 1 stated, on 4/24/22 when she entered Resident 1's room and Resident 1 was shaking and was afraid. FR 1 stated that Resident 1 informed her of alleged abuse by CNA 1, and FR 1 went to nurse's station to complain to LVN 1. FR 1 stated that LVN 1 came in spoke to her mother and put ointment on on skin tear and wrapped it. FR 1 stated that she saw the skin tear was bleeding. FR 1 stated that she was told CNA would not work with her and LVN 1 completed a grievance form. During a review of Resident 2's Admission Record dated 5/20/22, the record indicated, Resident 2 was originally admitted to the facility on [DATE]. During a review of Resident 2's MDS, dated [DATE], the MDS Section C indicated, Resident 2's BIMS score was 12 out of 15, which indicates intact mental status. During a review of Resident 2's Progress Notes completed by LVN 1 dated 4/25/22 showed, writer asked [Resident 2] to explain what happened. [Resident 2] stated, when she asked [CNA 1] to look for charger [CNA 1] stated she had no time, then [Resident 2] stated she tried to a call out to her [NAME] device to call 911, [CNA 1] spanked left leg before leaving. During an interview with the Resident 2 on 5/20/22, at 8:12 a.m., Resident 2 stated, on 4/24/22, CNA 1 hit her leg when she asked look for her phone charger. Resident 2 stated it made her feel mad. Resident 2 stated, she should help me not hurt me. During an interview with CNA 1 on 5/20/22, at 12:45 p.m., CNA 1 stated, she recalled going into Resident 2's room on 4/24/22 but denied the abuse allegation. During a concurrent interview and record review on 5/20/22, at 11:48 p.m., Director of Staff development (DSD) and ADM, facility's undated, Investigation Summary for Resident 1 and Resident 2 was reviewed. The ADM and DSD stated facility's Abuse investigation summary for Residents 1 and 2 did not have documentation of interviews with other residents under CNA 1's care, a family member and other staff as per facility policy. During a phone interview with the DON on 5/20/22 at 9:55 a.m., the DON stated, she was the one who completed the Investigation Summary for abuse allegations made by Resident 1 and Resident 2 on 4/29/22. The DON stated, she spoke to some residents to complete a thorough abuse investigation, however was unable to recall the number and name of residents participated in abuse investigation and the date/time she conducted the interviews. The DON stated, she would only document the interviews with other residents if they complained about CNA 1. The DON stated CNA 1 was not removed from resident care area until around 11:00 a.m. on 4/25/22 [the next day abuse allegation was made against her]. During a concurrent interview and record review on 5/20/22, at 11:48 p.m., with DSD, facility's Policy and Procedure (P&P) titled, Abuse prohibition and prevention policy and procedure and reporting reasonable suspicion of a crime in the facility policy and procedure, revised on 3/2018 was reviewed. The P&P section F Investigation indicated, 1. All incidents of suspected or alleged abuse will be promptly investigated by the assigned staff, who will be informed of the nature of the incident and continue the investigation process. The investigation and report shall include: . j. Interviews facility staff members who have had contact with the resident during the period of the alleged incident; . k. Interviews the resident's roommate, family members, and visitors; .l. Interviews other residents to whom the accused employee provides care of services; .o. Prepares an investigation report documenting findings of the investigation. During a phone interview with Certified Nursing Assistant (CNA 1) on 5/23/22, at 11:30 a.m. CNA 1 stated, around 11:30 a.m. on 4/24/22, she served lunch meal trays to the residents. CNA 1 stated she helped Resident 1 out of the bathroom and gave her the meal tray. CNA 1 stated she then left the room and was told by LVN 1 that she could not enter Resident 1's room or assist her. CNA 1 stated LVN 1 told her she could continue to serve meal and provide care for her assigned residents [Resident 2, 4, 5, 6, 7, 8 and 9]. CNA 1 stated she assisted Resident 2, 4, 5, 6, 7, 8 and 9 with repositioning and personal hygiene until 2:30 p.m. on 4/24/22. CNA 1 stated she came back to work for her regular resident care assignment at 6:30 a.m. on 4/25/22. CNA 1 stated she continued to provide care for Resident 2, 4, 5, 6, 7, 8 and 9 until she was sent home at 10:00 a.m. on 4/25/22. During a review of facility's, Documentation Survey Report v2 for the month of 04/2022, document indicated, on 4/24/22 CNA 1 provided direct resident care including turning/ repositioning, bed mobility, serving nourishment, meals, range of motion- passive for Residents 2, 4, 5, 6, 7, 8, and 9 even after facility was made aware of physical abuse allegation. The report further showed CNA 1 assisted Resident 5 and 11 with ADL's including bed mobility, transfers, dressing, locomotion on and off unit, walk in corridor, walk in room, meals, and toileting, until 09:10 a.m. on 4/25/22 During a review of Certified Nursing Assistant 1's employee timecard, State Audit Report, for the period of 4/21/22 -5/21/22 indicated that, CNA 1 left the facility at 2:38 p.m. and 2:52 p.m., on 4/24/22 and 4/25/22 respectively. During an interview with ADM on 5/20/22, at 12:10 p.m., the ADM stated, facility should have removed CNA1 from resident care area immediately after Resident 1 reported a physical abuse allegation against CNA 1. The ADM also stated facility did not follow its protocol to complete a thorough abuse investigation. During an interview with DSD on 5/20/22, at 12:15 p.m., DSD stated, facility placed its residents at risk of further abuse by not removing CNA 1 from resident care area even after hearing about Resident 1's physical abuse allegation against her on 4/24/22. During a review of facility's P&P titled, Abuse Prohibition and Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime in the Facility Policy and Procedure, revised on 3/2018, the P&P indicated, E. Protection 1. The facility will ensure residents are protected from physical and psychosocial harm during and after the investigation .b. If the suspected perpetrator is an employee: 1. Remove employee immediately from the care or vicinity of residents .3. Suspend employee until the investigation is complete and the findings have been reviewed by the administrator.

Based on interview and record review the facility failed to immediately report a physical abuse allegation by Resident 1 against Certified Nursing Assistant (CNA 1) to facility's Administrator (ADM), California Department of Public Health (CDPH), Long Term Care (LTC) Ombudsman (an advocacy group for residents in skilled nursing facilities), and Police for over 24 hours. Resident 1 reported CNA 1 squeezed her right wrist hard causing bleeding and the bandage to come off an original skin tear. This failure resulted in delayed reporting of a physical abuse allegation by Resident 1 against CNA 1. Cross Reference F610 Findings: During a record review of Admission Record dated 5/20/22, the record indicated, Resident 1 was admitted to the facility on [DATE]. During a record review of Resident 1's Minimum Data Set (MDS- An assessment used to guide care) dated 04/13/22 indicated, Resident 1's Brief Interview for Mental Status (BIMS- cognition assessment) score was 13 out of 15, indicating intact cognitive function. During an observation and interview with Resident 1 on 5/20/22, at 8:10 a.m., Resident 1 stated, on 4/24/22 at lunch time she was in bed and had lunch menu in her right hand. CNA 1 grabbed menu from her, squeezed her wrist hard and bandage came off of her right wrist. Resident 1 stated, she had broken skin on her right wrist, and which started to bleed after the bandage came off. Resident 1 stated her skin tear hurt quite a bit after and it made her feel upset and angry. During an electronic record review of Resident 1's progress notes dated 4/24/22, at 1:07 p.m. completed by Licensed Vocational Nurse (LVN 1), progress notes indicated, at 12:45pm CNA 3 alerted that Resident 1 had skin tear on right arm. FR 1 alerted nurse that she had talked to mother and Resident 1 stated, when she was looking at food menu, CNA 1 pulled the paper menu and scratched her arm. Resident 1 also stated, she requested something from CNA 1, CNA 1 waived hand in air and walked away. Resident skin tear cleansed with normal saline, triple antibiotic applied and bandaged. During an interview with LVN 1 on 5/20/22, at 9:05 a.m., LVN 1 stated, around 1:00 p.m., on 4/24/22 FR 1 informed her CNA 1 had grabbed Resident 1's wrist and caused skin tear to open. LVN 1 stated, Resident 1's had an open skin tear a quarter sized skin flap and it was bleeding. LVN 1 stated, she cleansed the skin tear with saline and applied anti-biotic ointment and bandage. LVN 1 stated, CNA 1 stayed in facility until end of shift around 2:00 p.m. LVN 1 stated, she was not aware of requirement to immediately notify administrator, MD, CDPH or police after hearing about physical abuse. LVN 1 also stated, that she did not call police because she did not want to be a prosecutor. LVN 1 stated, that she completed a grievance form regarding the abuse allegation by Resident 1. During a review of the facility's document titled, SOC-341, dated 4/25/22, the document indicated, California Department of Public Health was notified at 4:11 p.m., via fax. SOC indicated facility notified law enforcement and Local Ombudsman. During an interview with the ADM on 5/20/22, at 9:45 a.m., the ADM stated, all facility employees were mandated reporters and it was not okay that LVN 1did not report the incident to police, LTC Ombudsman, CDPH right away. During a telephone interview with Director of Nursing (DON) on 5/20/22 at 9:55 a.m., the DON stated, she did not find out about Resident 1's alleged abuse allegation against CNA 1 until 4/25/22. The DON stated the facility must report physical abuse allegations within 2 hours. During a review of facility's Policy and Procedure (P&P) titled, Abuse Prohibition and Prevention Policy and Procedure and Reporting Reasonable Suspicion of a Crime in the Facility Policy and Procedure, revised on 3/2018, the P&P indicated, Reporting/Response . 1. Facility staff, owners, operators, managers, agents, and contractors are Mandatory reporters . 2.b. The facility will report allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property even if no reasonable suspicion .i. When: 1. Immediately- no later than 2 hours- all abuse (actual, alleged, or potential) OR results in serious bodily injury . 2.b. ii. To whom: 1. Facility Administrator, 2. State Survey Agency, 3.law Enforcement, 4. Ombudsman .

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), was free from a significant medication error when a prescribed anticoagulant (medication that helps prevent blood clots) was not administered for two days. This failure had the potential to result in Resident 1 developing a DVT (Deep Vein Thromboses - a blood clot in a deep vein, usually in the legs) causing pain, swelling and usually fatal if it becomes dislodged and travels to the lungs. Findings: During an interview on 8/17/21, at 1:43 p.m., with Family Member (FM), FM stated Resident 1's [MEDICATION(S)] (an anticoagulant medication) was stopped, but [MEDICATION(S)] (an anticoagulant medication) was not administered as ordered prior to a scheduled biopsy (the removal of tissue from the body). During an interview on 8/18/21, at 2:21 p.m., with the Assistant Director of Nursing (ADON), ADON stated Resident 1 had a pre-operative note from the physician to discontinue all anticoagulants one week prior to the biopsy. After a concern was raised from FM that Resident 1 was not receiving [MEDICATION(S)] as ordered, ADON clarified with the ordering provider and [MEDICATION(S)] was started. During a review of Resident 1's Progress Notes (PN), dated 6/18/21 at 12:43 p.m., by the Director of Nursing (DON), which indicated, New orders to d/c (discontinue) [MEDICATION(S)] and ASA (aspirin) 7 days prior to appointment. Start [MEDICATION(S)] on 6/21 BID (twice a day) 30 mg (milligram). Orders in place. During a review of Resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The first dose of [MEDICATION(S)] was administered on 6/23/21 at 0900 (9:00 a.m.).