Every finding on record at Morgan Hill Healthcare Center

Based on interview and record review, the facility failed to follow their discharge policy for one of three sampled residents (Resident 1) when Resident 1 was not allowed to return to the facility after a doctor's appointment. This failure had the potential to compromise Resident 1's health and safety.Review of Resident 1's clinical record titled, admission Record, dated 12/5/2025, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility), cerebrovascular disease (CVA-stroke, loss of blood flow to a part of the brain), hypertension (HTN-high blood pressure), other amnesia (loss of memories, including facts, information, and experiences), and alcohol dependence, uncomplicated (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking).Review of Resident 1's Nurses Progress Note dated 12/4/2025, indicated, Resident left facility without out on pass at 13:30 [1:30 PM]. Resident reported to this nurse that he had an appointment with a PCP [primary care physician] outside of the facility. Informed social services. Resident went out of facility without an order from MD [medical doctor].During an interview with the nurse practitioner (NP) on 12/5/2025 at 1:18 a.m., the NP confirmed she received a message from their group chat on 12/4/2025 at 6:37 p.m., it indicated, patient left AMA [against medical advice] around 2 p.m. NP further confirmed she did not respond to the message because it was already after hours. NP stated nurses should have notified the after hour on-call physician or NP.During a phone interview with licensed vocational nurse A (LVN A) on 12/5/2025 at 1:48 p.m., LVN A confirmed he was the nurse in the evening shift on 12/4/2025. LVN A stated their social services director (SSD) instructed them not to allow Resident 1 back to the facility, and to call 911 to accept him back to the facility. LVN A further stated, Resident 1 was in a cab when he came back around 6:00 p.m. on 12/4/2025, and he was on the phone talking to his sister. LVN A confirmed he did not ask Resident 1 to come back inside the facility, he did not call the DON and their doctor about the situation. LVN A further confirmed he just followed the SSD's instruction not to accept Resident 1 back to the facility and he went back inside the facility to continue with passing medications to his residents.During an interview with certified nursing assistant B (CNA B) on 12/5/2025 at 2:13 p.m., CNA B confirmed their SSD informed the evening staff that Resident 1 left AMA, she did not go to full details, and instructed them not to allow Resident 1 back to the facility. CNA B stated the SSD handed her the AMA form to provide to Resident 1 if he comes back. CNA B further stated, Resident 1 came back on the same day at around 5:30 p.m., she handed him the AMA form, and Resident 1 told her that he had nowhere to go. CNA B stated Resident 1 was upset, obviously in disbelief because he just went out to an eye doctor's appointment. CNA B further stated Resident 1's sister called the police, and the police called the paramedics to send Resident 1 to the hospital. CNA B confirmed Resident 1 was outside the facility for at least an hour.During an interview with the SSD on 12/5/2025 at 2:29 p.m., the SSD stated she overheard from staff that Resident 1 went out for an appointment. The SSD further stated, she checked her calendar and Resident 1's physician order and it indicated there was no doctor's appointment scheduled for the day and there was no order that Resident 1 could go out on pass. SSD stated she called her consultant, and she was advised that Resident 1 went AMA. SSD confirmed she initiated Resident 1's AMA form and she instructed the evening shift staff not to accept Resident 1 back to the facility. SSD further confirmed that there was no physician's order related to Resident 1's AMA discharge and she was just following the AMA situation.During a concurrent interview with the director of nursing (DON) and record review of Resident 1's nurses progress notes dated 12/4/2025, and order summary report on 12/5/2025 at 3:08 p.m., the DON confirmed there was no documentation that the doctor was notified about Resident 1's return and the SSD was the only one notified. The DON further confirmed there was no AMA order. The DON stated she was only notified in the morning of 12/5/2025 that Resident 1 came back and was brought to the hospital.During an interview with the administrator (ADM) on 12/5/2025 at 3:34 p.m., the ADM stated the nurse should have allowed Resident 1 back to the facility, did their assessment, and if Resident 1 needed to be transferred to the hospital, they should have called the doctor and transferred him as needed.Review of the emergency department's (ED) provider note dated 12/4/2025, indicated, 70 y.o. [year old] male.brought to the ED by EMS [emergency medical services] after patient was discharged from his nursing home - [name of the facility]. Reportedly patient has been a resident there for 4 months went to his scheduled ophthalmology [eye doctor] appointment and when he returned his belongings was collected into bags and he was told that he had left AGAINST MEDICAL ADVICE.Differential diagnosis: Abandonment.CLINICAL IMPRESSION: 1. Neurocognitive disorder 2. Suspected victim of abandonment in adulthood, initial encounter.During a review of the facility's undated policy and procedure titled, Against Medical Advice (AMA) Discharge Policy - Admissions, Transfers and Discharges, indicated, Residents, or their responsible party (RP), have the right to request discharge from the facility at any time including against medical advice (AMA). Such discharges are considered resident-initiated discharges and are distinct from facility-initiated discharges. The facility will honor this right while ensuring that required notifications and documentation are completed. Required Notifications.The attending physician or on-call provider must be notified immediately.Documentation: The assigned nurse or designee will document in the medical record: a. The resident's or RP's stated intent to leave AMA. b. Notification of the physician.

Based on observation, interview and record review, the facility had a medication error rate of 9.68%, when three medication errors out of 31 opportunities occurred during medication administrations for two of four residents (Residents 7 and 13) as follow: 1. Resident 7 missed to receive Gabapentin (medication used for nerve pain) and Docusate Sodium (DSS-stool softener used to treat and prevent constipation) during medication pass observation; and 2.Resident 13 was given Xarelto (Rivaroxaban - used to treat or prevents blood clots) 20 milligram (mg, metric unit of measurement) medication without meal. These deficient practices resulted in medications not being given in accordance with the prescriber's orders and/or manufacturer's specifications, which could have resulted in the residents not receiving the full therapeutic effects of the medications. Findings: 1. During a medication pass observation on 4/8/25, at 8:36 a.m., with Licensed Vocational Nurse (LVN) A, LVN A administered ten oral medications to Resident 7. A review of Resident 7's medication administration record indicated to give gabapentin oral capsule 100 mg, 1 capsule by mouth three times a day for type 2 diabetic mellitus(DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic Neuropathic Arthropathy(a progressive condition that causes the bones and joints in the foot to degenerate[deterioration of a tissue] at 9:00 a.m. and DSS Capsule 250 mg (Docusate Sodium) 1 capsule by mouth one time a day for constipation at 9:00 a.m. medication to be given. During a concurrent interview and record review with LVN A on 4/8/25, at 10:44 a.m., LVN A verified the order indicated to give gabapentin capsule and docusate sodium capsule at 9:00 a.m., it was missed to administer the two medications to Resident 7. LVN A stated I thought I gave it. During an interview with Pharmacy Consultant (PC) on 4/10/25 at 4:20 p.m., the PC stated if the medication is not given the nurse should have put what's the reason why. The PC further stated it's not ok for not giving the medication. 2. During a medication pass observation and interview with LVN C on 4/8//25 at 4:40 p.m., LVN C administered one medication to Resident 13, LVN C prepared Xarelto 20 mg tablet, on the blister pack written to give 1 tablet by mouth one time a day for blood clot prevention take with dinner. Review of facility mealtimes are as follow Dinner: 5:45 pm cart 1, 6:00 pm - Cart 2, and 6:15 pm - Cart 3. During a concurrent observation and interview with LVN C on 4/8/25 at 4:52 p.m., LVN C verified the order summary report of Xarelto oral tablet 20 mg to give one tablet by mouth a day for blood clot take with dinner. LVN C acknowledged the physician's order for Xarelto (Rivaroxaban) indicated to take with dinner. During an interview with Regional Nurse Consultant (RNC), on 4/10/25 at 10:10 a.m., the RNC stated the licensed nurse should have matched the medication administered and the medication ordered by the doctor. The RNC further stated its a triple check making sure following the right medication, right dose, right dosage. During an interview with Pharmacy Consultant (PC) on 4/10/25 at 4:20 p.m., the PC stated the medication Xarelto based on the guidelines it should be given with food in the evening. A reviewe of drug resource, DailyMed(https//dailymed.nlm.nih.gov/dailymed). If you take XARELTO for: Blood clots in the veins of your legs or lungs: For the 15 mg and 20 mg doses, take XARELTO with food at the same time each day. A review of the facility's policy titled, Medication Administration, dated 3/1/2023, indicated, Medication s are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .14. Administrated medication as ordered in accordance with manufacture specification a. Provide appropriate amount of food and fluid.

Based on observation, interview, and record review, the facility failed to ensure, kitchen equipment were sanitary and dishwashing chemicals and garbage containers were stored in accordance with professional standards for food safety when: 1. There were kitchen large pan trays and kitchen equipments that were unsanitary; and 2. Dishwashing chemicals and garbage containers in the kitchen were not stored safely and properly. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) or cross-contamination (transfer of harmful substances or disease-causing microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils which are not cleaned properly) and food contamination (unintended presence of potentially harmful substances) for the fifty-one residents who received foods from the facility kitchen. Findings: 1. During the initial kitchen tour observation with cook F (COOK F), on 4/7/25 at 9:05 a.m., there were brownish to blackish discoloration and rusty spots in their large tray pans and plate storage containers. During the interview with COOK F, who was also around during the initial kitchen tour observation, on 4/7/25 at 9:08 a.m., COOK F verified the unsanitary brownish to blackish discoloration and rusty spots in their large tray pans and plate storage containers and would inform the certified dietary supervisor (CDS) about them. During another kitchen observation on 4/9/25 at 10:30 a.m. to 10:35 a.m., there were stainless racks carrying the plastic pitchers, plastic containers for utensils, baking pans and large tray pans which had brownish to blackish discolorations and rusty spots in them. During the interview with COOK F on 4/9/25 at 10:37 a.m., COOK F verified the unsanitary stainless racks carrying the plastic pitchers, plastic containers for utensils, baking pans and large tray pans, that had brownish to blackish discolorations and rusty spots in them. During the interview with the certified dietary supervisor (CDS) on 4/9/25 at 10:38 a.m., CDS acknowledged those unsanitary stainless racks carrying the plastic pitchers, plastic containers for utensils, baking pans and large tray pans, that had brownish to blackish discolorations and rusty spots in them. CDS further acknowledged that they would replace those unsanitary stainless racks and kitchen equipment. 2. During the initial kitchen tour observation with COOK F on 4/7/25 at 8:55 a.m., the two containers of dishwashing chemicals and one garbage container were placed beside the plastic pitchers and plastic containers for utensils. During the interview with COOK F on 4/7/25 at 8:57 a.m., COOK F acknowledged that the dishwashing chemicals and garbage container should have not been placed beside the plastic pitchers and plastic containers for utensils, which they were still using currently for the residents. During the initial kitchen tour observation with COOK F on 4/7/25 at 9:00 a.m., three more containers of dishwashing chemicals and another garbage container were stored beside the flour, pancake flour and mashed potatoes flour. During the interview with COOK F on 4/7/25 at 9:03 a.m., COOK F acknowledged that the dishwashing chemicals and garbage container should have not been placed beside the flour, pancake flour and the mashed potatoes flour. During the interview with the registered dietitian (RD) on 4/9/25 at 3:18 p.m., RD verified the above findings: the unsanitary kitchen equipments and dishwashing chemicals and garbage containers in the kitchen were not stored safely and properly. RD further verified that she would follow up on these concerns and she would do in-services with the staffs. Review of the facility's policy and procedure titled, Sanitization, revised November 2022, indicated, The food service area is maintained in a clean and sanitary manner kitchen areas are kept clean, free from garbage and debris, and protected from rodents and insects. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions that may affect their use or proper cleaning Review of the undated facility's policy and procedure titled, Poisonous and Toxic Materials, indicated, Poisonous and toxic materials shall be stored in areas away from the food service area poisonous and toxic materials will be stored on shelves that are used for no other purpose, or stored in a place outside the food storage, food preparation, and cleaned equipment and utensil storage areas

Based on observation, interview, and record review, the facility failed to ensure the controlled substance (drugs with high potential for abuse or addiction) medications were fully accounted for on the medication administration record (MAR) to indicate they were given for three out of six residents (Residents 13, 39, and 49) showed that medications were signed out of the Antibiotic or Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications). This failure had the potential for access to medications and supplies by unauthorized persons such as residents and visitors. Findings: 1. The CDRs for six (6) random residents receiving PRN (meaning as needed) controlled medications were requested for review during the survey. a. A review of Resident 13's MAR indicated to give Butalb-APAP-CAFF (Butalbital -Acetaminophen -Caffeine (used to treat tension headaches) 50-325-40 MG (milligram, unit of dose of measurement) 1 tablet by mouth every 4 hours as needed for severe migraines 7-10 with start date of 9/18/24. During a concurrent interview and record review with the Regional Nurse Consultant (RNC) on 4/10/25 at 9:42 a.m., review of Resident 13's CDR for Butalb-APAP-CAFF and the January and March 2025 MAR reflected the nursing staff signed out of the CDR (meaning they removed the medication from the locked controlled medication compartment in the medication cart) but did not document the respective administration on the MAR on 1/2/25 at 20:36 p.m., and 3/14/25 at 9:29 a.m., and 3/21/25 at 12:24 p.m. The RNC verified this finding and acknowledged three (3) tablets of Butalb-APAP-CAFF was not accounted for all the dates the medication was given in the MAR. b. Resident 39's had a physician's order, dated 4/3/25 for Hydrocodone- Acetaminophen (used to manage pain) Oral Tablet 5 -325 MG every 6 hours as needed for pain management Administer for pain (5-7). During a concurrent interview and record review with the RNC on 4/10/25 at 9:55 a.m., review of Resident 39's CDR for Hydrocodone- Acetaminophen Oral Tablet 5 -325 MG and the 3/2025 MAR reflected the nursing staff signed out in the CDR but did not document the respective administration on the MAR on 4/4/25 at 20:30 p.m. The RNC verified this finding and acknowledged one Hydrocodone- Acetaminophen tablet was not accounted c. A review of Resident 49's MAR indicated to give Tramadol (a controlled medication for pain) HCL Oral Tablet 50 MG by mouth every 6 hours as needed for pain During a concurrent interview and record review with the RNC on 4/10/25 at 10:00 a.m., review of Resident 49's CDR for Tramadol HCL and the 3/2025 MAR reflected the nursing staff signed out of the CDR but did not document the respective administration on the MAR on 4/5/25 at 10:56 a.m., and 4/5/25 at 20:09 p.m. The RNC verified this finding and acknowledged two (2) Tramadol HCL tablet were not accounted. During an interview with the RNC on 4/10/24 at 10:07 a.m., RNC further stated narcotics medication should have been accounted for by the nursing staff both in MAR and the CDR because of diversion. During an interview with Pharmacy Consultant (PC) on 4/10/25 at 4:30 p.m., PC stated medication should have been documented in both papers and MAR to avoid diversion of medication. Review of the facility's policy titled Controlled Substance Administration &Accountability, dated 5/1/23, indicated, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion or accidental exposure. General Protocols' all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug record, or other facility specified form and placed in the patient's medical record.

Based on observation, interview, and record review, the facility failed to ensure, provision of care and services related to pressure ulcers were consistent with professional standards of practice for one of 14 sampled residents (Resident 22), when there were no proper description and measurements of the pressure ulcer of Resident 22 in her weekly wound assessments. These failures had the potential for the residents with pressure ulcers, not being properly monitored and treated which could delay the healing or worsen the wound. Findings: During the observation of Resident 22 on 4/7/25 at 12:46 p.m., Resident 22 was in her bed, eating lunch. She needed total assistance with feeding. Resident was calm, comfortable and able to answer questions. Review of Resident 22's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident), indicated, Resident 22 was admitted to the facility on [DATE] with diagnoses including chronic systolic congestive heart failure (progressive syndrome where the left ventricle loses the ability to contract normally), stage 4 pressure ulcer (most serious pressure ulcer, extending below the subcutaneous fat into the deep tissues, including muscle, tendons, ligaments and even as far down as the cartilage or bone) of the sacral region or sacrum (at the bottom of the spine and lies between the fifth segment of the lumbar spine and the coccyx or tailbone) and functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord). Review of Resident 22's clinical records indicated, Resident 22 had chronic (persistent), non-healing stage 4 pressure ulcer to sacrum that was present upon admission. Review of Resident 22's nursing weekly wound assessments indicated, Resident 22 did not have proper description and measurements of her pressure ulcer in the sacral region, in Resident 22's nursing weekly wound assessments on 2/10/25, 2/17/25, 2/24/25, 3/3/25, 3/10/25, 3/17/25, 3/24/25 and 3/31/25. During the concurrent review of Resident 22's weekly wound assessments and interviews with licensed vocational nurse supervisor E (LVNS E) and licensed vocational nurse B (LVN B) on 4/10/25 at 1:30 p.m., both, LVNS E and LVN B acknowledged that there were no proper description of the pressure ulcer in the sacral region of Resident 22, including the measurements, color, drainage, odor and whether it's painful, in Resident 22's nursing weekly wound assessments on 2/10/25, 2/17/25, 2/24/25, 3/3/25, 3/10/25, 3/17/25, 3/24/25 and 3/31/25. During the interview with the regional nurse consultant (RNC), on 4/11/25 at 11:50 a.m., RNC verified that nurses should have proper documentation for weekly wound assessments. RNC also stated nurses should have documented properly, the description of the pressure ulcer which includes the measurement, color, drainage, odor and pain assessment of the pressure ulcer to promote wound healing. Review of the facility's policy and procedure titled, Skin Assessment and Documentation Policy, implemented on 6/1/24 indicated, It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. This policy includes the documentation guidelines skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter Documentation of skin assessment: document observations, type and or description of wound, describe wound measurements, color, type of tissue in wound bed, drainage, odor and pain, document if resident refused assessment and other information as indicated or appropriate.

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medication for one of one medication storage room and one of two medication carts, when: 1. Three blister pack of Buspirone HCL (used to treat anxiety disorder) 5 milligram (mg-unit of dose measurement) has expired on 2/2/25; 2. Two vials of tuberculin purified protein (Aplisol- a sterile aqueous solution of purified protein fraction for intradermal administration used in the diagnoses of tuberculosis) with no open date written on the vial; 3. A bottle of Latanoprost 0.005% (used to treat glaucoma [a condition in which increased pressure in the eye can lead to gradual loss of vision]) eye drop with expiration date of 4/7/25; 4. A bottle of Ciprofloxacin 0.3 % (used to treat infections of the eye) eye drop with no open date written on the bottle; 5. One vial of unopened Humulin R (a short acting, human-made injection that helps manage blood sugar levels in people with diabetes) was not refrigerated; 6. Oral medication and eye drop bottles were stored in one drawer in the medication cart; 7. One drawer in medication cart were not clean and sticky substance (material with particular features); and 8. Discontinued medications were stored in one of two medication carts. These deficient practices had a potential for residents to receive medications with reduced potency from expired medications, and /or medication error due to medications not being labeled. Findings: 1. During an inspection of medication cart AA and interview with Licensed Vocational Nurse (LVN) B on 4/9/25 at 11:25 a.m., a blister pack of Buspirone HCL was found in the medication cart AA that has expired on 2/2/25. LVN B confirmed the medication has expired and should have been discarded medication. During an interview with the Pharmacy Consultant (PC) on 4/10/25 at 2:32 p.m., the PC stated discontinued medication should be taken away in the active medication to prevent medication error. 2. During an inspection of medication refrigerator in the medication storage room with Minimum Data Set Consultant (MDSC) on 4/9/25 at 10:41 a.m., has identified two open vials of Tuberculin Purified Derivatives was identified without an open date. The MDSC confirmed that the two vials of tuberculin was not dated. Review of the facility's policy titled Labeling of Medications and Biologicals, dated 2/1/24, indicated All medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. 8. Labels for multi-used vials must include: The date the vials was initially opened or accessed(needle-puncture). 3. During a concurrent inspection of medication cart AA and interview with LVN B on 4/09/25 at 11:52 a.m., a bottle of latanoprost 0.005% of eye drop was identified open with expiration date of 4/7/25. LVN B verified the medication has expired. 4. During an inspection of medication cart AA and interview with LVN B on 4/09/25 at 11:54 a.m., a bottle of Ciprofloxacin 0.3 % eye drops was identified with no open date. LVN B confirmed the bottle of eye drop has no open date. LVN B further stated it should have a date to avoid giving expired medications. During an interview with the Regional Nurse Consultant (RNC) on 4/10/25 at 10:20 a.m., the RNC stated open date should have been written on the medication bottles of the to make sure the efficacy (the ability to produce a desired or intended result) of the medications. 5. During an inspection of medication cart AA and interview with LVN B on 4/9/25 at 11:46 a.m., it was identified a vial of Humulin R that was unopened and not refrigerated. LVN B confirmed the unopened vial of Humulin R should have been refrigerated. Review of the facility's policy titled Medication Storage, dated 3/1/23, indicated, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medication rooms according to the manufacturer's recommendation s and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.6. Refrigerate Products: a. All medications requiring refrigeration's are stored in refrigerators located in the pharmacy and at each medication room. 6.During an inspection medication cart AA and interview with LVN B on 4/9/25 at 11:56 a.m., it was identified that oral medication and eye drop were stored in one drawer. LVN B confirmed the medications were stored in one drawer and it should have been separated accordingly. During interview with RNC on 4/10/25 at 10:24 a.m., RNC stated the oral medication should have been separated from eye drop to avoid mix up. Review of the facility's policy titled Medication Storage, dated 3/1/23, indicated, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medication rooms according to the manufacturer's recommendation s and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. 4.Internal Products: Medications to be administered by mouth are stored separately from other formulations (i.e., eye drops, ear drops, injectables). 7. During an inspection of medication cart AA and interview with LVN B on 4/9/25 at 12:01 p.m., one drawer in the medication cart was found not clean with sticky substance. LVN B confirmed the bottom part of the medication cart drawer was sticky and not clean, she further stated it was because of the medication. During an interview with the RNC on 4/10/25 at 10:25 a.m., the RNC stated the nurse should have maintained the medication cart clean. 8.During an inspection of medication cart BB and interview with LVN D on 4/9/25 at 4:07 p.m., discontinued medication of residents were stored in the medication cart. LVN D confirmed the medications were discontinued and should been given to the Director of Nursing (DON). During an interview with the covering DON on 4/9/25 at 4:30 p.m., the DON stated discontinued medication will be collected for destruction. The DON further stated it should have been stored in a lock cabinet. During an interview with the RNC on 4/10/25 at 10:43 a.m., the RNC stated once the medication was discontinued, it should have been removed from the cart. NC further stated the nurse should give the discontinued medication to the DON. During an interview with the PC on 4/10/25 at 2:23p.m., the PC stated no discontinued medication should have been kept in the medication cart. The PC further stated it should have been separated to active medication to prevent medication administration error. Review of the facility's policy and procedure(P&P) titled Medication Storage , dated 3/1/2023, the policy indicated, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and /or medication rooms according to the manufacturer's recommendation and sufficient to ensure proper sanitation , temperature , light, ventilation , moisture control , segregation , and security .8.Unused Medications: the pharmacy and all medication room are routinely inspected by the consultant pharmacist for discontinued , outdated , defective , or deteriorated medications with worn, illegible , or missing labels . These medications are destroyed in accordance with our destruction Unused Drugs policy.

Based on observation, interview and record review, the facility failed to ensure the food recipes for making puree (smooth, crushed or blended food that's made by breaking down solid foods into a creamy paste or liquid) were being followed when the cook did not follow the recipes for making pureed baked beans and deluxe coleslaw. These failures had the potential to lead in decreased food palatability that could decrease the food consumed by residents which could lower the nutrient intakes for the eight residents on puree diet order out of fifty-one facility residents. Findings: 1. During the puree making observation with cook F (COOK F) on 4/9/25 at 11:15 a.m., COOK F was making puree baked beans. COOK F put 36 ounces (oz, a unit of measurement for weight) of baked beans, good for the 8 residents on puree diet, plus 1 extra serving, into the robot coupe machine (used for making puree foods), then pureed the baked beans. She added 2 teaspoons of thickener and set it aside after in the container with desired temperature. Review of the facility's undated recipe titled, Baked Beans: Puree, it stated, Place portions needed into a food processor, process until smooth, reheat to 165 degrees Fahrenheit (F, a unit of temperature measurement) and serve. The recipe did not mention to add thickener in the puree baked beans. 2. During another pureed making observation with COOK F on 4/9/25 at 11:37 a.m., COOK F was making pureed deluxe coleslaw. COOK F put 36 ounces of deluxe coleslaw, good for the 8 residents on puree diet, plus 1 extra serving, into the robot coupe machine, then pureed the deluxe coleslaw. She added 1 teaspoon of thickener and set it aside after in the container with desired temperature. Review of the facility's undated recipe titled, Deluxe Coleslaw: Puree, it stated, Serve pureed cooked vegetable of your choosing. There was no mention of adding thickener. During the concurrent review of the recipe for making puree baked beans and puree deluxe coleslaw and interview with COOK F on 4/10/25 at 10:45 a.m., COOK F acknowledged that the recipe for making puree baked beans and puree deluxe coleslaw were not followed and stated that she would check on those recipes and would follow them next time. During the concurrent review of the recipe for making puree baked beans and puree deluxe coleslaw and interview with the certified dietary supervisor (CDS), on 4/9/25 at 3:25 p.m., CDS verified that the recipe for making puree baked beans and puree deluxe coleslaw were not followed and stated that he would check on the recipes and would follow up on those concerns. During an interview with the registered dietitian (RD), on 4/9/25 at 3:18 p.m., RD verified that the cook should have followed the recipe and not adding thickener when making puree baked beans and puree deluxe coleslaw. Review of the facility's policy and procedures titled, Food Preparation Guidelines, implemented on 3/1/2023 indicated, It is the policy of this facility to prepare foods in a manner to preserve or enhance a resident's nutrition and hydration status The cook or designee, shall prepare menu items following the facility's written menus and standardized recipes

Based on observation, interview, and record review, the facility failed to implement infection control measures when one out of 14 sampled Residents (Resident 6's) nasal cannula was not replaced in a timely manner. Findings: During an observation on 4/7/25 at 9:18 a.m., Resident 6's nasal cannula (NC, flexible tubing inserted into the nostrils and attached to an oxygen [a colorless and odorless gas that people need to breathe] tubing was dated 3/25/25. Review of Resident 6's Order Summary Report dated 5/10/24, indicated, Change and date nasal cannula tubing every Thursday if actively in use one time a day every Tue. During a concurrent observation and interview on 4/7/25 at 1:15 p.m., with the License Vocational Nurse (LVN) A, LVN A confirmed the nasal cannula was dated 3/25/25. LVN A further stated NC should had been changed every week to prevent infection, it's a weekly change of NC. Review of the facility's policy and procedure(P&P) titled Oxygen Administration, dated 5/1/23, the P&P indicated, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goal and preferences. 5 .Other infection control measures include b. Change oxygen tubing and mask /cannula weekly and as needed if it became soiled or contaminated.

Based on observation, interview and record review, the facility failed to ensure multiple rooms had at least 80 square feet per resident. Having less than 80 square feet per resident had the potential to compromise the care and services the residents receive. Findings: During the initial pool observation on 4/7/2025 at 9:35 a.m., the following was observed: Room Beds Sq.ft./Room Sq.Ft./Resident 1 3 224.28 74.76 2 3 194.67 64.89 3 3 194.67 64.89 6 3 194.67 64.89 7 3 194.67 64.89 12 3 189.03 63.01 14 2 140.52 70.26 15 2 146.46 73.23 During multiple observations and staff and resident interview during survey, there were no care issues identified regarding the size of the rooms. Recommended continuance of the room waiver.

Based on observation, interview and record review, the facility failed to ensure treatment and care provided were in accordance with professional standards of practice when vital signs monitoring was not done for one (Resident 1) out of two sampled residents. This failure resulted in unrecognized decline of Resident 1's physical and mental status that led to hospitalization . Findings: The clinical records of Patient 1 was reviewed. She was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (a movement disorder of the nervous system that worsens over time) without Dyskinesia (involuntary movements), Spinal Stenosis, cervical region (spinal canal in the neck narrows, compressing the spinal cord and nerves), psychotic disorder (mental disorder characterized by disconnection from reality) with hallucinations (a perception of having seen, heard, touched, tasted or smelled someting that wasn't actally there). A review of Resident 1's Progress Notes dated 10/16/24 at 07:50 a.m. by Licensed Vocational Nurse (LVN) A indicated, Received report from pm [afternoon] shift that this resident didn't eat dinner and didn't drink anything. So monitor her the whole shift. VS [vital signs] at 0100 .able to open eyes when called. At 0300 resident not responding but with shallow breathing .Called 911 . A review of Resident 1's hospital records dated 10/16/24 and timed 12:00 a.m. by Medical Doctor (MD) B, indicated, Critical Care Consultation And ICU Admitting Note: History of Present of Present Illness: .The patient has 24 hour assistant. She is fed by staff .was brought in from nursing facility by ambulance with chief complaint concern for altered mental status. The patient is nonverbal in the ER [emergency room ] with decreased level of consciousness .Hypotensive with blood pressure 80/50 .The patient will be admitted to ICU [Intensive Care Unit] with: 1. Septic Shock . 2. Urinary tract infection, possible cystitis [inflammation of the bladder] . During an interview on 1/15/25 at 12:51 p.m. with LVN C, LVN C stated that Resident 1 was non-verbal, needed assistance and someone had to feed her. During an interview on 1/15/25 at 1:03 p.m. with LVN D, LVN D stated that Resident 1 was totally dependent, needed to be fed and only on rare occasions would answer staff. A review of Resident 1's Vital Signs Monitoring record indicated that Blood Pressure (BP) and Heart Rate (HR) were checked six times in September 2024 (September 3rd, 7th, 14th, 21stand 28th) and four times in October 2024 (October 5th, 10th, 12th and 16th). BP and HR were monitored and recorded twice on September 3rd. During a concurrent interview and record review on 1/15/25 at 2:13 p.m. with the Director of Nursing (DON), the DON verified that vital signs were not consistently checked for Resident 1 for the month of October 2024. The DON verified that prior to Resident 1's transfer to the hospital on 10/16/24, the previous vital signs documented were dated 10/12/24, four days prior to Resident 1's change in condition on 10/16/24. The DON stated that vital signs monitoring is done according to the physician's order. The DON verified there was no physician order for Resident 1's vital signs monitoring. A review of Resident 1's physician ordered dated 5/15/23, indicated, I certify that Skilled Nursing Services are required on an inpatient basis. A review of facility's policy and procedure (P&P) titled Vital Signs implemented on 6/12/24, the P&P indicated, .3. Vital Signs shall be obtained at least in the following circumstances: c. Daily or as often as ordered by physician for a resident receiving skilled services .

Based on observations, interviews, and record reviews, the facility failed to ensure appropriate and timely treatment and care was provided to one of three sampled Residents (Resident 1) when Resident 1 was only seen by a hand surgeon 33 days from the date of the Physician's order for the referral for possible osteomyelitis (inflammation or swelling that occurs in the bone caused by infection). This failure resulted in Resident 1's left middle finger amputation (surgical removal of a body part) and hospitalization that put Resident 1 at risk for sepsis (a life-threatening complication of an infection). Findings: The clinical records of Resident 1 were reviewed. Resident 1 was originally admitted to the facility on [DATE], readmitted on [DATE] with diagnoses including Other Paralytic Syndrome following unspecified cerebrovascular disease, bilateral (a condition that occurs when a stroke causes loss of muscle movement, or paralysis); chronic obstructive pulmonary disease (COPD, group of lung diseases that block airflow and make it difficult to breathe), diabetes mellitus (too much sugar in the blood), reduced mobility, anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations) and, major depressive disorder (a serious mood disorder that involves a persistent feeling of sadness and loss of interest in activities). Review of Resident 1's Brief Interview for Mental Status (BIMS, (BIMS - an assessment to test a person's cognition level, a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact] dated 9/3/2024, no BIMS score was indicated as this part was not filled out. Review of Resident 1's Interfacility Transfer Report from the acute hospital dated 9/18/2024, indicated, . Nursing Documentation: Behavior: calm cooperative, . Level of Consciousness: alert, Orientation: oriented x 4, Speech: Spontaneous, Mood: Calm During a concurrent observation and interview in Resident 1's room on 11/1/24 at 3:05 p.m. with Resident 1, Resident 1 stated her left-hand hurts when pressed or moved. Resident 1's left-hand had four fingers (thumb, index finger, ring finger, and little finger). A review of Resident 1's progress notes dated 8/1/24 timed 7:30 p.m. by Licensed vocational Nurse (LVN) A indicated, Resident out to appointment accompanied by social services . A review of Resident 1's documents entitled Patient Instructions from the Wound Care Doctor (WCD) dated 8/1/24 indicated, .your left 3rd finger was assessed. You have refused to sign consent for debridement [the process of cleaning a wound and removing any dead tissue]. The document also indicated that WCD recommended Resident 1 to see a hand specialist. The document indicated the name of the Hand Surgeon (HS) and his number. A review of Resident 1's progress notes dated 8/1/24 timed 12:17 p.m. by LVN B indicated, Received orders . for resident to see a hand surgeon .social services aware of referral . A review of Resident 1's X-ray (a photographic or digital image of the internal composition of something, especially a part of the body) of Fingers or Thumb Left dated 8/1/24 indicated, Conclusion: 1. Prominent (obvious) soft tissue (connect, support, and surround the different body organs) swelling tip 3rd finger with large area of ulceration (open sore or wound on the skin) and subjacent (below) bony destruction of the 3rd distal phalanx (the distal or third of the three bones in each finger when counting from the hand to the tip of the finger) from the tuft [tip] of mid shaft [principal part of a long bone] is concerning for underlying soft tissue infection and associated osteomyelitis. A review of Resident 1's progress notes dated 8/9/24 and electronically signed at 9:36 a.m. by Medical Doctor (MD) C indicated, History of Present Illness .Has been seen by wound care who also recommend pt [patient] be seen by hand surgery for further intervention. She completed 6-week course of terbinafine [medication for fungal infections] without any improvement .Plan .pt has completed course of terbinafine without any significant improvement in infection and infection appears to be spreading on hands .Insurance auth [authorization] pending for hand surg [surgeon] consultation . A review of Resident 1's progress notes dated 8/14/24 timed 12:05 p.m. by Social Services Assistant (SSA) indicated, Contacted .hand surgeon's office to schedule appointment for patient. No answer. Left message requesting call back to schedule appointment. No other concerns. A review of Resident 1's progress notes dated 9/3/24 by MD C indicated, Pt has ongoing pain over l. [left] middle finger w [with] some slight bleeding now noted. Pt has appointment w hand surg [surgeon] today .pt states she is amenable to going to the appointment .Plan Hand surg appt [appointment] today .per update from staff later in the day, hand surg recommends pt be taken immediately to ED [emergency department] as she likely has underlying osteomyelitis and may need further amputation of the digit [finger] . A review of Resident 1's progress notes dated 9/3/24 timed 2:57 p.m. by the Director of Nursing (DON) indicated, DON received call from hand surgeon visiting with patient during call while patient is out at the appointment. And surgeon gave verbal recommendations that patient be transferred to ED [emergency department] for further evaluation and treatment for possible finger infection . A review of Resident 1's Last General Surgery Note dated 9/3/24 2:00 PM by HS indicated, . Subjective: . female presents with 3-month history of progressive gross (growth?) along the right (typo, meant left) hand that are tender and painful and associated with skin discoloration and ulceration. There is also associated bony destruction of the third distal phalanx which was noted on 8/1/2024 x-ray at her local hospital. She unfortunately did not receive treatment despite the fact there was concern for soft tissue infection and osteomyelitis. As such the infection has progressed. Patient is coming from SNF. She has not undergone MRI to confirm the diagnosis of osteomyelitis. Assessment .In summary, . female with left distal hand infection predominantly involving the long digit but also involving the adjacent digits at the level of the nail. It appears it could be fungal in nature; however, viral and bacterial etiologies are also suspected at this time. Given the finding of potential osteomyelitis on x-ray, there has been a large delay in care since 8/1/2024, that needs to be rectified immediately. I strongly have urged the patient to present to the hospital at this time. She needs infectious disease consultation [IDC, is a conversation between a physician and an infectious disease specialist about a patient or clinical question], MRI [Magnetic Resonance Imaging, a medical imaging technique that uses radio waves to generate detailed pictures of the inside of the body] with conscious sedation [a drug-induced state that helps patients feel relaxed and comfortable during medical or dental procedures while remaining awake and responsive] and consideration for long-term IV antibiotic therapy [a treatment that involves administering antibiotics directly into a vein to fight bacterial infection]. 1. Infection of left hand . Plan: - Recommend patient presents to the emergency room at this time for admission to medicine. - Recommend infectious disease consultation to identify etiology. - Recommend MRI with conscious sedation to rule out osteomyelitis, and if positive, needs 6 weeks of IV antibiotics. A review of Resident 1's progress notes dated 9/3/24 and timed 5:56 p.m. by LVN D indicated, Resident left facility for hospital with ambulance . A review of Resident 1's progress notes dated 9/18/24 and timed 11:22 p.m. by LVN E indicated, Resident arrived [at the facility] at 1930 [7:30 p.m.] .via ambulance . Amputation to left middle finger . A review of Resident 1's Physician Discharge Summary from the hospital with date of service 9/18/2024 indicated, admitted : 9/3/2024 . discharge date : 9/18/2024 .Hospital Problems: . Left 2nd and 3rd distal phalanx [bone at the tip of fingers] infection with osteomyelitis . s/p [status post, a state after an event or procedure] closing wedge osteotomy [a surgical procedure that realigns a bone by removing or opening a wedge of bone]. Left long finger ray amputation [a surgical procedure that removes a finger or toe along with the corresponding bone in the hand or foot] .9/9 [9/9/24] . A review of Resident 1's hospitalization records dated 9/18/24 indicated, XR [x-ray] Hand Left Result date: 9/3/2024 .Impression: Osteomyelitis of the distal phalanx (the third and final bone in each finger, counting from the hand to the fingertip) of the second and third digit [finger] . During a concurrent interview of the Social Services Assistant (SSA) on 11/1/24 at 1:30 p.m., the SSA reviewed Resident 1's progress notes and stated she is responsible for processing residents' referrals to consultant doctors. SSA confirmed she accompanied Resident 1 on her appointment with WCD on 8/1/24 and was aware of WCD's order for referral to a HS. SSA stated she cannot recall the date and time and did not document on Resident 1's chart when she called to schedule an appointment for Resident 1 to see the Hand Surgeon (HS). SSA stated it is a must to document anything done for the resident. SSA stated she should have documented on Resident 1's chart when she received the appointment scheduled for 9/3/24. SSA was not able to present any log or report sheet for social services for tracking finished and pending workload such as residents' referrals to consultant doctors. SSA stated she used a personal notebook to keep track of her work. SSA verified Resident 1's Insurance Authorization Letter for the HS was dated 8/5/24. SSA stated she did not inform Resident 1's primary care doctors that Resident 1 was scheduled to be seen by the HS on 9/3/24. SSA stated she did not ask Resident 1's primary care doctors if there was a need to look for another surgeon with an earlier available schedule. SSA stated she should have informed Resident 1's doctors of the appointment for 9/3/24 to see the HS. During a concurrent interview and record review on 11/1/24 at 2:25 p.m. with the DON, the DON stated he cannot recall the date when he became aware of Resident 1's referral to the HS. The DON stated he knew that SSA was taking care of the referral and did not ask SSA about an update. The DON verified Resident 1's Insurance Authorization Letter for referral to HS was dated 8/5/24. The DON verified on Resident 1's progress notes that there were Interdisciplinary Team Meetings (IDT) done on 8/16/24 for Weight Gain and on 8/29/24 for Open Area to Right Buttock. The DON verified that in both IDTs, the DON was present and Resident 1's pending referral to the HS was not discussed. The DON stated there was a delay for the HS appointment if the referral was made on 8/1/24 and was scheduled on 9/3/24. The DON stated he should have asked SSA what was the cause of the delay. During a telephone interview on 11/5/24 at 12:50 p.m. with the hand surgeon (HS), the HS stated, I can strongly say that the amputation of the finger would have been prevented if she was seen and checked earlier. The HS stated he thought of elderly abuse and negligence when he saw Resident 1's condition. The HS also stated that Resident 1 had MDRO (multidrug-resistant organisms, bacteria that are resistant to more than one antibiotic). The HS stated, I also ran her situation with three other surgeons and all of us were shocked. The HS also stated that the worst that could happen was sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection or injury) and that could be fatal. During a telephone interview on 11/7/24 at 10:09 a.m. with the WCD, the WCD stated there was nothing acute (urgent) when he saw Resident 1 on 8/1/24 in his clinic. The WCD confirmed he ordered an x-ray of the left hand and a referral to a hand surgeon for Resident 1 on 8/1/24. The WCD stated that there was a delay if it was a month before Resident 1 was seen by the HS after the referral to the HS was ordered. During a telephone interview on 11/7/24 at 3:51 p.m. with MD C, MD C stated that she noted external growth on Resident 1's middle finger and it was progressing quite extensively. MD C stated she was never informed that x-ray of the left hand was done for Resident 1 on 8/1/24 and its result. MD C also stated that if she was informed of the result of the x-ray, she would have immediately sent Resident 1 to the emergency department. MD C stated she was not informed when Resident 1's insurance approved the referral to see the HS. MD C also stated that the facility was supposed to inform her when a referral to a consultant doctor was approved by the insurance. MD C stated that on 9/3/24, she visited Resident 1 in the facility, and she was informed of Resident 1's appointment to see the HS on the same day. MD C also stated that if she was informed after the insurance authorized the referral to HS that the appointment was to be on 9/3/24, she would have asked for another surgeon with an earlier available date and she would have ordered a CT scan (a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) of the left hand at least. A review of facility's policy and procedure (P&P) entitled Abuse and Neglect- Clinical Protocol revised July 2017, the P&P indicated, Assessment and Recognition .The nurse will assess the individual and document related findings. Assessment date will include: .j. All active diagnoses; and k. Any recent labs. 2. The nurse will report findings to the physician. As needed, the physician will assess the resident/patient to verify or clarify such findings, especially if the cause or source of the problem is unclear .5. Along with other staff and management, the physician will help identify situations that might constitute or could be construed as neglect . A review of facility's policy and procedure (P&P) entitled Referrals, Social Services Policy dated 7/1/24, the P&P indicated, .3. Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician. 4. Social services will document the referral in the resident's medical record .

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. There were opened and undated food items in the reach-in refrigerator; 2. There was a dented can on the food preparation table; 3. The kitchen staff were not following their policy for checking dishwasher temperature and sanitizing frequency. These failures had the potential to cause food contamination and food-borne illness to 45 of 45 residents who received their food from the kitchen. Findings: 1. During an initial kitchen tour on 12/4/23 at 8:15 a.m., accompanied by the dietary aide B (DA B), in the reach-in refrigerator there was an opened undated 46 fluid ounce container of prune juice and an opened undated 32 fluid ounce container of soy milk. DA B confirmed the 2 items were opened and not dated, and stated all items should be dated when opened. DA B stated the prune juice and the soy milk must be discarded. Review of the facility's undated policy and procedure manual titled Recommended Storage Practices, indicated . C. Refrigerated . Label all cooked and opened items with open and use by dates. 2. During a kitchen observation on 12/4/23 at 8:30 a.m., DA B was observed putting sweet potatoes from a can into a large metal pan on the preparation table. There were 3 cans on the preparation table, one of the cans was dented. When the DA B opened the dented can, she was asked if she should be using the sweet potatoes from the dented can. The DA B confirmed the can was dented and stated it was not good to use. The DA B said the dented can of sweet potatoes must be discarded. Review of the facility's undated policy and procedure manual titled Recommended Storage Practices, indicated . Leaking, dented, or rusty cans should be disposed of promptly to prevent contamination. 3. During a record review and concurrent interview on 12/6/23 at 9:30 a.m., with the dietary supervisor (DS), he was asked how frequently the kitchen staff checked the temperature and the sanitizing solution of the dishwasher. The DS stated the dishwasher was a low temperature machine and the staff checked the temperature during the wash and rinse cycles every morning. The DS also stated the chlorine sanitizer check was also done at the same time every morning. The DS produced the kitchen logs that indicated these functions were performed once every day. The policy and procedure manual was reviewed with the DS, which indicated the dishwashing temperature and sanitizer level are to be checked three times a day. The DS stated he was unaware of this requirement and stated has always directed his staff to only check it once a day in the morning. Review of the facility's undated policy and procedure manual titled Guidelines for the Food and Nutrition Service Department, indicated . C. Dishwashing Temperatures - Required Records .The temperature of the dish machines will be recorded three times a day . Temperatures will be recorded for each meal's dish washing . The sanitizer will also be checked and recorded.

Based on observation, interview and record review, the facility failed to implement infection control practices when: 1. Certified nursing assistant D (CNA D) did not perform hand hygiene when assisting two residents (Residents 16 and 24) with meals; 2. Licensed vocational nurse A (LVN A) did not perform hand hygiene in between glove changes during Resident 47's wound treatment; 3. Certified nursing assistant G (CNA G) practiced double gloving (wearing of inner and outer gloves) during Resident 47's incontinent care; and 4. Resident 10's urinary drainage bag was found lying on the floor. These failures had the potential to compromise resident's health and safety in the facility. Findings: 1. During dining observation on 12/4/2023 at 12:39 p.m., inside the dining room, Resident 24 was eating lunch using her fork. CNA D held Resident 24's fork and knife to help slice the meat on her plate. After assisting Resident 24, CNA continued feeding Resident 16 using his spoon. CNA D did not perform hand hygiene after assisting Resident 24. During an interview with CNA D on 12/4/2023 at 12:45 p.m., CNA D confirmed she forgot to perform hand hygiene after helping Resident 24 in slicing the meat on her plate. CNA D stated she should have performed hand hygiene before she assisted Resident 16. During an interview with infection preventionist (IP) nurse on 12/7/2023 at 3:59 p.m., IP agreed CNA D should have performed hand hygiene in between resident's meal assistance. During a review of the facility's policy and procedure titled, Hand Hygiene, dated 7/1/2023, indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, resident, and visitors. Review of the Centers for Disease Control and Prevention's (CDC) Hand Hygiene in Healthcare Settings, it indicated, Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient .after touching a patient or patient's immediate environment. 2. During wound treatment observation on 12/7/2023 at 9:05 a.m., LVN A showed both sacrum ((part of the body located in between the bilateral buttocks) and right ischial (lower part of the buttocks) wounds of Resident 47. LVN A removed his dirty pair of gloves and donned (put on) a new pair without performing hand hygiene. LVN A cleansed the sacrum wound, touched a box of gloves, and doffed (removed) his dirty gloves. LVN A donned a new pair of gloves without hand hygiene. LVN A touched the box of gloves again and moved it closer to him, then doffed his gloves and donned a new one without performing hand hygiene. LVN A applied an ointment to remove damaged tissue to sacrum wound, packed it with wet gauze, then applied a dry gauze. LVN A removed his dirty gloves and donned a new one without hand hygiene. LVN A was about to apply wet gauze to the right ischium wound, but he touched Resident 47's overbed table and pulled towards him, took a pair of bandage scissors, and cut a piece of gauze. LVN A doffed his dirty gloves and donned a new one without hand hygiene. LVN A continued covering the right ischium wound with dry dressing. During a follow up interview with LVN A on 12/7/2023 at 9:35 a.m., LVN A confirmed he did not perform hand hygiene after doffing and before donning of gloves. During an interview with the infection preventionist (IP) nurse on 12/7/2023 at 3:53 p.m., IP nurse stated nurses should perform hand hygiene before donning a new pair of gloves and after removal of dirty gloves. During a review of the facility's policy and procedure titled, Hand Hygiene, dated 7/1/2023, indicated, .If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. 3. During a wound treatment observation on 12/7/2023 at 9:05 a.m., CNA G was present to help Resident 47 maintained a left side lying position while LVN A was performing wound treatment. Resident 47 had a small soft bowel movement while getting a wound treatment. CNA G wiped it out with the used of wet wipes and continued to hold Resident 47's right hip with same dirty gloves. At 9:31 a.m., CNA G removed the pair of dirty gloves and observed she still had a remaining pair of gloves on. LVN A instructed CNA G to remove the second pair of gloves, but CNA G refused to follow LVN A's instruction. CNA G stated. Okay, it's me. CNA G donned a new pair of gloves on top of the second layered gloves and continued cleaning Resident 47. During an interview with CNA G on 12/7/2023 at 9:50 a.m., CNA G confirmed she wore double gloves. CNA G stated she preferred to wear double gloves and she further stated, I feel protected. CNA G confirmed she refused to follow the CDC guidelines in hand hygiene and proper use of gloves. CNA G stated she would always wear double gloves. During an interview with the IP on 12/7/2023 at 3:53 p.m., the IP nurse stated used of double gloves was not allowed in the facility. During a review of the facility's policy and procedure titled, Hand Hygiene, dated 7/1/2023, indicated, The use of gloves does not replace hand hygiene. 48590 4. Review of Resident 10's clinical record indicated, he was admitted to the facility on [DATE] with clinical diagnosis of neuromuscular dysfunction of bladder (a condition wherein a person lacks bladder control due to brain, spinal cord, or nerve condition). Resident 10 had a physician order, dated 9/27/23, for a Foley catheter (a sterile tube inserted into the bladder to drain urine). During a concurrent observation and interview on 12/7/23 at 11:09 a.m., Licensed Vocational Nurse(LVN) I confirmed that the urinary drainage bag was found on the floor. LVN I stated the urinary drainage bag should be off the floor. During an interview on 12/7/23 at 3:53 p.m. with IP nurse, the IP nurse stated the urinary drainage bag should always be off the floor. During a review of the facility's policy and procedure titled, Catheter Care, dated 3/1/23, indicated, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care . ; Ensure drainage bag is located below the level of the bladder to discourage backflow of urine.

Based on observation, interview, and record review, the facility failed to ensure the daily staffing information posted was the current date. This failure had the potential to result in nurse staffing misinformation to the residents, family and visitors. Findings: During an initial facility rounds on 12/4/2023 at 10:30 a.m., the Census and Direct Care Service Hours Per Patient Day (DHPPD - contains daily staffing information) form was posted in front of the nurse station, dated 11/30/23. During another facility rounds on 12/5/2023 at 10:00 a.m., the DHPPD form was still posted with the same date, 11/30/23 ( 5 days past). During a concurrent observation and interview with director of nursing (DON) on 12/7/2023 at 1:14 p.m., DON reviewed the DHPPD posting. The DON confirmed the date in the DHPPD form was 12/6/2023. DON stated the posting was always the day before the current date. DON was informed of the date observed on 12/4 and 12/5/2023. The DON stated nobody updated the staffing information on a weekend. During a concurrent observation and interview with the administrator in training (AIT) on 12/8/2023 at 10:05 a.m., the AIT confirmed the date in the DHPPD form was 12/7/2023. During a follow up interview with the chief executive officer (CEO) and the AIT on 12/8/2023 at 10:08 a.m., the CEO agreed that the daily staffing information posted should be the current date, and he stated, this is a good learning experience for us and from now on we will start posting the staffing information indicating the current date and will include in our QAPI (quality assurance and performace improvement). During a document review from the Centers for Medicare and Medicaid Services Compliance Group, titled Posted Nurse Staffing Information, dated 4/30/2021, indicated, The required information that needs to be posted includes: Facility name, current date .The data should be clear, readable, up to date and current.

Based on observation, interview and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for one of six residents (Resident 101) on respiratory treatment when: 1. The licensed nurse failed to ensure oxygen was administered as specified in the physician's order; 2. The facility staff failed to monitor Resident 101's shortness of breath as specified in the physician's order for more than two months. These failures had the potential to compromise Resident 101's health and safety. Findings: 1. Review of Resident 101's clinical record indicated he had diagnoses including chronic respiratory failure with hypoxia (inability to keep oxygen and carbon dioxide at normal levels), congestive heart failure (heart works less efficiently and can lead to buildup of fluid in the lungs and shortness of breath), hypertensive heart disease with heart failure (type of high blood pressure that affects the blood vessels of the heart). During an observation on 12/4/23 at 10:08 a.m., Resident 101 was lying in bed receiving oxygen at 4 liters per minute (LPM, rate of oxygen administration) via a nasal cannula (flexible tubing placed into the nostrils and connected to an oxygen source). During a second observation on 12/5/23 at 8:56 a.m., Resident 101 was lying in bed receiving oxygen at 5 LPM via nasal cannula. Review of Resident 101's physician's order, dated 10/13/23, indicated he was to receive oxygen via nasal cannula at 2 liters per minute every shift for chronic hypoxemic respiratory failure. During an observation and concurrent interview with licensed vocational nurse A (LVN A) on 12/5/23 at 9:04 a.m., LVN A looked at Resident 101's oxygen concentrator (machine used to deliver oxygen) and stated it was set at 5 LPM. LVN A checked Resident 101's physician order and stated the oxygen concentrator should have been set at 2 LPM. LVN A confirmed he did not check Resident 101's concentrator to ensure the oxygen was administered at the prescribed rate. 2. Review of Resident 101's physician's order, dated 10/13/23, indicated to monitor for shortness of breath every shift for chronic hypoxemic respiratory failure. The physician's order had further monitoring details indicating: 0=none, 1=SOB (shortness of breath) with activity and/or increased number of pillows to sleep; 2= Increased SOB with activity; 3= Unrelieved SOB, SOB with rest, sits upright in chair to rest. Review of Resident 101's medication administration record (MAR) , for November and December 2023, indicated facility licensed nurses were monitoring Resident 101's SOB by documenting with a single checkmark and initial. Licensed nurses were not using the number codes identified on Resident 101's physician order to monitor for SOB. During a record review and concurrent interview with the director of nursing (DON) on 12/5/23 at 10:00 a.m.,the DON reviewed the MAR for November and December 2023 and she confirmed the licensed nurses were monitoring Resident 101's SOB by indicating with a single checkmark. The DON stated the licensed nurses should follow the physician's order and characterize Resident 101's SOB using the number codes identified in the physician's order ( )= none (no SOB) and 1= SOB) rather than putting check marks The DON further stated the documentation on the MAR should indicate the presence or absence of SOB, because the single check mark does not indicate licensed nurse's assessment of Resident 101's presence or absence of SOB. Review of facility's policy Oxygen Administration, implemented 5/1/23, indicated oxygen is administered to residents who need it, consistent with professional standards of practice . 1. Oxygen is administered under orders of a physician . 3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy.

Based on observation, interview, and record review the facility failed to provide a clean, safe, comfortable, and homelike environment for five of 14 sampled residents (Residents 6, 47, 40, 44 and 41) when: 1. Resident 6's privacy curtain was not properly hooked to the rod; 2. Resident 47's privacy curtain had a dark red stain; 3. Resident 40's privacy curtain had a white stain; 4. Resident 44's room was cold; 5. Resident 41's room was cold; and 6. Facility hallways, lobby, and dining room temperatures were not maintained within the range of 71 to 81 degrees Fahrenheit (a scale for measuring temperature). These failures had the potential to result for residents decreased sense of well-being, and exposed to an uncomfortable environment. Findings: 1. During an observation on 12/4/2023 at 10:15 a.m., Resident 6's privacy curtain was not properly hooked at the ceiling rod. Four holes in the privacy curtain were not in a hook and was just hanging. During another observation on 12/5/2023 at 9:32 a.m., Resident 6's privacy curtain was not properly hooked to the ceiling rod. During an interview with the licensed vocational nurse H (LVN H) on 12/5/2023 at 9:46 a.m., LVN H stated the maintenance director (MD) was in charge of checking the residents' privacy curtains. During a follow up interview at 11:00 a.m., LVN H stated the MD did room rounds every day. LVN H further stated, staff would call MD if something were needed to be fixed. During a concurrent environmental tour and interview with MD on 12/5/2023 at 12:18 p.m., MD confirmed Resident 6's privacy curtain was not properly hooked at the ceiling rod and had to be fixed. 2 During an observation on 12/5/2023 at 9:00 a.m., Resident 47's privacy curtain had a dark red stain. During an interview on 12/5/2023 at 12:15 p.m., the MD stated housekeepers did the laundry of the privacy curtains as part of resident room's deep cleaning. The MD further stated the infection preventionist (IP) nurse would schedule each resident room's deep cleaning. During a concurrent environmental tour and interview with MD on 12/5/2023 at 12:18 p.m., the MD confirmed Resident 47's privacy curtain had dark red stain. The MD agreed Resident 47's privacy curtain needed to be cleaned. During a concurrent environmental tour and interview with IP nurse on 12/5/2023 at 12:22 p.m., the IP nurse confirmed the housekeepers complete resident room's deep cleaning monthly that included the privacy curtains. The IP nurse stated she also did her daily room rounds. She checked Resident 47's privacy curtain and confirmed that the dark red stain on it was dried blood, and stated Resident 47's privacy curtain should be laundered. 3. During a concurrent observation and interview with Resident 40 on 12/5/2023 at 10:56 a.m., Resident 40's privacy curtain had a white stain. Resident 40 stated, Their curtains here are dirty and ugly. During a concurrent environmental tour and interview with the MD on 12/5/2023 at 12:18 p.m., the MD agreed Resident 40's privacy curtain need to be laundered. During a review of the facility's policy and procedure titled, Routine Cleaning and Disinfection, dated 7/1/2023, indicated, .14. Privacy curtains in resident rooms will be changed when visibly dirty by laundering or cleaning with an EPA [Environmental Protection Agency - a government agency responsible for protecting human health and the environment] registered disinfectant per the curtain and disinfectant manufacturer's instructions. 48590 4. During an observation on 12/4/23 at 9:02 a.m., Resident 44 was sleeping with fleece blanket cover. During a concurrent observation and interview on 12/4/23 at 10:59 a.m., in Resident 44's room, Resident 44 stated she informed the staff that her room was cold all the time, and cold air was blowing through the air vent. The air vent was located on the ceiling over Resident 44's bed. Resident 44 stated the staff offered blankets when it was cold. During a concurrent environmental tour and interview with the Maintenance Director (MD), on 12/6/23 at 11:07 a.m., the MD measured Resident 44's room temperature using the infrared thermometer (a device used to measure the temperature from a distance) and it indicated 68.4 degrees Fahrenheit (F - a scale of temperature). 5. During an interview on 12/4/23 at 11:06 a.m., Resident 41 stated her room gets cold at night and the staff would provide extra blankets. During a concurrent environmental tour and interview with MD on 12/6/23 at 11:07 a.m.,the MD measured the temperature of Resident 41's room using the infrared thermometer which indicated 70.2 degrees F. 6. During a concurrent environmental tour and interview with MD, on 12/6/23 at 11:07 a.m.,the MD measured the temperature the following rooms using the infrared thermometer:: Room A = 68.4 F; Room B= 70.2 F; Hallway A = 70.7 F; Hallway B = 70.3 F; lobby = 70.9 F; and dining area = 69.6 degrees Fahrenheit. The MD was unable to state the temperature range to maintain a comfortable environment. During an interview with the Director of Nursing (DON) on 12/7/23 at 9:29 a.m., DON stated the maintenance staff monitored the temperature of the residents' rooms. The DON was not able to state the temperature range to maintain a comfortable environment. During a review of the facility's Temperature and Homelike Environment policy, dated 3/1/23, indicated Will maintain comfortable and safe temperature levels, Common resident areas between 71 and 81 degrees Fahrenheit.

Based on observation, interview, and record review, the facility failed to ensure adequate safety monitoring for four of 14 sampled residents (Resident 16, 31, 37, and 38) when the wanderguard device was not checked for proper functioning. This failure had the potential for the alarm system to not work and increase the risk for elopement (leave a facility without staff knowledge). Findings: During an observation on 12/4/23 at 10:07 a.m., Resident 31 was dressed in street clothes and lying on top of his bed sleeping. There was a Wanderguard (a device that activates an alarm when a resident attempts to leave a safe area) on his right wrist. Review of Resident 31's physician order dated 1/2/22 indicated: Wanderguard on at all times, check placement to right wrist every shift. Review of Resident 31's quarterly Elopement Risk Assessment, dated 11/30/23, indicated a score of 8 (A score of 6 or more indicates that the resident should be considered High Risk for elopement.) During an observation on 12/4/23 at 10:40 a.m., Resident 38 was sitting on the edge of his bed dressed in street clothes. There was a Wanderguard on his left ankle. Review of Resident 38's physician order dated 3/21/23 indicated Wander guard to be worn at all times every shift. Device located on left ankle. Review of Resident 38's Wandering Risk Assessment, dated 3/4/23, indicated a score of 13 (A score of 6 or more indicates that the resident should be considered High Risk for elopement.) During an observation on 12/5/23 at 1:37 p.m., Resident 16 was sitting in his wheelchair in his room. There was a Wanderguard on his left ankle. Review of Resident 16's physician order dated 5/15/23 indicated Wander guard to be worn at all times on left ankle, every shift check placement of device. Further review of Resident 16's medication administration record (MAR) indicated licensed nurses were initialing and using a checkmark to monitor for placement of the wanderguard every shift. During an interview and concurrent record review with licensed vocational nurse A (LVN A), he confirmed Resident 16 had a Wanderguard on his left ankle. LVN A stated there is a physician order to check placement of Resident 16's Wanderguard. When asked if there was a physician order to monitor the functioning of the Wanderguard, LVN A stated there was no physician order to monitor Resident 16 Wanderguard's functionality. LVN stated the staff need to check that the Wanderguard is working, and he stated I take the residents to the front door to test and see if the alarm goes off. When asked if he documents his testing of the Wanderguard, he responded I don't write it down anywhere. During an observation on 12/5/23 at 2:09 p.m., Resident 37 was lying in his bed in the room. There was a Wanderguard on his right ankle. Review of Resident 37's clinical record indicated there was no physician order for the use of the wanderguard. During a observation and concurrent interview with the director of nursing (DON) on 12/6/23 at 2:25 p.m., she checked Resident 37 and confirmed he was wearing a Wanderguard on his left ankle. During a follow-up record review and interview with the DON on 12/6/23 at 2:30 p.m., she confirmed that Resident 37 did not have a physician order for the use of a Wanderguard and she stated she did not know when the Wanderguard was applied to Resident 37. She stated that Resident 37 should have a physician order if he is wearing a Wanderguard. The DON was questioned about the staff's responsibility for monitoring those residents in the facility who are wearing wanderguards. The DON stated there should be a physician's order to check the placement and functionality of all Wanderguards worn by any residents in the facility. The DON reviewed the physician orders for Resident 16, 31, 37, and 38 and confirmed there were no physician orders to check the functioning of the Wanderguards for these 4 residents. The DON stated there are physician orders to check placement of the Wanderguards for Residents 16, 31, 37, and 38 but no orders to check functionality of their Wanderguards. The DON stated there should be physician orders in place so that the Wanderguards can be assessed, at least daily, for proper functioning. Review of the facility's policy titled Resident Exit Alarms/Wanderguard Policy, implemented 7/1/23, indicated .7. Monitoring and modification . When alarms are utilized, additional monitoring shall be provided, including but not limited to; . ii. Verifying alarms are working properly.

Based on observation, interview, and record review, the facility failed to protect a resident's rights to confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment) when licensed nurse left the computer screen open and unattended on top of the medication cart. This failure had the potential to compromise the resident's privacy and confidentiality. Findings: During an observation on 12/5/23 at 10:05 a.m., a computer with a resident's medical record information was left opened and unattended on a medication cart in the hallway with two residents nearby potentially seeing the information. During an observation and concurrent interview with the Director of Staff Development (DSD) on 12/5/23 at 10:08 a.m., the DSD walked by the nurses' station and noticed the computer screen on top of the medication cart open. The DSD stated the Medication Administration Record (MAR, a record of medications given) ) of one of the residents was open and it was a HIPPA (Health Insurance Portability and Accountability Act, a federal law to protect privacy and security of health information) violation and locked the screen. The DSD stated no chart has to be exposed specially in the hallway where anyone can see. During an interview on 12/6/23 at 8:20 a.m., with the Director of Nursing (DON), the DON stated she was informed of the incident of an electronic health record that was left open and unattended in the hallway. The DON also stated information must be kept private and staff should make sure to close the screen or lock the computer before leaving the medication cart. The DON acknowledged staff had violated the privacy of the resident. During a review of the facility's Safeguarding of Resident Identifiable Information policy, dated 3/1/23, indicated Implement reasonable and appropriate measures to protect and maintain the safety and confidentiality of the resident's identifiable information and to safeguard against destruction or unauthorized release of information and records; Medical records shall not be left in open areas where unauthorized persons could access identifiable resident information.

Based on observation, interview, and record review the facility failed to ensure resident's care needs were accommodated for two of 14 sampled residents (Resident 47 and 40) when Resident 47 and Resident 40's call light buttons were not within reach to use. These failures had the potential to affect residents' physical and psychosocial well-being. Findings: 1) Review of Resident 47's clinical record titled, Admission Record, indicated Resident 47 was admitted to the facility with diagnoses including paraplegia (a paralysis that occurs in the lower half of the body. It can be a result of an accident or a chronic condition), osteomyelitis (infection of the bone) and pressure ulcer (PU-damage to the skin caused by prolonged pressure) of sacral region (part of the body located in between the bilateral buttocks), stage 4 (PU stage with full-thickness skin loss and possible involvement of the muscle, bone, tendon or joint). During an observation and concurrent interview on 12/4/2023 at 9:30 a.m., Resident 47 was lying in bed with head of bed (HOB) elevated. Resident 47's call light button (a red button used to request assistance) was located below the left bed rail. Resident 47 tried to reach for his call light button but he couldn't reach it. 2) Review of Resident 40's clinical record titled, Admission Record, indicated Resident 40 was admitted to the facility with diagnoses including chronic (persisting for a long time or constantly recurring) atrial fibrillation (an irregular and often very rapid heart rhythm), anxiety disorder (a mental illness that causes constant fear) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During an observation and concurrent interview on 12/6/2023 at 1:15 p.m., Resident 40 was sitting in his wheelchair at the end of the bed, with the overbed table in front of her facing the bedroom's door. Resident 40 was observed still eating lunch. Resident 40 requested the evaluator nurse to press the call light button located at the right bed rail. Resident 40 complained of unable to reach her call light button. Resident 40 stated, I need help. I want to go to bed. During an interview on 12/6/2023 at 1:28 p.m., certified nursing assistant E (CNA E) confirmed Resident 40 was located far from the call light button. CNA E apologized and stated, call light button should be placed within Resident 40's reach. During an interview with the director of nursing (DON) on 12/7/2023 at 1:35 p.m.,the DON stated she did her morning rounds every day whenever she was in the facility. DON further stated residents' call light button should always be within residents' reach. A review of the facility's policy and procedure titled, Call Lights: Accessibility Policy dated 3/1/2023, indicated, .4. Staff will ensure the call light is within reach of resident and secured .5) The call light system will be accessible to the residents while in their bed .

Based on observation, interview and record review, the facility failed to treat two of 14 sampled residents (Resident 16 and 10) with respect and dignity when: 1. Certified nurse assistant D (CNA D) was standing while feeding Resident 16 in the social dining area; and 2. Resident 10's urinary drainage bag was not covered with a privacy bag. These failures had the potential to negatively affect resident's emotional and psychosocial well-being. Findings: Review of Resident 16's clinical record titled, Admission Record, indicated resident was admitted to the facility with diagnoses including hemiplegia (paralysis of one side of the body/a severe or complete loss of strength in the arm, leg, and sometimes face on one side of the body) and hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) following cerebral infarction (also called stroke) affecting left non-dominant side, dysarthria (difficulty speaking) following cerebral infarction and vascular dementia (a condition caused by a stroke affecting thinking and social abilities interfering with daily functioning). During a dining observation on 12/4/2023 at 12:32 p.m., Resident 16 was sitting on a wheelchair. CNA D was observed standing while feeding Resident 16. During an interview with CNA D on 12/4/2023 at 12:43 p.m., CNA D confirmed she was standing while feeding Resident 16. CNA D stated she should sit on a chair when assisting resident with meals. During an interview with the director of staff development (DSD) on 12/5/2023 at 1:01 p.m., the DSD stated staff should sit beside the resident when feeding or assisting them with meals to show respect and to treat them with dignity. During a review of the facility's policy and procedure titled, Promoting/Maintaining Resident Dignity, dated 03/02/2022, it indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity .as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 48590 2. During a review of Resident 10's clinical record, indicated he was admitted to the facility on [DATE] with clinical diagnosis of neuromuscular dysfunction of bladder (a condition wherein a person lacks bladder control due to brain, spinal cord, or nerve condition). Resident 10 had a physician order, dated 9/27/23, for a Foley catheter (a sterile tube inserted into the bladder to drain urine). During a concurrent observation and interview on 12/7/23 at 11:09 a.m., Licensed Vocational Nurse (LVN ) I confirmed that the urinary drainage bag was found on the floor without the dignity bag. LVN I stated the urinary drainage bag should be off the floor and covered with privacy bag. During an interview on 12/7/23 at 3:53 p.m. with Infection Preventionist (IP), IP stated the urinary drainage bag should always be off the floor with a privacy bag. During a review of the facility's policy and procedure titled, Catheter Care, dated 3/1/23, indicated, .residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use; Privacy bags will be available and catheter drainage bags will be covered at all times while in use.