Every finding on record at Morning Star Post Acute

Based on observation, interviews, and record review, the facility failed to ensure a safe environment and adequate supervision for one of three sampled residents (Resident 1) when Resident 1 exited the facility unsupervised through the main entrance door, where the door alarm failed to sound an audible alert and staff did not conduct the required fifteen-minute checks. This failure resulted in Resident 1 who was cognitively impaired and has insulin dependent diabetes (IDDM-a chronic condition where the pancreas makes little or no insulin, the hormone which allows sugar to enter cells to produce energy) eloping from the facility and roaming city streets for approximately three hours and eight minutes (between the hours of 3:55 p.m. and 7:03 p.m.) with ambient outdoor temperatures of 98 to 100 Fahrenheit (F-a temperature scale) placing Resident 1 at immediate risk for getting hit by a car and severe medical complications, including dehydration (a condition that occurs when your body loses more fluids that it takes in), heat exhaustion (the body's response to excessive fluid and salt loss from prolonged sweating in high temperatures), and acute blood sugar emergencies (low blood sugar). Findings: During a review of Resident 1's admission Record (AR) (document containing resident demographic information and medical diagnosis), dated 7/17/16, the AR indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included but are not limited to .Type 2 Diabetes Mellitus without Complications (chronic condition that affects the way the body processes blood sugar), Hypertensive Heart Disease (problems with your heart that can develop if you have high blood pressure) without Heart Failure (a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), Cognitive Communication Deficit (problems with communication that happen because of trouble with thinking skills), Asthma (a chronic lung disease caused by inflammation and muscle tightening around the airways making it hard to breathe), Adjustment Disorder (an emotional or behavioral reaction to a stressful event or change in a person's life) with Mixed Anxiety and Depressed Mood (patients who suffer from both anxiety and depressive symptoms of limited and equal intensity accompanied by at least some unconscious processes). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 5/14/26, the MDS, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 11 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 1 had moderate cognitive impairment.During an observation on 6/17/26 at 9:55 a.m., no alarm was triggered upon entry into the facility's main entrance (south) door. During a phone interview on 6/17/26 at 12:51 p.m. with the Good Samaritan (GS- a person who stops to help a stranger in distress without expecting a reward), the GS stated on 6/14/26 around 6-6:06 p.m. she was driving on [NAME] Ave. toward [NAME] Ave. and saw Resident 1 had fallen on the right sidewalk. The GS stated she pulled over to help Resident 1 who did not speak English, so she called a friend to help translate. The GS stated Resident 1 was sweating and had stumbled so was concerned as it was really hot outside and may have affected the resident. The GS stated Resident 1 had to hold onto her when she walked to her air-conditioned car as her legs gave out. The GS stated Resident 1 did not know where she was going. The GS found Resident 1's phone in her backpack and called her daughter who provided the facility's details and asked the GS to return the resident to the facility. The GS stated the facility was a 49-minute walk from her current location. The GS stated she returned Resident 1 to the facility at 7:08 p.m. During an interview on 6/17/26 at 1:28 pm with the Licensed Vocational Nurse (LVN) 1, the LVN 1 stated residents' elopement risk was assessed upon admission. LVN 1 stated if the resident was determined to be at risk for elopement or displayed exit seeking behaviors the charge nurse would notify the MD and staff would be alerted to perform frequent rounds on the resident to ensure resident's safety. The LVN 1 stated residents without exit seeking behaviors were rounded on every two hours, however, residents at risk of elopement may be checked on by staff every 15, 20 or 30 minutes depending on the resident. LVN 1 stated the facility doors were not locked so they would place alarms on the doors which may sound like a rooster or chime when someone enters or exits the door. LVN 1 stated the Certified Nurse's Aide (CNA) and licensed nurses (LN) were usually responsible for monitoring residents every 15 minutes (Q15'). LVN 1 stated when the CNA went on a break, they would hand off Q15' checks to the LN. LVN 1 stated if the LN got busy, they would delegate Q15' check to another CNA on the floor. The LVN 1 stated Resident 1 ambulated independently without a walker and would carry her backpack. LVN 1 stated Resident 1 was forgetful and a known wanderer since admission, but she was initially easily redirectable, however, the longer she stayed at the facility her wandering got worse. LVN 1 stated on 6/11/26 Resident 1 was sent to the hospital for evaluation after she had a change in behavior after she clawed at staff with her nails, increased wandering and not being easily redirected. LVN 1 stated upon return from the hospital Resident 1 was placed on visual checks Q15' without having to document the resident's location on a log. LVN 1 stated she was burdened because Resident 1 required so much oversight. During a concurrent observation and interview on 6/17/26 at 1:52 p.m. with LVN 1, staff and visitors walked through the entrance door and no alarm was heard. LVN 1 stated the alarm was not plugged into the wall socket outside of the Administrative Office door. The west door exited towards the parking lot and a rooster alert sounded when the door was opened. The north door exited towards a secure patio and a chime alert sounded when the door was opened. The east door exited towards a secured patio and did not chime when the door was opened. During an interview on 6/17/26 at 2:12 p.m. with CNA 1, CNA 1 stated a resident who wandered, checked the doors, was not content with staying still and was always on the move could be at risk for elopement. CNA 1 stated when a resident was identified at high risk for elopement, the CNAs would check on them more frequently, monitor if they walked outside or redirect the behavior such as taking them to activities. CNA 1 stated when a resident was placed on Q15's checks, the CNAs would check on the resident every 15 minutes and document the resident's location on a log and initial the entry. CNA 1 stated all nursing staff were responsible for monitoring residents on Q15' checks and could document on the Q15' log. CNA 1 stated the licensed nurses were responsible to ensure Q15' monitoring was occurring. CNA 1 stated the purpose of the log was to show where the resident went to identify behavior patterns and to ensure the resident's safety and well-being. CNA 1 stated if Q15' was not maintained, the residents could elope and be at risk of getting hit by a car. CNA 1 stated the facility had door alarms that triggered when someone opened the door. CNA 1 stated all exit doors should have an alarm. CNA 1 stated the front entrance door should have an alarm plugged into the wall socket. CNA 1 stated maintenance ensures the door alarms are in place and function. CNA 1 stated Resident 1 was nice, active and walked up and down the hall, would check here and there. CNA 1 stated prior to the elopement incident, Resident 1 was frequently monitored but was not on Q15's checks. CNA 1 stated Resident 1 was placed on Q15's checks with logging her location on the log after the elopement incident. During a concurrent observation and interview on 6/17/26 at 2:32 p.m. with the Administrator (ADM), the entrance door was observed without an alarm plugged into the wall socket outside of the AD office. The ADM stated there should be an alarm in the wall socket when the facility had a resident who was at risk of elopement. The ADM stated if the facility did not have a high risk for elopement residents in the building, the facility would not maintain the front door alarm. The ADM stated all facility exit doors were equipped with a Wander Guard sensor system however the system was no longer functioning the company no longer sold the bracelets or ankle monitors. The ADM stated the facility adopted a new system by installing door sensors on each exit door that were paired to an alarm device that was plugged into a nearby wall socket. The ADM stated when the door opened, the alarm would produce a siren, rooster or chime sound. The ADM stated the exit alarms were in place one day after Resident 1 admitted and was identified at risk for elopement. The ADM stated he ensured the alarms were in place at all exit doors. During a concurrent record review and interview on 6/17/26 at 2:47 p.m. with LVN 2, Resident 1's Care Plan (CP) dated 5/11/26, 5/15/26 and 6/15/26 were reviewed. The CP dated 5/11/26 indicated Elopement Care Plan monitor location throughout the shift. Document wandering behavior and attempt diversional interventions as needed. The CP dated 5/15/26 indicated Mood Care Plan.Resident visual checks every 15 minutes. The CP dated 6/15/26 indicated Risk of injury related to impaired safety awareness, cognitive impairment and unauthorized facility exit (elopement) with subsequent unwitnessed fall while off premises. Interventions-escalate elopement interventions: engineering egress control at the front entrances (door alarm); reassess monitoring level beyond 15-minute checks, consider relocation within staff line of sight. LVN 2 stated all residents were assessed for the risk of elopement upon admission and if the residents displayed behaviors concerning elopement during their stay. LVN 2 stated if residents were identified at risk of elopement and appeared restless, the staff would offer the resident food, water or assistance to the restroom. LVN 2 stated if the resident declined food, water or assistance to the restroom, they may call the resident's family to try and redirect the resident's behavior. LVN 2 stated all staff visually check where Resident 1 was located throughout the shift but did not have to document the resident's location unless she tried to go outside. LVN 2 stated that when visual checks every 15 minutes were initiated on 5/15/26, the staff would check to see where the resident was but did not have to document the resident's location as was not on 1:1 supervision (one staff member assigned to monitor one resident). LVN 2 stated she worked and was assigned to Resident 1 on 6/14/26 the shift she eloped. LVN 2 stated Resident 1 was known to be at risk of elopement. LVN 2 stated Resident 1 ambulated independently and wanted to go home. LVN 2 stated the facility was a compact building and staff did not leave Resident 1 alone. LVN 2 stated when the door alarms ringed everyone would look to see who came into the door. LVN 2 stated if there was no alarm, therapy, admissions, the desk nurse and the ADM would monitor the door. LVN 2 stated on 6/14/26 at approximately 3:50 p.m. LVN 2 was sitting at the nursing station and made eye contact with Resident 1 who stood by the family room entrance that was next to the entrance door. LVN 2 stated she then performed finger stick blood sugar (FSBS-a test to measure the level of glucose (sugar) in your blood) checks for her assigned residents in preparation for dinner. LVN 2 stated she completed FSBS checks for her residents within 15 minutes and approximately 4:10 p.m. looked for Resident 1 to check her blood sugar but could not find her in her room, the restroom or the Dining Hall. LVN 2 asked Resident 1's CNA but the CNA had not seen the resident. LVN 2 asked the charge nurse at the nursing station to call a code 10 (used to alert staff a resident is missing and to trigger an all staff search for the resident). LVN 2 stated one nurse checked the surveillance cameras, while other staff searched each room, closet, and locked offices. LVN 2 stated the surveillance camera indicated Resident 1 went into the family room and waited for a little bit then eloped out the front door. LVN 2 stated Resident 1 was returned to the facility around 7:05 pm and was informed the resident had a fall. LVN 2 stated Resident 1 was assessed, vital signs were stable, FSBS was fine, the resident was not in any pain. LVN 2 stated Resident 1 was fed, showered, and Q15's checks with documentation log were initiated. During an interview on 6/17/26 at 4:03 pm with the admission Coordinator (AC), the AC stated he monitored the front entrance doors to ensure an exit seeking resident did not leave the building. The AC stated the team was responsible for monitoring the door, but for the most part, therapy and admissions were responsible to monitor who goes in or out of the building. The AC stated he started employment on 6/1/26 and the front door alarms were not in place. The AC stated the alarms were in place about a week after he started working as the alarm would go off constantly and was annoying. The AC stated that if the entrance doors were not monitored when there was a resident at risk for elopement in the building, the resident would have an increased safety risk for successfully eloping. The AC stated would receive communication via group chat to alert staff of a high risk for elopement residents. The AC stated it was important for all staff to be aware of elopement risk residents to increase the number of eyes monitoring the residents and to ensure resident safety and well-being. The AC stated the risk of not monitoring the risk of elopement residents would increase their ability to elope. The AC stated he was not working on 6/14/26, the day Resident 1 eloped as he does not work on the weekend. The AC stated he was not aware of who would be responsible for monitoring the doors when Admissions or therapy staff were not working. During an interview on 6/17/26 at 4:30 p.m. with the Physical Therapy Assistant (PTA), the PTA stated everyone was responsible for monitoring who goes in and out of the front door. The PTA stated a door alarm would trigger when anyone went in or out of the entrance door. The PTA stated therapy staff paid more attention to the entrance door as the therapy room was next to the front door and the therapy staff were familiar with all residents. The PTA stated if a resident was observed walking out of the entrance door, the staff would follow the resident and redirect them to return to the facility. The PTA stated most therapy staff worked only on weekdays, however, a Certified Occupational Therapy Assistant (COTA) therapy staff member was routinely scheduled on weekends and worked on 6/14/26, the day Resident 1 eloped. The PTA stated Resident 1 was a very confused lady and would always try to go outside once she passed the nursing station. During an interview on 6/18/26 at 10:18 a.m. with Housekeeping (HSKP), HSKP stated she does not receive a report of residents who are at risk of elopement. The HSKP stated if she were aware of an at risk for elopement resident, she would monitor the exit doors, so the resident does not leave the building. The HSKP stated the entrance door had an alarm, the back door did not have an alarm because the area was gated and secured but did not pay much attention to either door because she was assigned to the [NAME] Hall and paid attention to the west door alarm when triggered. During an interview on 6/18/26 at 10:32 a.m. with the Certified Dietary Manager (CDM), the CDM stated when the facility identified an at risk for elopement resident it would be communicated to all staff during the morning huddle when the team reviews pertinent information for kitchen staff. The CDM stated all staff were responsible for monitoring residents at risk for elopement. The CDM stated when a door was opened, it triggered an alarm with an annoying sound so all staff would go who went out the door. The CDM stated door alarms were in place for the entrance door, north and west doors but the east door did not have an alarm as it exited to a secure area. The CDM stated door alarms were put in place when the facility had an identified at risk of elopement resident. The CDM stated that when an elopement resident walked toward the door, the staff would shadow the resident but did not hover over the resident to avoid annoying the resident. The CDM stated if the resident stepped outside, the staff would follow the resident and redirect the resident inside. The CDM stated she was not present when Resident 1 eloped on 6/14/26. The CDM stated surveillance cameras were installed in the hallways pointing toward each exit door and the ADM and Maintenance (MAIN) had access to surveillance footage.During an interview on 6/18/26 at 10:45 a.m. with the Activity Director (AD), the AD stated the DON would communicate when there was an at risk for elopement resident during huddle or morning meetings. The AD stated she was not sure who was responsible for monitoring at risk for elopement residents. The AD stated the facility doors had alarms that required bracelets but were not sure if they were being used. The AD stated staff monitored the exit doors and the facility recently implemented a doorbell system a week ago that did not require bracelets. The AD stated staff with an office near an exit door would monitor the doors as well as the CNAs. During an interview on 6/18/26 at 10:51 a.m. with the maintenance (MAIN), the MAIN stated he started working at the facility two and a half years ago and the pre-existing Wander Guard system that required a bracelet was not functioning. The MAIN stated the facility had an Elopement Binder at the nursing station that had a Face sheet of any residents at risk for eloping. The MAIN stated the desk nurse, DON or ADM would communicate to him when there was an at risk for elopement resident and he would plug an alarm into the wall socket programed for each exit door that would remain in place all day and all night until the resident was discharged or determined no longer at risk for eloping. The MAIN stated the door alarms were placed at each door even if it led to a secure area. The MAIN stated exit doors which did not lead to a secure area would trigger an obnoxious sound. The MAIN stated if the facility did not have any at risk for elopement residents, he would remove the door alarms. The MAIN stated the purpose of the door alarms was to notify those closest to the door that the door was opened so they monitor what was going on. The MAIN stated if the doors did not have an alarm, at risk for elopement residents could leave the facility. The MAIN stated he was notified of Resident 1's elopement risk on the day of admit, 5/11/26 and the door alarms were installed to all exit doors that day. The MAIN stated the door alarms should remain in place 24 hours a day seven days a week, until the resident was discharged . The MAIN stated the facility had 16 security cameras installed to monitor each hallway, front door exit to the parking lot, west door exit to the parking lot, back gate, north exit to the lawn area, the north covered patio and east exit laundry area. The MAIN stated the camera surveillance system captures those who enter and exit the building and parking lots. The MAIN stated he, Information Technology (IT), ADM, and DON had access to video footage. The MAIN stated he was not aware how long the footage was stored. During an interview on 6/18/26 at 11:39 am with the Certified Occupational Therapy Assistant (COTA), the COTA stated the facility had an Elopement Binder at the nursing station and the therapy supervisor would communicate with the staff when there was an at risk for elopement resident in the building. The COTA stated all staff would monitor the residents to make sure the residents do not attempt to go out of the facility. The COTA stated the therapy room was close to the entrance door and therapy staff would monitor who entered and exited the door, but they were not assigned to monitor the door as they were busy with treatments. The COTA stated therapy staff were aware of at-risk residents and would try to redirect the residents when they tried to go out or would alert the nurse for interventions. The COTA stated he worked on 6/14/26, the day Resident 1 eloped. The COTA stated he was the only therapy staff who worked that Sunday. The COTA stated the AC was not in the office that day so the charge nurse at the nursing station would be responsible for monitoring the facility entrance. The COTA stated the nurses monitored the doors and would manage whether the alarm was in place. The COTA stated he did not hear the entrance door alarm on 6/14/26. The COTA stated he did not witness Resident 1 elopement on 6/14/26 as he was performing bedside treatment when a CNA entered the room and asked him if he had seen Resident 1. During a concurrent record review and interview on 6/18/26 at 12:09 p.m. with Social Services (SS), the Wandering and Elopements Policy and Procedure (P&P), dated 3/2019 was reviewed. The P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The SS stated residents who wandered around would have a formal elopement risk assessment. The SS stated if a resident was determined at risk for elopement their Facesheet would be placed in the Elopement Binder at the nursing station so the staff could review which residents were at risk for elopement and required additional monitoring. The SS stated some residents would be placed on Q15' checks and the staff would keep an eye on the resident as a collective team. The SS stated she was not aware of who was responsible for ensuring Q15' monitoring was implemented. The SS stated the Q15' monitoring should be documented on the progress notes. The SS stated the staff ensure the door alarms were in place and the alarms should be in place 24 hours seven days a week whenever an at risk for elopement resident was identified. The SS stated everyone should monitor the doors for who goes in or out. The SS stated on weekends the doors were monitored by the charge nurse (aka. Desk nurse) and therapy staff if they were onsite. The SS stated it was important for the facility to prevent residents from eloping as they could be harmed, would not have access to medication they needed and could fall and hurt themselves. The SS stated she was not working on 6/14/26. The SS stated the facility failed to monitor the door to prevent Resident 1 from walking out. During a phone interview on 6/18/26 at 1:39 p.m. with LVN 3, LVN 3 stated residents were assessed for elopement risk upon admission and throughout their stay at the facility. LVN 3 stated if a resident started to pack their belongings, walk towards the door, or say they wanted to go home their elopement risk would be assessed. LVN 3 stated the facility implemented elopement prevention interventions such as placing alarms on the doors which trigger a sound when the door was opened, all staff monitored the doors to see who goes in or out of building and staff would communicate using walkie talkies to communicate with other staff what the at risk residents were doing or if they needed someone else to watch an at risk resident. LVN 3 stated it was important to monitor the doors when there was an at risk for elopement residents to maintain the residents' safety. LVN 3 stated if a resident eloped, it would not be safe if the weather was hot as even health people may get dehydrated. LVN 3 stated some residents would be placed on Q15' monitoring but could not recall if Resident 1 was on Q15' monitoring prior to her elopement. LVN 3 stated after Resident 1 eloped, he printed Resident 1's Face sheet and placed it in the elopement binder to ensure all staff were ware of her elopement risk. LVN 3 stated he was not aware Resident 1 was at risk for elopement. LVN 3 stated he worked on 6/14/26, returned from lunch break at 3:54 p.m., and went to the nursing station. LVN 3 stated around 4:10-4:15 p.m. he was alerted by LVN 2 that Resident 1 was missing. LVN 3 stated LVN 2 went to check Resident 1's FSBS and could not find her. LVN 3 stated he announced to search the building and check every room. LVN 3 stated all staff searched inside of every room, closets and outside, and they realized that Resident 1 was not in the building. LVN 3 stated he sent two CNAs to look around outside, and they returned but did not find Resident 1. LVN 3 stated he notified the DON, physician (MD) and resident representative (RP) of Resident 1's elopement and the DON notified the ADM. LVN 3 stated he notified law enforcement and provided a description of Resident 1 and potential places the resident may have visited. LVN 3 stated law enforcement dispatched an officer to look for Resident 1 and provided him a case # and call back number for communication updates. LVN 3 stated around 7 p.m. someone returned Resident 1 to the facility, and he contacted the RP, law enforcement, MD, DON, supervisor and ADM to notify of Resident 1's return. LVN 3 stated he completed a head-to-toe assessment of Resident 1, checked her vital signs and FSBS, changed the resident's clothes that were wet with sweat as it was hot outside, fed her and gave her fluids. LVN3 stated the MD ordered Resident 1 to be sent to the hospital for an evaluation and treatment, however Resident 1 and her son refused. LVN 3 stated the MD was notified of Resident 1's and son's refusal for hospital evaluation, the MD ordered 72-hour monitoring of the resident for delayed injury, Q15' checks to include documentation of the resident's location on a log. LVN 3 stated everyone should have been monitoring Resident 1 and the doors for elopement. LVN 3 stated he was assigned as the desk nurse and could monitor three doors from the nursing station but was responsible for answering phone calls, and assisting whoever went to the nursing station for help. LVN 3 stated he could not recall hearing the entrance door alarm on 6/14/26 at 3:54 p.m. when he entered after his lunch break. LVN 3 stated he was unsure if the door alarm was triggered at the start of his shift at 10:30 a.m. LVN 3 stated he did not know Resident 1 was an elopement risk and was not concerned the alarm was not working as Resident 1 had not tried to elope before. LVN 3 stated Resident 1's elopement was the first incident that he was aware of. LVN 3 stated when monitoring at risk for elopement residents, the CNA was primarily responsible, then the licensed nurses secondary, followed by all staff. LVN 3 stated the facility had lapses in Resident 1's supervision, including himself. During a concurrent record review and interview on 6/18/26 at 2:09 p.m. with the Assistant Director of Nursing (ADON), Resident 1's Skilled Nursing-admission Initial Eval - V11 Elopement Risk Score (Elopement), dated 5/11/26, Resident 1's Elopement Care Plan (CP) dated 5/11/26, Resident 1's Cognitive CP dated 5/15/26 and Resident 1's Mood CP dated 5/15/26 were reviewed. The Elopement indicated Resident 1 was considered at risk of elopement. The Elopement CP indicated resident was at risk for wandering and/or elopement related to cognitive impairment with suspected dementia, history of wandering, impaired judgement and decreased safety awareness with positions ALS, NALL, and SS to identify pattern of wandering and intervene as appropriate, the positions CNA, NALL and SS were to monitor Resident 1's location throughout the shift and positions ALS and NALL were to document wandering behavior and attempted diversional interventions as needed. The Cognitive CP indicated Resident 1 had moderately impaired cognition and positions SS, SSD, NALL, and CNA were to allow the resident time to adjust to surrounding and people, provide redirection as needed. The Mood CP indicated Resident 1 was at risk for altered mood and behavior as exhibited by episodes of wanting to leave facility and Nursing Services were to redirect resident to other activity and resident visual check every 15 minutes. The ADON stated all residents were assessed for their elopement risk upon admission. The ADON stated if the resident was at risk for elopement, the facility would initiate an elopement care plan, alert the CNA and LN to monitor the residents, place the resident's Face sheet in the Elopement Binder at the nursing station and monitor door alarms. The ADON stated once a high risk for elopement resident was identified, the facility would notify maintenance to install door alarms at each exit door that would be in place 24 hours a day, 7 days a week. The ADON stated all staff ensured the door alarms were in place and functioning properly. The ADON stated if a door alarm was missing or broken, the staff would report it to maintenance for replacement. The ADON stated the doors were monitored by all staff and the therapy and business office staff knew how to keep an eye on the entrance door as their offices were near that door. The ADON stated on weekends the entrance doors were monitored by all staff and staff would use radios to communicate where high risk for elopement residents was located. ADON stated all staff take the same amount of responsibility for monitoring high risk for elopement residents. The ADON stated Resident 1 was identified as high risk for elopement at the time of admission. ADON stated the CP interventions auto populated the positions indicating which staff were responsible to implement the chosen intervention. The ADON stated CNA was for the Certified Nursing Assistants, SS was for Social Services, and was unsure which staff were assigned for NALL. ADON stated the CNAs, [NAME] and SSs would be responsible for monitoring the resident's location and documenting wandering behaviors and attempted diversional interventions throughout the shift in a progress note. The ADON stated Resident 1's BIMS was 12 indicating she was moderately cognitively impaired. ADON stated as of 5/15/26, the CNA and LN were responsible for checking the resident's location and documenting their findings every 15 minutes. The ADON stated that even if all elopement prevention interventions were in place, there would be a risk of Resident 1 eloping, especially on the weekend when LNs and CNAs were busy performing patient care tasks. The ADON stated if the staff did not implement elopement prevention interventions, the resident could elope and would be at a higher risk of injury due to her low cognitive function and medical conditions would not be supervised. During an interview on 6/18/26 at 2:45 p.m. with CNA 2, CNA 2 stated that when a resident was identified as an elopement risk, their Face sheet would be placed in the Elopement Binder at the nurse's station. CNA 2 stated Resident 1's Face sheet was not in the binder prior to her elopement. CNA 2 stated if a resident's Face sheet was in the binder, the CNAs, LN, everyone in the building should keep an eye on the resident including therapy, housekeeping, maintenance, activities staff. CNA 2 stated if a resident was on Q15', staff would need to locate the resident and document their location every 15 minutes on a log. CNA 2 stated the CNA would be responsible for monitoring the resident Q15' and if the CNA had to assist another resident when the Q15' was due, the CNA would need to hand off the task to the LN or another CNA. CNA 2 stated the Q15' checks were to ensure the residents were safe and in the building. CNA 2 stated if Q15's checks were not performed in a timely manner the resident would be at risk of eloping and not being safe. CNA 2 stated the entrance door alarm would make a noise whenever someone went out. CNA 2 stated the door alarm was in place all the time. CNA 2 stated staff who were near the doors and staff at the nursing station were responsible for monitoring the doors, especially when the CNAs were busy with patient care. CNA 2 stated[TRUNCATED

Based on observation, interviews and record reviews, the facility failed to prepare and store food in accordance with professional standards for food safety for all residents who consumed meals prepared in the kitchen when a of five-pound bag of chicken with a used by date of 2/16/26 was stored in the refrigerator available for residents use. This failure placed residents at potential risk to develop gastrointestinal illness (illness that affects the digestive system [GI tact] which runs from mouth to anus) which could result in serious health conditions. During a concurrent observation and interview on 2/17/26 at 8:22 a.m. during initial tour in the kitchen with Dietary Service Manager (DSM), in the refrigerator there was a bag of chicken with prep date of 2/14/26 and used by date of 2/16/26. The DSM stated, It [chicken] was supposed to be used yesterday [2/16/26]. The DSM stated the dietary staff defrosted the chicken more than was needed During an interview on 2/19/26 at 8:28 a.m. with the DSM, the DSM stated the cook was responsible in pulling out food to thaw for use. The DSM stated refrigerators and freezers are monitored daily and checking food for the expiration dates ensuring food past the used by date are not left inside the refrigerator. The DSM stated the bag of expired chicken should have been remove from the refrigerator to avoid use. The CDM stated staff might accidentally use the expired chicken and serve to residents and somebody might get sick and we do not want that. During an interview on 2/20/26 at 8:10 a.m. with the Registered Dietitian (RD), the RD stated she was in the facility once a week and spot check refrigerators and freezers. The RD stated once meat was thawed, it was required to be served, and any portions not used was to be discarded. The RD stated it was the responsibility of all dietary staff to check daily for expired food and discard as needed. The RD stated serving food passed its used by date could cause bad taste and food borne bacteria. During a review of facility's policy and procedure (P&P) titled, Food Storage (Dry, Refrigerated, and Frozen), dated 2020, the P&P indicated, .All food items will be labeled. The label must include the name of the food and the date . Rotate products so the oldest are used first. Staff shall be instructed to use products with the earliest expiration date before those with a later expiration date. Discard food that has passed the expiration date . Follow and adhere to the guidelines regarding proper storage temperatures and maximum length of storage .

Based on observation, interview, and record review, the facility failed to ensure garbage was stored and disposed of in a manner that prevented unsanitary conditions for all the residents in the facility when two of three outdoor dumpsters were observed with the lids open and overflowing.This failure placed residents at potential risk for exposure to pest, offensive odors, and contamination of food or medications which could compromised residents health, safety, and the overall sanitary environment of the facility. During a concurrent observation and interview on 2/18/26 at 8:15 a.m. with Dietary Service Manager (DSM), the facility's dumpster located behind the building was observed with two of the lids in the open position. One dumpster contained overflowing garbage in a plastic bag, which prevented the lid from closing securely. The DSM stated, They should have made sure to throw garbage bag in the back first for the lid to close.During an interview on 2/19/26 at 8:35 a.m. with DSM, the DSD stated the facility's dumpster was everybody's responsibility. The DSM stated leaving the dumpster open attracts vermins and causes odor. The DSM stated it was the reason why the dumpster lids should be kept shut to avoid vermins going in and contain the odor. During an interview on 2/19/26 at 9:15 a.m. with the Environmental Supervisor (EVS), the EVS stated it was his responsibility to ensure dumpster lids to remain closed at all times. The EVS stated the facility's dumpsters contained dirty briefs, foods, and other garbage which could attract pests. The EVS stated keeping garbage lids properly closed at all times help contained odors and prevent the attraction of unwanted pests. During a review of facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, Revised date 10/17, the P&P indicated, .All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered . Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests . Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter .

Based on observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for two of 10 sampled residents (Residents' 5 and 10) when: 1.Resident 5's change in condition on 2/14/26, when the resident complained of a cough and subsequently received new physician orders, including cough medication, steroids (medicine used to reduce swelling and inflammation), antibiotics (medicine used to treat infections caused by bacteria [germs]) and diagnostic testing. This failure had the potential to result in inconsistent care, lack of staff awareness regarding Resident 5's change in condition and failure to monitor the effectiveness of interventions, which could have led to a decline in Resident 5's respiratory status. 2.Resident 10 did not have a care plan for a fall that happened on 2/15/26. This failure put Resident 10 at risk for additional fall and for potential injuries from the fall.1.During a review of Resident 5's admission Record (AR -a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/19/26, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses of fracture (a break or crack in a bone) of right lower leg, and muscle weakness (the muscles [a soft tissue in the body that helped a person move] did not work as strongly as they usually did). During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/3/26, the MDS indicated Resident 5 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 5 was cognitively intact. During a concurrent observation and interview on 2/17/26 at 8:26a.m. with Resident 5 in his room, Resident 5 stated he had developed a productive cough beginning on 2/14/26. Resident 5 stated he had been receiving cough syrup, and throat lozenges and had undergone a chest X-ray, with results pending at the time of interview. During an interview of 2/19/26 at 9:29a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated a care plan was something she followed as a CNA. CNA 1 described it as her guide for how to care for the residents and referred to it as the resident's personal index. CNA 1 further stated new developments should be care planned because it provided her with an FYI on what to monitor and how to look out for changes in the resident's condition. During a concurrent interview and record review of Resident 5's electronic health record on 2/19/26 at 10:09 a.m. with Registered Nurse (RN)1, review of Resident 5's physician orders indicated guaifenesin (medication used to help loosen mucus in the chest) 15militers (ml- a way to measure small amounts of liquid) every 6 hours as needed for cough, dextromethorphan-benzocain (a medicine to help relieve cough and sooth a sore throat) lozenges every 4 hours as needed, Prednisone (a medicine used to reduce swelling and inflammation in the body)10 miligram (mg-a way to measure very small amounts of something, usually medicine) once daily for 5 days and azithromycin (a medication used to treat infections) 250 mg daily for 4 days. A chest x-ray revealed bilateral lower lung field atelectatic changes (small parts of the lungs had partially collapsed or were not fully filling with air). RN 1 stated there should have been a care plan in place at the time of the change in condition on 2/14/26, when Resident 5 complained of having a cough. RN 1 further stated care plans were important to ensure care was provided in accordance with the established plan. During an interview on 2/20/26 at 12:52p.m. with the Director of Nursing (DON), the DON stated it was her expectation that the nurse would initiate a care plan as soon as a change in condition was identified. During a record review of the facility's policy and procedure (P&P) titled, Care Plans Comprehensive Person-Centered, dated 2/2022, the P&P indicated, .assessments of residents are ongoing and care plans are revised as information about the resident and the residents' condition change.the interdisciplinary team reviews and updates the care plan when there has been a significant change in the residents condition. 2. During a concurrent observation and interview on 2/17/26 at 9:25 a.m. during initial tour in Resident 10's room, Resident 10 was observed lying in bed reading and observed with external fixator (medical device used to stabilize broken bones using metal pins or wires drilled into the bone, attached to a rigid frame or rods outside the body) on her left ankle/leg. Resident 10 stated she had a fall at home and broke her left ankle and was in the hospital where they put the metal in her leg. Resident 10 stated she had another fall in the facility recently when she slipped out of her wheelchair. Resident 10 stated she had no injury. During a review of Resident 10's AR dated 2/19/26, the AR indicated Resident 10 was admitted to the facility on [DATE] with diagnoses which included fracture (break on the bone) of left lower leg, muscle weakness and difficulty walking. During a review of Resident 10's MDS dated [DATE], the MDS assessment indicated Resident 10's BIMS score was 13 out of 15 which indicated Resident 10 had no cognitive deficit. During a concurrent interview and record review on 2/18/26 at 1:55 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 10's clinical record and stated Resident 10 had a fall at home and sustained a fracture on her left lower leg. LVN 2 stated Resident 10 was admitted to the facility with an external fixator on her left leg. LVN 2 stated Resident 10 had another fall in the facility on 2/15/26 but did not find a care plan. LVN 2 stated there should have been a care plan for the fall. LVN 2 stated care plan was important to direct staff on how to care for residents. LVN 2 stated it was the responsibility of licensed nurses to initiate care plans. During an interview on 2/19/26 at 9:35 a.m. with CNA 4, CNA 4 stated she was working on the day Resident 10 had a fall. CAN 4 stated she was on her lunch break when Resident 10 fell off her wheelchair. CAN 4 stated Resident 10 was reaching out and slipped off her wheelchair. CAN 4 stated Resident 10 requires assistance with turning and repositioning and did not complain of pain. During a concurrent interview and record review on 2/19/26 at 1:45 p.m. with Assistant Director of Nursing/Infection Preventionist (ADON/IP), Resident 10's clinical record was reviewed, and ADON/IP stated Resident 10 fell off her chair on 2/15/26 with injuries. The ADON/IP stated a change of condition report was completed on 2/15/26 but did not find a care plan. The ADON/IP stated there should have been a care plan initiated for the fall but there was none. During a concurrent interview and record review on 2/20/26 at 12:15 p.m. with the DON, the DON stated Resident 10 had a recent fall in the facility on 2/15/26, a change of condition was completed but no care plan initiated. The DON stated her expectation was for the nurses to initiate a care plan after change of condition was completed. The DON stated care plan was important because It shows what we are doing to the patient, implement intervention, and solve the problem. During a review of the facility's policy and procedures (P&P) titled, Care Plans Comprehensive Person-Centered, dated 2/2022, the P&P indicated, .person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental and psychosocial well-being.reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review the facility failed to meet professional standards of practice for three of 10 sampled residents (Resident 12, 49 and 29 ) when:1. Resident 12 was administered 2.5 LPM (liter per minute-a unit of measurement for the flow rate of oxygen) of oxygen therapy (a colorless, tasteless gas essential to living organisms) without a physician's order.This failure resulted in Resident 12 receiving oxygen therapy without a physician's order which had the potential to result in shortness of breath, oxygen toxicity (lung damage that happens from breathing in too much extra oxygen therapy), and serious medical conditions.2. Resident 49 was not monitored or observed while receiving her medication through hand held nebulizer (HHN-device designed to convert liquid medication into fine mist for treating asthma and respiratory issues), nebulizer machine was turned off by a CNA when Resident 57 stated her treatment was completed and licensed nurse did not verify medication in the HHN was completedThis failure had the potential for Resident 57 to not received the whole medication dose which could lead to continued respiratory distress.3.The facility did not ensure appropriate reassessment and management of Resident 29's permacath (a special soft tube that was placed into a large vein in the chest to allow blood to be cleaned) after hemodialysis (a treatment that used a machine to clean a person's blood when their kidneys were not working properly) treatments were discontinued. This failure had the potential risk to result in improper catheter maintenance, increased risk of infection and delayed removal of an unnecessary invasive device no longer in use. 2. During a concurrent observation and interview on [DATE] at 10:15 a.m. during the initial tour of the facility in Resident 49's room, Resident 49 was observed sitting at edge of bed holding a handheld nebulizer. Resident 49 appeared appropriately dressed and stated she did not have any concerns. Resident 49 stated she also used oxygen pointing at a portable oxygen concentrator (breathing machine to help with low blood oxygen levels) at bedside, nasal cannula (flexible, plastic tube with two small prongs that fit just inside the nostrils to deliver supplemental oxygen) dated [DATE]. During a review of Resident 49's AR dated [DATE], the AR indicated Resident 49 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease , muscle weakness and heart failure (heart becomes too weak or stiff to pump blood efficiently, failing to meet the body's needs for oxygen. During a review of Resident 49's MDS assessment dated [DATE], the MDS assessment indicated Resident 10's BIMS assessment score was 15 out of 15 which indicated Resident 49 had no cognitive deficit. During a review of Resident 49's OSR dated [DATE], the OSR indicated, .Albuterol Sulfate Inhalation Nebulization Solution (2.5MG/3ML [milligram-unit of measurement/milliliter-unit of measurement] . inhale orally via nebulizer . Order Date: [DATE] . Start Date: [DATE] . During a concurrent observation and interview on [DATE] at 10:20 a.m. with CNA 5 inside Resident 5's room, CNA 5 assisted Resident 49 and turned off the nebulizer machine after Resident 49 asked for the machine to be turned off. CNA 5 stated CNAs are not allowed to turn on or off any machine residents are using, stated not part of our job description. CNA 5 stated HHN machine had medication, and CNAs are not allowed to touch resident medications. CNA 5 stated she asked Resident 49's nurse if she could turn off the nebulizer machine and was told yes by LVN 2. During an interview on [DATE] at 1:35 p.m. with LVN 2, LVN 2 stated she should have stayed with Resident 49 while the HHN machine was still on because there was still medication in the chamber. LVN 2 stated the practice was to stay with residents to ensure medication was completed and Resident 49 received the whole dose of medication. LVN 2 stated it was important to stay with Resident 49 while the machine was on to assess and to monitor for any possible side effects of the medication. LVN 2 stated she misunderstood CNA 5 and did not realize CNA 5 had asked if she could turn off the nebulizer machine. During an interview on [DATE] at 10:18 a.m. with the Director of Staff Development/Infection Preventionist (DSD/IP), she stated CNAs are not allowed to turn on/off oxygen and or nebulizer machines. The DSD/IP stated, It is not part of their job description. The DSD/IP stated LVN 2 should have stayed with Resident 49 while the machine was on and after the medication was completed should have wiped down the tubing and placed it in the bag. During an interview on [DATE] at 11:50 a.m. with the DON, the DON stated her expectation was, Licensed nurses to be around the vicinity within visual when not at bedside during HHN treatment. The DON stated CNAs are not allowed to turn on/off HHN machines and oxygen. During a review of facility's policy and procedure (P&P) titled, Nebulizer, dated [DATE], the P&P indicated, .5. Administer Treatment: Instruct the resident to take slow deep breaths the mouthpiece or mask. Continue until the medication is fully nebulized (15 minutes). Monitor resident for tolerance, adverse reactions, and effectiveness . Record . Resident response (e.g., improvement in breathing, side effects) . 3. During a review of Resident 29's AR, dated [DATE], the AR indicated Resident 29 was admitted to the facility on [DATE] with diagnoses of cirrhosis of liver (a serious condition where the liver became badly scarred and damaged over time), alcohol abuse ( when a person drank too much alcohol too often, in a way that hurt their body, affected behavior, or caused problems in their life) and heart failure ( a condition where the heart did not pump blood as well as it should). During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29 had a BIMS score of 13, which suggested Resident 29 was cognitively intact. Resident 29's MDS indicated he received hemodialysis on admission and during stay. During a concurrent interview and observation on [DATE] at 8:36 a.m. with Resident 29 in his room, the right upper chest permacath was observed covered with a bordered gauze dressing dated [DATE]. The dressing appeared discolored with visible yellow-brown staining noted along the right and lower edges. The adhesive border was lifting and was not fully adherent to the surrounding skin. The central gauze pad appeared soiled. No active drainage was visible externally. The surrounding skin appeared intact without visible redness or swelling. Resident 29 stated he last received hemodialysis one month ago. During an interview on [DATE] at 9:29a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was aware Resident 29 had a permcath. CNA 1 stated her responsibility was to ensure the area remained clean to help prevent infection. CNA 1 stated she cleaned around the site but did not change the dressing. During a concurrent interview and review of Resident 29's electronic health record on [DATE] with Registered Nurse (RN) 1, RN 1 stated Resident 29 had previously been on hemodialysis but was no longer receiving treatments and had not received hemodialysis for some time. RN 1 stated Resident 29 still had his hemodialysis access. RN 1 stated staff cleaned and reinforced the permacath dressing. RN 1 stated she was not sure of the exact frequency and indicated the dressing was to be reinforced and maintained. RN 1 stated she did not see documentation of this task on the Treatment Administration Record (TAR) but staff were aware it was to be performed. RN 1 stated there should have been a care plan addressing the permcath, including care, cleaning and reinforcement of the dressing. RN 1 stated she did not know when the permacath dressing was last changed and stated she had not observed it on that day. During a concurrent interview and review of Resident 29's electronic health record with the Social Services Director (SSD), the SSD stated Resident 29 had been receiving hemodialysis at the time of admission to the facility; however, treatments had since been discontinued. The SSD stated she was unsure of the exact date hemodialysis stopped but believed it occurred during the first week of [DATE]. The SSD stated she had arranged Resident 29's hemodialysis transportation and was unsure whether discharge orders had been received from the dialysis facility. The SSD stated she was aware the facility was working on having Resident 29's permcath removed and believed the facility was waiting to hear back from a physician, although she was unsure which physician. The SSD stated Resident 29 did not have any upcoming appointments scheduled with a nephrologist (kidney doctor). The SSD stated she participated in the interdisciplinary Team (IDT- a group of professionals from different fields that coordinated patient centered care) meetings and confirmed the IDT last met on [DATE]. Review of the IDT meeting notes dated [DATE] did not include documentation addressing the discontinuation of hemodialysis treatments or a plan of care moving forward. During a review of Resident 29's Order Listing Report, dated [DATE], the Order listing Report indicated a discontinued order for hemodialysis was identified. The order had a start date of [DATE] and a revision date of [DATE]. Further review of the Order Listing Report indicated an active order for permcath site (R) chest-ensure dressing remains intact every shift; reinforce as needed. Hemodialysis center provides permcath access maintenance and dressing changes. During a review of Resident 29's Progress notes, dated month of [DATE], the Progress notes indicated Resident 29 last received hemodialysis on [DATE], at which time a post-treatment weight was obtained and the nephrologist (a doctor who specialized in treating kidney problems) recommended holding dialysis for one week. A progress note dated [DATE] indicated the nephrology group (a team of doctors and healthcare providers who specialized in treating kidney problems) contacted the facility to confirm laboratory orders for [DATE] and hemodialysis remained on hold for one week. A progress note dated [DATE] indicated laboratory results were faxed to the nephrologist, and the facility received notification from the nephrology office that Resident 29 no longer required continuation of hemodialysis treatments. During an interview on [DATE] at 12:44 p.m. with the DON, the DON stated residents were required to have current physician orders. The DON stated there should have been a new order for permcath dressing changes after hemodialysis was discontinued and appropriate orders and care should have been in place. During a review of the facility's policy and procedure (P&P) titled, Hemodialysis, dated [DATE], the P&P indicated, The facility will coordinate and collaborate with the dialysis facility to assure that: d. there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 2/22, the P&P indicated, .the IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition change. During a review of the facility's policy and procedure (P&P) titled, Central Venous Catheter Care and Dressing Changes, dated 2/22, the P&P indicated, .perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened, or visibly soiled).maintain sterile dressing for all central vascular access devices.change the dressing if it becomes damp, loosened, or visibly soiled and: a. at least every 2 days for sterile gauze dressing. C. immediately if the dressing or site appear compromised.assess the integrity of securement devices with each dressing change. During a review of Resident 12's admission Record (AR -a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated [DATE], the AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD-lung and airway disease that restricts breathing) , hypertensive heart disease (structural and functional heart damage caused by long-term, unmanaged high blood pressure), and heart failure (condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen). During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE], the MDS indicated Resident 12 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 12 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 12 was moderately cognitively impaired. During an observation on [DATE] at 9:04 a.m., in Resident 12's room, Resident 12 was observed lying in bed with her nasal cannula (a thin, flexible tube with two prongs that fit into the nostrils and deliver oxygen) in her nose. Resident 12's nasal cannula was observed connected to the oxygen concentrator (medical device that helps residents breathe). The oxygen concentrator was observed on the left side of the bed turned on at 2.5 LPM. During a concurrent observation and interview on [DATE] at 10:47 a.m. with Licensed Vocational Nurse (LVN) 2, in Resident 12's room, Resident 12 was observed lying in bed with her nasal cannula in her nose. Resident 12's nasal cannula was observed connected to the oxygen concentrator. The oxygen concentrator was observed on the left side of the bed turned on at 2.5 LPM. LVN 2 stated she was Resident 12's nurse and was familiar with Resident 12's care needs. LVN 2 stated Resident 12 had received oxygen therapy since she was admitted to the facility. During a concurrent interview and record review on [DATE] at 10:50 a.m. with LVN 2, Resident 12's Order Summary Report (OSR), dated [DATE] was reviewed. LVN 2 stated Resident 12 did not have any active, discontinued or expired physician's orders for oxygen therapy. LVN 2 stated oxygen was a medication and required a physician's order to be administered. LVN 2 stated Resident 12 had COPD and was at risk for worsening of her condition if she received too much oxygen outside of her needs. During an interview on [DATE] at 2:44 p.m. with LVN 1, LVN 1 stated oxygen was a medication and required a physician's order to be administered. LVN 1 stated oxygen therapy administered without a physician's order was outside the professional scope of practice for licensed nursing staff. LVN 1 stated residents with COPD and heart failure were at increased risk of hyperoxygenation (excess oxygen) which could result in decreased drive to breathe. LVN 1 stated oxygen toxicity (damage to the lungs that happens from breathing in too much oxygen) could result in serious medical conditions. During an interview with the Director of Nursing (DON) on [DATE] at 12:22 p.m., the DON stated oxygen was a medication and required a physician's order to be administered. The DON stated if oxygen therapy was administered in an emergent situation an order was expected to be placed to reflect the use and continuing use of oxygen therapy. The DON stated Resident 12 was at risk of being over oxygenated when she was administered oxygen therapy with no physician order or oversight. The DON stated professional standards or practice, and facility policy and procedure were not followed when Resident 12 was administered 2.5 LPM of oxygen therapy with no physician order. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated [DATE], 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 goals and preferences.oxygen is administered under orders of a physician, except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable. During a review of the facility's P&P titled, Physician Orders, dated [DATE], the P&P indicated, .medications should be administered only upon the signed order of a person lawfully authorized to prescribe. During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse .

Based on observation, interview, and record review, the facility failed to safely and securely label and store medications ready for residents use when:1.The medication room contained four expired Fexofenadine Hydrochloride (medication used to treat allergy symptoms) 180 milligrams (mg-a unit of measurement for medication) tablet bottles, one expired Dextromethorphan HBr 20 mg Guaifenesin 400 mg (medication used to treat cough and chest congestion symptoms) bottle and two expired 8.5 fluid ounce Vashe wound solution (skin cleanser used for debriding and irrigating wounds) bottles.This failure placed residents at potential risk to receive ineffective or unsafe medications and wound care solutions, which could lead to delayed wound healing, worsening of underlying medical conditions or preventable hospitalization.2. Two over the counter medication bottles and one metered dose inhaler (MDI-small, handheld, pressurized devise used to deliver a specific, measured amount of medication directly into the lungs as a fine mist) were observed on top of Resident 32's over the bed table available for use.This failure placed Resident 32 at potential risk for medication error, experienced adverse drug reactions, or overdose which could lead to serious health condition. During a concurrent observation and interview on 2/17/26 at 11:01 a.m. with the Director of Nursing (DON), in the medication room, four unopened bottles of Fexofenadine Hydrochloride 180 mg were observed with a manufacturer expiration date of 1/2026. One unopened bottle of dextromethorphan HBr 20 mg Guaifenesin 400 mg was observed with a manufacturer expiration date of 11/2025. Two unopened 8.5 fluid ounce Vashe wound solution bottles were observed with a manufacturer expiration date of 2/2025. The DON stated all the items were expired. The DON stated the medication room should not contain any expired medications or wound treatment solutions to prevent accidental administration to residents. The DON stated licensed nursing staff reviewed expiration labels when they removed and opened medication bottles form the medication room for use. The DON stated she reviewed the medication room weekly for expired medications, supplies, and wound treatment solutions and removed expired items. The DON stated the Pharmacist Consultant (PC) reviewed the medication room monthly for expired medications and removed expired medications. During an interview on 2/19/26 at 10:44 a.m. with the Pharmacist Consultant (PC) and Pharmacist Consultant Supervisor (PCS), the PC stated expired medication needed to be removed to prevent accidental administration of expired medication to residents. The PCS stated expired medication efficacy could not be guaranteed past expiration dates. The PC stated the PC did a spot check of the medication room monthly and removed expired medications. The PC stated licensed nursing staff were expected to review expiration labels before opening and removing medications from the medication room. The PCS stated the facility was expected to adhere to all policies and procedures regarding expired medications. The PCS could not state facility policy and procedure regarding expired medications. During an interview on 2/20/26 at 12:22 p.m. with the DON, the DON stated facility policy and procedure was not followed when the medication room contained five expired bottles of Fexofenadine Hydrochloride 180 mg, one bottle of Dextromethorphan HBr 20 mg Guaifenesin 400 mg, and two bottles of Vashe wound treatment solution. The DON stated residents were at risk for accidental administration of expired medications and use of wound treatment solutions which could result in decreased potency of intended doses. During a review of the facility's manual title, California LTC Facility's Pharmacy Services and Procedures Manual, the policy and procedure (P&P) titled, 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, dated 12/1/07, the P&P indicated, .facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier.medications with a manufacturer's expiration date expressed in month and year will expire on the last day of the month.facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other applicable law.facility personnel should inspect nursing stations storage areas for proper storage compliance on a regularly scheduled basis. During a review of the facility's P&P titled, Medication Storage, dated 9/2/22, the P&P indicated, .the pharmacy and all medication rooms 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 facility policy. During a review of the facility's P&P titled, Medication Administration, dated 9/2/22, the P&P indicated, .identify expiration date. If expired, notify nurse manager. 2.During a concurrent observation and interview on 2/17/26 at 9:30 a.m. in Resident 32's room, Resident 32 was observed sitting up in bed applying her make-up. Resident 32 stated she was at the hospital for left leg pain, and she is still in pain. Observed two medication bottles and one MDI on top of her over the bed table. Resident 32 stated her partner brought the medications for her to use. Resident 32 stated she needed the MDI for her breathing and was using it at home prior to going to the hospital. Resident 32 stated she was not sure when she used the inhaler last, but she had used it since her partner brought it in the facility. Resident 32 stated one of the bottles contained lotion and she opened one of the medication bottles and inside was a jellylike white substance which Resident 32 claimed to be lotion. Resident 32 opened the second medication bottle and inside was white powder and stated, It is to help with my constipation. Resident 32 stated she had problems with constipation caused by pain medications she was taking in the facility. Resident 32 stated her partner did not want to bring the whole bottle of the powder medication, so he poured the powder in an empty medication bottle and crossed out over the label and written the instruction on how to take the powder. Resident 32 stated she was not sure if she told the nursing staff about the medications, but she was sure they must have seen the bottles on top of her table but did not say anything and stated, I thought it was OK. During an interview on 2/18/26 at 1:45 p.m. with Licensed Vocational Nurse (LVN)2, LVN 2 stated residents are not allowed to keep medications at bedside. LVN 2 stated she did not remember any nursing staff reporting about medications left at Resident 32's bedside table and did not remember seeing it when she administered Resident 32's medications in the morning. LVN 2 stated Resident 32's partner visits daily and must have brought it and not notified nursing staff. LVN 2 stated the practice was to educate residents and families about the facility practice of not allowing home medications brought in the facility. LVN 2 stated it was dangerous for Resident 32, she could overdose or develop allergic reactions to the medication and other residents could access the medication and take the medication themselves, not knowing if they are allergic to the medication. During an interview on 2/19/26 at 10:18 a.m. with the Director of Staff Development/Infection Preventionist (DSD/IP), the DSD/IP stated residents are not allowed to keep medications at bedside. The DSD/IP stated medications from the hospital and or home are stored in the medication room and be given to residents upon discharge. The DSD/IP stated nursing staff should be paying attention to their surroundings. The DSD/IP stated leaving medications at bedside could cause medication overdose and adverse interaction developed when taken with other medications. During an interview on 2/19/26 at 3:15 p.m. with LVN 1, LVN 1 stated the facility does not allow families to bring medications from home for resident use while in the facility. LVN 1 stated residents are not allowed to keep medications at bedside either because other confused residents could access medications and potentially may cause allergic reactions. LVN 1 stated nursing staff had to document all medications administered to residents. During an interview on 2/20/26 at 11:44 a.m. with the DON, the DON stated the facility does not allow medications to be kept at bedside. The DON stated Resident 32 was alert and oriented, her partner visits daily and brought the medications and did not let the nurse know. The DON stated, We can not go through their belongings to check for medications. The DON stated if Resident 32 wanted to take the medication they could discuss it with her medical doctor (MD) and get an order. The DON stated keeping medications at bedside could potentially put other residents in danger because they could take the medication and develop adverse interaction with other medications leading to more serious health conditions. During a review of facility's policy and procedure (P&P) titled, Medication Storage Policy, date reviewed/revised 2/17/26, the P&P indicated, .All drugs and biologicals are stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature control. During a review of facility's P&P titled, Medications Brought to the Facility by the Resident/Family/Physician/Prescriber, Revision Date: 09/15/24, the P&P indicated, .Facility staff should not administer medications including over-the-counter medications. brought to facility by a resident, a resident's responsible party, or a resident's physician/prescriber without physician/prescriber's order.When medications from the resident's personal inventory are not ordered by the physician/prescriber, Facility staff should return the medications to the resident's family.

Based on observation, interview, and record review the facility failed to ensure an effective infection prevention and control program was maintained for two of 15 sampled residents when:1. The facility did not ensure Resident 5 was tested for COVID-19 (Coronavirus is an infectious respiratory disease) in accordance with the facilities policy and procedure titled COVID-19, after Resident 5 developed a cough. This failure had the potential to delay identification of communicable diseases and increase the risk of transmission to other residents and staff within the facility.2. LVN 1 did not wear enhanced barrier precaution (EBP- infection control intervention designed to reduce transmission of multidrug-resistant organisms) personal protective equipment (PPE- protective equipment designed to protect and prevent spread of infection or illness) while handling Resident 4's gastrostomy tube (G-tube-an indwelling medical device inserted into the stomach) during a enteral feeding (a feeding tube that delivers nutrients directly into the stomach) administration. This failure had the potential to result in the spread of germs and bacteria that could result in infection and illness. 1. During a review of Resident 5's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/19/26, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses of fracture (a break or crack in a bone) of right lower leg, and muscle weakness (the muscles [a soft tissue in the body that helped a person move] did not work as strongly as they usually did). During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/3/26, the MDS indicated Resident 5 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 5 was cognitively intact. During a concurrent observation and interview on 2/17/26 at 8:26 a.m. with Resident 5 in his room, Resident 5 stated he had developed a productive cough beginning on 2/14/26. Resident 5 stated he had been receiving cough syrup, and throat lozenges and had undergone a chest X-ray (imaging test to take pictures of the inside of the body), with results pending at the time of interview. Resident 5 described the cough as painful and stated no other testing had been performed aside from the chest X-ray. During an interview of 2/19/26 at 9:29a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated her role was to observe residents and report any changes in condition to the nurse immediately. CNA 1 stated if a resident had a cough, she would report it to the nurse. During a concurrent interview and record review of Resident 5's electronic health record on 2/19/26 at 10:09a.m. with Registered Nurse (RN)1, RN 1 stated she was the nurse assigned to Resident 5 on 2/14/26 when he developed a cough. RN 1 stated the facilities COVID-19 protocol required resident's exhibiting signs or symptoms of COVID-19 to be tested. RN 1 stated Resident 5 was not tested for COVID-19. Review of Resident 5's Medication Administration Record (MAR) indicated Resident 5 had a PRN (as needed) order for COVID-19 testing, which had not been administered. RN 1 stated testing was important to determine the resident's COVID-19 status. During a concurrent interview and review of Resident 5's electronic health record with the Infection Preventionist/Director of Staff Development (IP/DSD), the IP/DSD stated Resident 5 had developed a cough. The IP/DSD stated she was unsure why the nurse did not test Resident 5 for COVID-19. The IP/DSD stated it was important to identify COVID-19, because it spreads rapidly. The IP/DSD stated the nurse assesses residents and determines if they meet criteria for testing. The IP/DSD further stated testing would have been beneficial to determine Resident 5's COVID-19 status. The IP/DSD stated COVID-19 tests are performed in-house with results available within 15 minutes. During a concurrent interview and record review on 2/20/26 at 12:52 p.m. with the Director of Nursing (DON), the facilities policy and procedure (P&P) titled, COVID-19, date unknown was reviewed. The P&P indicated, clinical criteria: at least one of the following symptoms-cough. The DON stated Resident 5 should have been tested according to the policy, as he already had a PRN order for testing. The DON stated staff could always test for COVID-19. The DON described Resident 5 as being in and out of the facility and stated there was always a risk when individuals were in and out of the facility. 2. During a review of Resident 4's (AR), dated 2/19/26, the AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (a condition of inadequate blood supply to the brain caused by a blockage), gastrostomy status (refers to a surgically opening in the stomach), type 2 diabetes mellitus (a condition of a high buildup of sugar in the blood), and dysphagia (difficulty swallowing). During a review of Resident 4's (MDS), dated [DATE], the MDS indicated Resident 4 had a (BIMS) score of 3 which suggested Resident 4 was severely cognitively impaired. Resident 4's MDS indicated he had a feeding tube. During a review of Resident 4's Order Summary Report (OSR), dated 2/19/26, the OSR indicated, Resident 4 had an active order for enteral feed every 4 hours via G-tube. The OSR indicated Resident 4 was on Enhanced Barrier Precautionsfor enteral feeding via G-tube. During an observation on 2/17/26 at 8:47 a.m., outside of Resident 4's room, Resident 4's room door had an EBP sign posted. The EBP sign stated, .providers and staff must also: wear gloves and gown for the following high-contact resident care activities.device care or use. During a concurrent observation and interview on 2/18/26 with Licensed Vocational Nurse (LVN) 1, in Resident 4's room, LVN 1 was observed handling Resident 4's G-tube with gloves while administering his enteral feeding. LVN 1 was not observed wearing a gown while handling Resident 4's G-tube. During an interview on 2/19/26 at 2:11 p.m. with the Infection Preventionist (IP/DSD), the IP/DSD stated residents with indwelling medical devices, such as G-tubes, were at increased risk of infections. The IP/DSD stated all residents with G-tubes were placed on EBP and staff were required to wear gowns and gloves when handling G-tubes. The IP/DSD stated EBP's were for resident protection and ensured infections were not introduced through the indwelling medical device during handling. During an interview on 2/19/26 at 3:26 p.m. with LVN 1, LVN 1 stated he had not worn a gown while handling Resident 4's G-tube. LVN 1 stated Resident 4 was on EBP and staff were required to wear PPE, gown and gloves, when handling Resident 4's G- tube during enteral feedings to prevent the spread of infections. LVN 1 stated Resident 4's G-tube was an indwelling medical device and Resident 4 was at increased risk of infection if staff did not wear PPE while handing his G-tube. During an interview with the Director of Nursing (DON), the DON stated Resident 4 had a G-tube and was on EBP. The DON stated enteral feeding was a high-contact resident care activity. The DON stated per standards of practice and facility policy PPE, gown and gloves, were both required to be worn when handling Resident 4's G-tube. The DON stated facility policy was not followed when LVN 1 did not wear a gown while administering Resident 4's enteral feeding. The DON stated Resident 4 was placed at increased risk of infection when LVN 1 did not follow EBP policies. During a record review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, undated, the P&P indicated, .enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [Multidrug-resistant organisms that are resistant to many antibiotics] as well as those at increased risk of MDRO acquisition (e.g., residents with.indwelling medical devices.).signage will be posted on the door or wall outside the resident room indicating the type of precaution, required personal protective equipment (PPE) , and the high-contact resident care activities that require the use of gown and gloves.make gown and gloves available prior to performing tasks.

Based on interview and record review the facility failed to ensure a complete and accurate informed consent was obtained prior to the administration of psychotherapeutic medication (prescription drugs designed to manage mental and emotional disorders by altering the brain's chemical makeup and nervous system) for one of five sampled residents (Resident 3) when Resident 3, who was her own representative party (RP-a person designated to received updates of resident's care and make decisions), did not sign an informed consent and was administered clonazepam (psychotherapeutic medication used to manage anxiety disorders) 0.5 milligrams (mg- a unit of measurement for medication dosage).This failure resulted in Resident 3's clonazepam informed consent not being complete and accurate prior to administration which lead to Resident 3 not being fully informed prior to receiving psychotherapeutic medication. During a review of Resident 3's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/19/26, the AR indicated Resident 3 was admitted to the facility on [DATE] with diagnoses of rhabdomyolysis (rapid breakdown of skeletal muscle releasing toxins into the blood), spinal stenosis (narrowing of spinal canal), chronic pain syndrome, and anxiety disorder (excessive, persistent fear or worry). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/6/26 , the MDS indicated Resident 3 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 3 was cognitively intact.During a review of Resident 3's Medical Record, dated 2/19/26, the Order Listing Report (OLR), indicated Resident 3 had an order for clonazepam 0.5 mg every 12 hours, as needed (PRN), for anxiety, from 2/5/26 to 2/17/26. The OLR indicated Resident 12's clonazepam 0.5 mg order was revised on 2/17/26 to be given every 12 hours, scheduled, for 14 days. Resident 3's Psychotherapeutic Drug Informed Consent Form (IC), dated 2/5/26, indicated informed consent had been obtained for Resident 3's clonazepam 0.5 mg every 12 PRN order. Resident 3's Medical Record did not indicate a new IC had been obtained for clonazepam 0.5 mg every 12 hours, scheduled, before administration. Resident 3's Medical Record indicated, clonazepam 0.5 mg every 12 hours, scheduled, had been administered on 2/17/26 at 9:00 p.m. and 2/18/26 at 9:00 a.m., before Resident 3 signed an IC.During a concurrent interview and record review on 2/18/26 at 9:54 a.m. with Registered Nurse (RN) 1, Resident 3's Medical Record, dated 2/18/26 was reviewed. RN 1 stated Resident 3 was her own RP and signed her own informed consents. RN 1 stated she could not locate an informed consent for Resident 3's clonazepam 0.5 mg, every 12 hours, for 14 days, scheduled order. RN 1 stated she could only locate Resident 3's previous order, clonazepam 0.5 mg every 12 hours, PRN, informed consent. RN 1 stated the current informed consent did not match the current order for clonazepam. RN 1 stated any time a psychotherapeutic medication changed, including frequency, a new informed consent was required. RN 1 stated it was important to obtain an informed consent prior to administration of psychotherapeutic medication to ensure the resident was aware of risks, benefits and potential side effects of the medication they were administered. During an interview on 2/18/26 at 10:54 a.m. with Resident 3, in Resident 3's room, Resident 3 stated she was unaware her clonazepam 0.5 mg medication was switched from PRN to scheduled every 12 hours. Resident 3 stated she requested the medication be changed from PRN to every 12 hours scheduled, so she could receive the medication at 9 a.m. and 9 p.m., but she did not know it had gone into effect yet.During a concurrent interview and record review on 2/18/26 at 9:47 a.m. with the Medical Records (MR), Resident 3's Medical Record, dated 2/18/26 was reviewed. The MR stated after informed consents were obtained they were brought to her to upload into the resident chart. The MR stated she reviewed informed consents before upload into the Medical Record to ensure accuracy and completion. The MR stated informed consents required Resident and/or Resident's RP signatures to ensure informed consent was obtained. The MR could not locate a consent for Resident 3's clonazepam 0.5 mg every 12 hours scheduled order.During a concurrent interview and record review on 2/19/26 at 3:49 p.m. with the Director of Nursing (DON), Resident 3's Medical Record, dated 2/19/26, was reviewed. The DON stated Resident 3 was a BIMS of 15, made her own medical decisions and signed her own informed consents. The DON stated on 2/17/26 Resident 3, the provider, and herself spoke on the phone and the provider agreed to switch Resident 3's medication from PRN to scheduled, as per Resident 3's request. The DON stated the provider gave a verbal order to give the medication scheduled. The DON signed her signature, as the receiving licensed nurse of the verbal order, on Resident 3's informed consent on 2/17/26. The DON stated Resident 3 did not sign the informed consent. The DON stated Resident 3's medication was then administered. The DON stated she was taught since the provider was not at bedside, Resident 3 could not sign the informed consent until the provider was at bedside. The DON stated she signed, as the licensed nursing staff, to give informed consent for Resident 3 on 2/17/26. The DON stated on 2/18/26 Resident 3 and the provider signed the informed consent. The DON stated Resident 3 had received two doses of clonazepam 0.5 mg every 12 hours, scheduled, before Resident 3 signed the informed consent.During an interview on 2/20/26 at 12:22 p.m. with the DON, the DON stated she could not locate a policy, in-service, or education that supported Resident 3 not being able to sign informed consent if the provider was not at bedside. The DON stated she reviewed facility policy, previous in-services and education, and facility policy had not been followed in obtaining informed consent for Resident 3. The DON stated licensed nursing staff could sign in place of the resident in emergent situations, but emergent conditions were required to be documented, which they were not. The DON stated an informed consent was required for all psychotherapeutic medications and when medication changes occurred. The DON stated informed consents were important to obtain to ensure residents were aware of their medication, risks, benefits and plan of care changes.During a review of the facility's manual title, California LTC Facility Pharmacy Services and Procedures Manual, the policy and procedure (P&P) titled, 3.8 Psychotropic Medication Use, dated 12/1/07, indicated .all medications used to treat behaviors must have clinical indication.facility staff should inform the resident and/or resident representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulations.During a review of the facility's P&P titled, Informed Consent, dated 1/1/26, the P&P indicated, .the facility shall ensure that informed consent is obtained, documented, maintained, and renewed for all psychotherapeutic drugs administered to residents in accordance with California law, resident rights requirements, and the California Department of Public Health (CDPH) Psychotherapeutic Drug Informed Consent Form CDPH 9168.Psychotherapeutic medications shall not be initiated or continued without valid informed consent, expect in documented emergency situations as permitted by law. this policy applies to all physicians.licensed nurses.pharmacy consultants, and medical records personnel involved in prescribing, administration, monitoring, and documentation of psychotherapeutic medications.a separate CDPH 9168 form shall be completed for each psychotherapeutic drug.informed consent must be obtained prior to administration of the psychotherapeutic drug.consent shall be obtained from the resident or the resident's legally authorized representative.the resident or representative shall sign and date section 15 of the CDPH 9168 form.if the resident of representative is unable to sign the consent form, a licensed nurse may document verification of consent.the licensed nurse shall complete and sign section 16 of the CDPH 9168 form, documenting diligent efforts to obtain the signature and the date consent was provided.in emergency situations where immediate medication is necessary and consent cannot be obtained, psychotherapeutic medication may be administered as clinically indicated.the emergency circumstances and rationale shall be clearly documented.consent shall also be re-obtained when there is a significant dosage change, medication change, restart after discontinuation, or identification of new risk.During a review of the facility's P&P titled, Resident Rights, dated 9/22/22, the P&P indicated, .the resident has the right to be informed of, and participate in, his or her treatment, including: .the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.the right to be informed, in advance, of changes to the plan of care.the right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Based on interview and record review, the facility failed to ensure its policy on against medical advice (AMA-patient chooses to leave before the doctor recommended discharge) was followed for one of three sampled residents (Resident 57) when Resident 57 left the facility AMA on 2/6/26, and there was no documentation the medical doctor (MD) and administrator (ADM) were notified.This failure had the potential to place Resident 57 at risk of health complications, including worsening of her condition. During a review of Resident 57's admission Record (AR- a document containing resident profile information) dated 12/9/25, the AR indicated Resident 57 was admitted to the facility on [DATE] with diagnoses which included right hip effusion (abnormal accumulation of excess fluid within the hip joint capsule), spinal stenosis (narrowing of spinal canal squeezing the nerves and causing pain, numbness, tingling, or weakness), muscle weakness and abnormalities of gait and mobility. During a review of Resident 57's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive, physical abilities and needs) assessment dated [DATE], the MDS assessment indicated Resident 57's Brief Interview for Mental Status (BIMS-screening tool sed to assess resident cognitive status) 0-15 scale (0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit)assessment score was 13 out of 15 which indicated Resident 57 had no cognitive deficit.During an interview on 2/19/26 at 3:01 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was working the day Resident 57 signed herself out AMA and assisted Resident 57's nurse with the process. LVN 1 stated Resident 57 was not happy and wanted to leave. LVN 1 stated he explained what AMA meant and the potential consequences, and Resident 57 signed the AMA form. LVN 1 stated he did not remember notifying or calling the MD and the ADM regarding of Resident 57's decision to leave AMA. During a concurrent interview and record review on 2/19/26 at 3:18 p.m. with Registered Nurse (RN)2, RN 2 stated she was Resident 57's nurse when Resident 57 signed herself AMA on 2/6/26. RN 2 reviewed Resident 57's progress notes and stated she sent a message to the Director of Nursing (DON) but did not notify Resident 57's MD or the ADM. RN 2 stated she assumed the DON notified the ADM. RN 2 stated, I am new in the facility and did not know what to do. During a concurrent interview and record review on 2/20/26 at 10:49 a.m. with Social Service Designee (SSD), Resident 57's SSD notes were reviewed. The SSD stated she did not find any documentation indicating she had spoken with Resident 57 about wanting to go home or requesting a room change. The SSD stated Resident 57 was not happy with her roommate and had been shown different room where she could have moved. The SSD stated she should have notified the ombudsman (an official advocate for resident's rights), but she did not, and did not call Resident 57 to follow-up after leaving AMA. During an interview on 2/20/26 at 12:20 p.m. with the DON, the DON stated, She (Resident 57) threatened to leave so many times and we talked to her but there are no documentations. The DON stated she was not sure about the facility policy on AMA, but we can not keep them against their will. The DON stated she reviewed the nurse documentation when Resident 57 signed herself out AMA. The DON stated the nurse progress note did not indicate the MD and ADM were notified or made aware of Resident 57's decision to leave AMA. During a review of facility's policy and procedure (P&P) titled, Transfer and Discharge (Including AMA), dated 12/19/22, the P&P indicated, . b. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. c. Documentation of this notification should be entered in the nurses' notes by the nursing department. The social service designee should document any discussions held with the resident/family in the social service progress notes .

Based on observation, interview, and record review, the facility failed to ensure Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of five sampled residents (Resident 58) when Resident 58's Infection of the foot in Section M (Skin Condition) was inaccurately coded in the MDS assessment dated [DATE]. This failure had the potential to result in Resident 58's care needs not met and the potential for adverse reaction to not be monitored.During a concurrent observation and interview on 2/17/26 at 10:48 a.m. during initial tour in Resident 58's room, Resident 58 was observed lying in bed with facial grimacing stating he has pain on his right foot. Resident 58's right foot was covered with kerlix roll dressing (sterile, crinkled, cotton gauze bandage used to cover, protect, and pack wounds) from above the left ankle to toes, left foot covered with elastic bandage ( stretchy, woven, and reusable fabric wrap) from below the knee to the toes. Resident 58 stated, The nurse said it is too soon for another pain medication. During a review of Resident 58's admission Record [AR-a document with personal identification and medical information], dated 2/19/26, the AR indicated Resident 58 was re-admitted to the facility on [DATE] with diagnoses which included Methicillin Resistant Staphylococcus Aureus (MRSA-a bacteria that does not respond to antibiotic [medicines that treat bacterial infections by killing bacteria or stopping their growth]) Infection, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and absence of other right toes. During a review of Resident 58's Order Summary Report [OSR], dated 2/19/26, the OSR indicated, .Clean wound to [R] plantar [bottom] foot with NS [Normal Saline-salt water solution] & Pat Dry. Apply iodine soaked gauze to the area and wrap w/ [with] Kerlix QD [daily] . Order Date: 2/16/26, Start Date: 2/17/26 . Clean wound to right heel with NS, pat dry . Start Date 2/17/26 . Vancomycin [antibiotic used to treat severe infections] . Use 250 ml [milliliter-unit measurement] intravenously [into a vein]one time a day for MRSA to BLE [bilateral lower extremity] wounds . Order Date: 2/13/26, Start Date: 2/13/26 . During an interview on 2/17/26 at 9:15 a.m. with Infection Preventionist (IP), the IP stated Resident 58 is on Isolation Precaution due to MRSA to wounds on his feet. The IP stated Resident 58 is currently on intravenous antibiotics for the wounds to his feet. The IP stated Resident 58's wounds are covered with dressings and changed daily. During an interview on 2/19/26 at 9:24 a.m. with Certified Nursing Assistance (CNA) 4, CNA 4 stated she was familiar with Resident 58's care. CNA 4 stated Resident 58 complained of pain on his feet and did not want to be touched to take care of him. During a concurrent interview and record review on 2/19/26 at 1:25 p.m. with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), Resident 58's clinical record was reviewed and she stated Resident 58 was sent out to acute hospital on 1/19/26 for debridement (cleaning out a wound to allow healthy, new tissue to grow) of wounds to bilateral heels. The ADON/IP stated Resident 58 has chronic wounds to heel area. The ADON/IP stated Resident 58 was re-admitted on [DATE] with intravenous antibiotic for MRSA until 3/3/26. During a concurrent interview and record review on 2/20/26 at 11:12 a.m. with Minimum Data Set Coordinator (MDSC), MDSC reviewed Resident 58's Admission/Medicare MDS assessment dated [DATE] Section M, MDSC stated Resident 58 is currently on antibiotic for MRSA to wounds on his foot and did not marked in Section M Resident 58 has infection of the foot. The MDSC stated, I made a mistake, I should have marked it yes. The MDSC stated she will make the correction. The MDSC stated it was her responsibility to ensure MDS assessment were accurate. During an interview on 2/20/26 at 12:30 p.m. with the Director of Nursing (DON), the DON stated her expectation was to ensure MDS assessments are accurate for reimbursement. The DON stated, Accurate MDS assessment was important so we know what is going on with a patient. During a review of the facility document titles, Job Description: MDS, dated [DATE], the Job Description indicated, . Conduct and coordinate the development and completion of the resident assessment (MDS) in accordance with current rules, regulations, and guidelines that govern the resident assessment . Maintain and periodically update written policies and procedures that govern the development, use, and implementation of the resident assessment . During a review of facility's policy and procedure (P&P) titled, Conducting an Accurate Resident Assessment, dated 12/19/22, the P&P indicated, .The appropriate, qualified health professional will correctly document the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status .

Based on observation during the survey period of 2/17/26 through 2/20/26, the facility failed to ensure each bedroom accommodated no more than four residents in 3 of 16 rooms (rooms [ROOM NUMBER]). This failure had the potential for residents to not have reasonable privacy or adequate space.Findings: During the initial tour on 2/20/26 at 10:53 a.m., the following rooms had more than four residents in each bedroom. Although the bedrooms accommodated more than four residents, each room met the particular needs of each resident. There was adequate closet and storage space. Wheelchair and toilet facilities were accessible. There was sufficient room for nursing care and for residents to ambulate. Bedside stands were available for each resident. The health and safety of residents would not be adversely affected by the continuance of this waiver. Room Number Number of Beds11 812 714 8 Recommend waiver continue in effect. _____________________________________HFES Signature Date Request waiver continue in effect. ____________________________________ Facility Administrator Signature Date

Based on interview and record review, the facility failed to recognize and appropriately act on the clinical change in condition for one of three residents, (Resident 1), when: Nursing staff did not notify the physician on 9/12/25 for abnormal blood lab results. Nursing staff did not notify the physician on 9/13/25 for Resident 1's low blood pressure of 91/55 millimeters of mercury (mmHg- unit of measurement), (normal BP 120/80), elevated heart rate (HR) 116 beats per minute (bpm), (normal range 60-100 bpm). Nursing staff did not recognize and act on the clinical decline of Resident 1 on 9/14/25 when Resident 1 had altered mental status, was weaker than normal, had declined in communication, exhibited shortness of breath and distress, with a BP 86/64 mmHg, HR 118 bpm, temperature 99.2 Fahrenheit (F-unit of measurement) and Oxygen saturation (amount of oxygen in the blood) 75% (normal range 95%-100%). These failures resulted in the grandson (GS) of Resident 1 bringing a change in Resident 1's condition to the attention of the nursing staff. This led to avoidable emergency transport to the local acute care hospital (ACH) emergency department and an admission from September 14 through October 3, 2025. During the hospitalization, Resident 1 was diagnosed with potentially avoidable sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection) and acute kidney injury (AKI- when the kidneys suddenly are not able to filter waste products from the blood), which required admission to the intensive care unit (ICU-refers to specialized hospital unit that provides close monitoring and critical care to patients with life-threatening conditions). During a review of Resident 1's admission Record (a summary of important information regarding a patient, which include patient identification, past medical history, insurance status, care provider, family contact information and other pertinent information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis of the arm, leg and trunk on the same side of the body), hemiparesis (weakness on one side of the body), cerebral infarction (stroke-when part of the brain was damaged, because it did not get enough blood and oxygen), dysphagia (when a person had trouble using language because of brain damage, often from a stroke) and diabetes mellitus (a disease where the body had trouble controlling the amount of sugar (glucose) in the blood. During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 11 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had moderate cognitive impairment.During an interview on 9/16/25 at 10:04 a.m., with Adult Protective Services Representative (APS- a public social program services that receives and investigates reports of abuse, neglect, in vulnerable adults), the APS Representative stated she received a call from Resident 1's grandson (GS) on 9/15/25. The APS Representative stated GS reported on 9/14/25, GS visited the facility and found Resident 1 warm to touch, and unresponsive. GS requested staff to check Resident 1's temperature which was recorded at 99 F (Fahrenheit-a temperature [normal range 97.7-98F] scale). The APS Representative stated the staff told GS since the temperature was only 99 F, there was no need to call 911. During an interview on 9/16/25 at 12:54 p.m., with the GS, the GS stated Resident 1 was admitted in the facility for acute rehabilitation (an intensive, goal-oriented therapy that begins soon after a severe injury or illness to help patients regain function and independence) after hospitalization for a stroke (occurs when blood flow to the brain is interrupted). The GS stated, on 9/14/25, between 3 and 4 p.m., he arrived at the facility and observed Resident 1 sitting up in bed with her head tilted back in an uncomfortable position, unresponsive, unable to speak, and felt hot to touch. The GS stated he requested assistance to check Resident 1's temperature. The GS stated the charge nurse took Resident 1's temperature, which was 99 F, but dismissed the findings, stating it was only 99. The GS stated he requested staff to call 911 three times while staff obtained Resident 1's oxygen saturation, which was 75%. The GS stated Resident 1 was transferred to an acute care hospital and later diagnosed with sepsis secondary to urinary tract infection (UTI- infection in the bladder). During an interview on 9/17/25 at 9:18 a.m. with the Director of Nursing (DON), the DON stated the GS of Resident 1 had visited the facility on 9/14/25. The DON reported GS was very upset and requested Resident 1 be sent to the hospital. The DON confirmed Resident 1 was sent to the hospital following his request. During a record review of Resident 1's Acute Care Hospital document titled ED [Emergency Department] Provider Notes (EPN) dated 9/14/25, the EPN indicated, Chief Compliant: Altered Mental Status (AMS hot and tachycardic [elevated HR].). [AGE] year old Spanish speaking female with a medical history of CVA [cerebrovascular accident - blood flow to the brain is interrupted, causing brain cells to die] with left side deficits [weakness on the left side of the body], HTN [hypertension- high blood pressure]. BIBA [brought in by ambulance] due to AMS . At 1600 [4p.m.] today. patient was coming from SNF [skilled nursing facility] where grandson stated he noted patient being altered. EMS [emergency medical services] states that nursing staff last rounded at 1430 [2:30 p.m.] and did not report that patient is altered. HR was 118. BP was 86/64. the patient was hot to touch. Patient was placed on O2 [oxygen] en route [on the way] . Sepsis: Per my clinical assessment, patient has sepsis. During a record review of Resident 1's Acute Care Hospital document titled ED [Emergency Department] Provider Notes (EPN) dated 9/14/25, the EPN indicated, Critical Care. Performed by: [name of physician] Critical care provider statement. Critical care time exclusive of: Bedside assessment. Due to the patient's unstable presentation, the patient required my immediate attention and intervention. I had to stop attending other patients to immediately assess the patient. Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Sepsis (AKI [Acute Kidney Injury, Hyperkalemia [a condition where the potassium level in the blood is too high] . During a record review of Resident 1's Acute Care Hospital document titled Critical Care Progress Notes (CCPN) dated 9/16/25, the CCPN indicated, . This patient is critically ill.On admission, patient was diagnosed with pyelonephritis (an infection of the upper urinary tract, caused by bacteria that ascend from the bladder) in the ED. Despite administration of three liters of crystalloid fluids (an intravenous [IV-into the veins] solution containing water, and electrolytes that can easily pass from the blood stream into the tissues), the patient's hemodynamic status failed to improve. and acute kidney injury with elevated BUN [blood urea nitrogen-waste product when the body breakdowns protein] (62 mg/dl[milligrams per deciliter-unit of measurement]) and creatinine (a normal waste product of the body) (1.89 mg/dl). Urinalysis consistent with urinary tract infection.admitted to the intensive care unit for further management of septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) secondary to pyelonephritis [infection of the kidneys] . During an interview on 9/17/25 at 11:59 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was familiar with Resident 1, having provided care to her when she was initially admitted to the facility. CNA 2 described Resident 1 as a Spanish-speaking resident who had been unable to use her left side and often experienced pain in her left arm due to a skin tear. Although Resident 1 had required assistance with mobility, she had typically been able to assist with turning onto her right side. CNA 2 reported she had worked the P.M. (2:00p.m.-10:30p.m.) shift on 9/14/25. At the beginning of her shift, she had checked Resident 1 and observed that Resident 1 had been asleep. Later during the shift, Resident 1's GS arrived. CNA 2 observed GS speaking to Resident 1 and repositioning her in the bed. CNA 2 stated the GS had then left the room, gone to the nurse's station, and expressed concern, stated that Resident 1 had not been like that the day before. CNA 2 stated Resident 1's vital signs had been obtained, with a temperature of 99.2F and an oxygen saturation level of 75%. Oxygen had been applied, and her oxygen level had improved to 96%. CNA 2 stated Resident 1 had appeared weaker than her normal baseline, had shown changes inher communication, had appeared to be in distress, and had experienced shortness of breath. CNA 2 also stated Resident 1 had been unable to assist with turning, as she normally would have. CNA 2 reported the GS had appeared very concerned and had repeatedly requested that 911 be called. Although the nursing staff had initially indicated they would continue to monitor Resident 1, 911 had ultimately been contacted. During an interview on 9/17/25 at 12:32 p.m., with License Vocational Nurse (LVN) 1, LVN 1 stated on 9/14/25 [EJ10] she worked the p.m. shift (2 p.m.-10:30 p.m.) and was assigned to Resident 1. LVN 1 stated she had cared for Resident 1 previously. LVN 1 stated Resident 1was normally alert with mild confusion, Spanish speaking, able to communicate, able to engage, make eye contact, and was able to use the call light. LVN 1 stated on 9/14/25 during the handoff (the real-time process of a nurse giving detailed, essential patient-specific information, responsibility, and authority to another nurse or team for the purpose of ensuring patient safety and care continuity) from the day shift nurse, Resident 1 was asleep, and no concerns were reported. LVN 1 stated at around 4 p.m., she heard a nurse call for her, reporting Resident 1's family was at the nurse's station and had concerns. LVN 1 stated she went to Resident 1's room. LVN 1 stated when she assessed Resident 1 her oxygen saturation was low and improved to 96%-97% after oxygen was applied. LVN 1 stated Resident 1 was not at her baseline (BIMS of 11) when first assessed, appeared weaker than usual, and had impaired alertness. LVN 1 stated the GS was upset and requested 9-1-1 to be called three to four times. LVN 1 stated Resident 1 was transported to ACH and was not alert at the time of transport. During an interview on 9/17/25 at 2:24 p.m. with CNA 3, CNA 3 stated on 9/14/25, during the day shift (6:00 a.m. to 2:30 p.m.) she was assigned to Resident 1. CNA 3 stated during the first few rounds after breakfast, Resident 1 was quiet and slow to respond, and appeared to be in pain. CNA 3 stated before lunch, Resident 1 requested to call her daughter. CNA 3 stated Resident 1 spoke with her daughter and reported she did not feel well, and her arm hurt . CNA 3 stated she informed the nurse Resident 1 was requesting pain medication .During a concurrent interview and record review on 9/17/25 at 3:21 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Progress notes (PN) were reviewed. The PN indicated on: On 9/10/2025 Resident 1's vitals signs were as follow: BP 101/59 mmHg, T 98.4, HR 114 bpm, Resp [respiratory- the number of breaths a person takes in one minute] 19. On 9/11/2025 no resident assessment (a medical check done for someone living in a care facility to understand their health and needs) was conducted. On 9/12/25 no resident assessment was conducted. On 9/13/25 Resident 1's vital signs were as follows: BP 91/55 mmHg, T 97.3F, HR 116 bpm, resp 18. Resident 1 was oriented to person, breathing normally, with redness to the perineal area (part of the body between the thighs). On 9/14/25 at 9:15 a.m. Resident 1's vital signs were as follows: BP 105/63, T 97.4 F, HR 64, resp 18, and O2 [oxygen] 95% on room air. Resident 1 was alert to self , breathing normal, with redness to the perineal area. On 9/14/25 at 7:38 p.m. Resident 1 had altered mental status (AMS), difficulty speaking, elevated temperature 99.2 F and Oxygen dropped to 75%. Resident 1 was sent to ACH. During a concurrent interview and review of Resident 1's electronic health record on 9/17/25 at 3:21p.m. with LVN 1, LVN 1 stated the facility protocol was to complete a resident assessment daily. LVN 1 stated Resident 1's daily assessment was not completed on 9/11/25 and 9/12/25 and should have been done to detect subtle or sudden changes in resident condition to ensure timely medical interventions. LVN 1 stated Resident 1's low blood pressure of 91/55 and a HR of 116 should have been communicated to the physician by the nurse to ensure timely interventions. During a concurrent interview and record review on 9/17/25 at 3:40 p.m., with LVN 1, Resident 1's Lab Result Report (LRP) dated 9/12/25 was reviewed. The LRP indicated, WBC 17.930 H [high]. BUN 45 mg/dl H [high-indicates that the kidneys may not be functioning properly] . LVN 1 stated as part of the facility's standard protocol for new admissions was to collect basic laboratory (lab) after 3 - 4 days of admission. LVN 1 stated the lab results were received on 9/12/25 at 12:31 p.m., showing an elevated WBC of 17.930, indicating an infection process. LVN 1 stated the physician was not notified of the abnormal lab results and the delay could have contributed to Resident 1's decline on 9/14/25. LVN 1 stated the physician should have been notified of the elevated WBC. During a concurrent interview and record review on 9/17/25 at 4:19 p.m. with the Director of Nurses (DON), the facility's policy and procedure P&P titled Blood Pressure Measuring, revised 9/2010 was reviewed. The P&P indicated, hypotension is defined as blood pressure less than 100/60.hypotension [a condition where the BP is abnormally low] should be reported to the physician. Staff should record several readings throughout the day, including before and after meals. The DON stated the nurse should have notified the physician when Resident 1's BP was 91/55 mmHg with a HR of 116 on 9/13/25, and with an elevated WBC at 17.930, but it was not reported to the physician. The DON stated the nurse should have rechecked Resident 1's BP and HR to confirm accuracy and ensure a safe clinical decision to prevent serious adverse outcomes. The DON stated the daily resident assessment should have been completed to detect early changes in resident's condition and communicated promptly with the physician to ensure timely medical interventions and that was not done for Resident 1. During an interview on 9/19/25 at 11:28 a.m. with Registered Nurse (RN) 1, RN 1 stated she was the nurse assigned to Resident 1 on 9/12/25. RN 1 stated she did not complete Resident 1's daily assessment on 9/12/25. RN 1 stated she should have completed the daily assessment to detect early changes in Resident 1's condition. RN 1 stated she received Resident 1's elevated WBC result of 17.930 on 9/12/25 but did not notify the physician. RN 1 stated the delay of notifying the physician could have contributed to Resident 1's development of sepsis on 9/14/25. RN 1 stated sepsis was an infection process that spreads rapidly to organs in the body, especially in vulnerable residents like Resident 1. During an interview on 10/7/25 at 11:04 a.m. with the GS, the GS stated Resident 1 was discharged from the hospital with Home Health services (a medically necessary skilled care provided by qualified professional in a patient's residence). The GS stated Resident 1 had been hospitalized for approximately one month and was just recently discharged on 10/3/25. The GS stated Resident 1 was still recovering from the infection. During a review of R1's Acute Care Hospital document titled Progress Notes (PN) dated 9/30/25, the PN indicated, Patient is medically discharged . Septic shock, resolved. UTI . AKI, resolved. During a review of the facilities policy and procedure (P&P) titled, Change in a Resident's Condition or Status, revised 11/2015, the P&P indicated, 1. The Nurse Supervisor/Charge Nurse will notify the resident's attending physician or on-call physician when there has been d. a significant change in the resident's physical/emotional/mental condition.2. A significant change of condition is a decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing disease-related clinical interventions b. impacts more than one area of the resident's health status, d. ultimately is based on the judgement of the clinical staff. During a review of the facilities policy and procedure (P&P) titled, Vital Signs, dated 2022, the P&P indicated, nurse aids may be assigned responsibility for obtaining routine vital signs and reporting abnormal findings to the nurse.licensed nurses are responsible for knowing the usual range of a residents vital signs, analyzing and interpreting routine vital signs and notifying the physician of abnormalfindings.4. Acceptable ranges for adults b. pulse 60-100 beats per minute d. blood pressure: average <120/ <80 . During a review of the facilities policy and procedure (P&P) titled, Laboratory Services and Reporting, revised 9/2022, the P&P indicated, promptly notify the ordering physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. During a review of the facilities policy and procedure (P&P) titled, Resident Examination and Assessment, revised 2/2014, the P&P indicated, the purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan.Reporting 2. Notify the physician of any abnormalities such as, but not limited to a. abnormal vital signs, 3. Report other information in accordance with facility policy and professional standards of practice. During a review of a professional reference from https://pathwayhealth.com/change-of-condition-the-quiet-signal-that-demands-a-loud-response/ titled Change of Condition: The Quiet Signal That Demands a Loud Response dated 5/28/25, the professional reference indicated, In the fast-paced world of clinical care, it's often the quietest signs that speak the loudest. A resident who suddenly seems more withdrawn. A subtle shift in appetite. A new complaint of pain. These aren't just passing moments, they could be the first indicators of a Change of Condition (COC), and your clinical instincts are the first line of defense. As nurses, CNAs, and interdisciplinary team members , your ability to recognize and act on these changes is critical-not just for compliance with CMS and RAI guidelines , but for the safety, dignity, and outcomes of the people you care for. This article is your guide to understanding what qualifies as a COC, how to document it effectively, and why your role in this process is not just important, it's essential. Why Early Detection Matters. Early detection of a Change of Condition can be the difference between a manageable intervention and a medical emergency. When clinical staff identify subtle changes early-before they escalate into acute issues, residents benefit from faster treatment, fewer hospital transfers, and better overall outcomes. It also allows the care team to adjust care plans proactively, reducing stress for residents and families alike. During a review of a professional reference from https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/gdmod1.html titled Improving Patient Safety in Long-Term Care Facilities the professional reference indicated, . A change in a resident's condition may mean that he or she is at risk. Action can be taken only if changes are noticed and reported, the earlier the better. Changes that are not reported can lead to serious outcomes, including medical complications, transfer to a hospital, or even death. In order to identify a change in condition and know when to report it, staff need to understand what is normal (baseline) for a particular resident's condition when he or she first comes into the nursing center, and over time after that. Armed with this information, staff will be able to identify changes and decide which ones need to be reported to others on the care team.

Based on interview and record review, the facility failed to provide services which met professional standards of practice for two of the five sampled residents (Resident 1, and Resident 5) when Resident 1 and Resident 5's medications were not available, and the license nurse did not notify the physician the medications were not administered. This failure had the potential risk for Resident 1 and Resident 5 to experience worsening of existing health conditions and delayed medical response. During a record review on 8/7/25 at 11:47 a.m. with the Licensed Vocational Nurse (LVN) at the nurses' station, Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/7/25 was reviewed. The AR indicated Resident 1 was admitted [DATE] with diagnoses of left knee osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), asthma (a chronic lung disease caused by inflammation and muscle tightening around the airways making it hard to breathe), hypertensive heart disease (problems with your heart that can develop if you have high blood pressure), hypothyroidism (thyroid gland doesn't make enough thyroid hormone), attention-deficit (not being able to keep focus), hyperactivity (excess movement that is not fitting to the setting) disorder, hyperlipidemia (high cholesterol), major depressive disorder (persistent feeling of sadness and loss of interest), anxiety (differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety) disorder and dry eye syndrome. During a concurrent interview and record review on 8/7/25 at 11:50 a.m. with the LVN, Resident 1's MAR dated 7/2025 was reviewed. The MAR indicated the Gabapentin (medication used to treat epilepsy [a brain condition that causes abnormal brain electrical activities]) 600 milligrams (mg-unit of measurements) tablet - give 2 tablets by mouth at bedtime for pain, Nortriptyline Hydrochloride (medication used to treat depression and its commonly prescribed for various pain) 10 mg capsule- give 10 mg by mouth at bedtime for depression, Sertraline Hydrochloride (medication used to treat depression and panic disorder) 100 mg tablet - give 100 mg by mouth at bedtime for depression and Icosapent ethyl (omega-3 fatty acids) 1gm capsule-give 1 capsule by mouth two times a day for HLD (hyperlipidemia-abnormal high levels of fats), all scheduled to start on 7/10/25, were not administered due to pending pharmacy delivery. The LVN stated when medications are unavailable and not given, the licensed nurse (LN) should have notified the physician so the physician could decide whether Resident 1 can skip the dose, needs an alternative medication, or should go to the hospital. The LVN stated she could not find any documentation the LN notified the provider. The LVN stated failure to follow the facility's unavailable medication procedure could put Resident 1 at risk for worsening chronic conditions. During a review of Resident 5's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/7/25, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses: right knee effusion (fluids in the tissues around your joint causing swelling), right knee arthritis (joint inflammation), anxiety disorder(differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety), irritable bowel syndrome (a common condition characterized by abdominal discomfort associated with altered bowel movements), and pain. During a review of Resident 5's MAR dated July 2025, the MAR indicated 7/19/25 Brimonidine Tartrate Ophthalmic Solution 0.2% (medication used to lower eye pressure by reducing fluid production in the eye) instill 1 drop in both eyes two times a day for eye lubricant at 18:00 [6 p.m.].Latanoprost Solution 0.0005% (medication used to lower eye pressure by increasing fluid outflow from the eye) instill 1 drop in both eyes at bedtime for eye lubricant at 20:00 [8 p.m.]. were held. During a review of Resident 5's Progress Note dated 7/19/25 indicated Brimonidine Tartrate Ophthalmic Solution and Latanoprost Solution 0.005% were pending delivery. During an interview on 8/7/25 at 2:37 p.m. with the Registered Nurse (RN), the RN stated when medications were not available, the LN would call the pharmacy to find out when the medications would be delivered. The RN stated if medications were not given, the LN would document in the MAR and progress note. The RN stated if medications ordered were new and the facility was awaiting pharmacy to deliver the medications; the LN did not need to notify the physician. During an interview on 8/14/25 at 3:15 p.m. with the Director of Nursing (DON), the DON stated the LN should have notified the physician when medications are unavailable and not given. The DON stated the nurse should have called the physician to report the medications were not available so the physician could decide if an alternative medication was needed. The DON stated the LN placed the residents at risk for worsening chronic health conditions by not reporting to the physician the medications were not given. The DON stated notifying the physician of medications not available and not given was standard practice. During a review of the facility's policy and procedure (P&P) titled, 7.0 Medication Shortages/Unavailable Medications, dated 8/01/24, the P&P indicated 5. If the medication is unavailable from Pharmacy or third-party Pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate Physician/Prescriber orders, as necessary. 6. If the medication is unavailable from the Pharmacy.Facility should collaborate with Pharmacy and Physician/Prescriber to determine a suitable therapeutic alternative. 7. If Facility nurse is unable to obtain a response from the attending Physician/Prescriber in a timely manner, Facility nurse should notify the nursing supervisor and contact Facility's Medical Director for alternate orders/directions, making sure to explain the circumstances of the medication shortage.9. When a missed does is unavoidable, Facility nurse should document the missed dose, and the explanation for such missed dose, on the MAR (Medication Administration Record) or TAR (Treatment Administration Record) and the nurse's notes per Facility policy.During a review of the National Library of Medicine Professional Referenced titled, Nursing Rights of Medication Administration, published 4/4/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK560654/) the reference indicated, .Right time-administering medications at a time that was intended by the prescriber.A guiding principle of this ‘right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability of other chemical mechanisms.

Based on interview and record review, the facility failed to follow professional standards practice and the facility's policy and procedure for one of four sampled residents (Resident 1) when Resident 1 was not administered medications as ordered by the physician on 5/23/25. This failure had the potential for Resident 1 to experienced worsening chronic conditions, health deterioration, re-hospitalization and or death. Findings: During a concurrent interview and record review on 6/12/25 at 3:33 p.m. with Licensed Vocational Nurse (LVN 2) at the nursing station, Resident 1's Medication Administration Record (MAR) and Progress Notes dated 5/23/25 were reviewed. The MAR, dated 5/23/25 at 9 a.m. indicated Resident 1 did not receive Allopurinol for gout (a type of inflammatory arthritis that causes pain and swelling in your joints, usually as flares that last for a week or two, and then resolve) , Duloxetine for depression (feelings of sadness don't go away and can get in the way of your everyday life), Empagliflozin for Diabetes Mellitus Type 2 Mellitus (DM2- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), Linagliptin for DM2, and Rifaximin for cirrhosis (a type of liver damage where healthy cells are replaced by scar tissue ) due to code 11 which indicated the medication was not available. The Progress Notes (PN) dated 5/23/25 indicated the Licensed Nurse (LN) did not document the provider was notified of Resident 1's missed medication dose. LVN 2 stated when a medication is unavailable and cannot be administered, the nurse was required to notify the prescribing physician so appropriate actions can be taken, such as ordering a substitute medication or directing staff to monitor Resident 1 for change of conditions. LVN 2 stated this failure could place Resident 1 at risk for worsening of chronic medical condition, overall health decline, increased chances of rehospitalization, or even death. LVN 2 stated the licensed nurse did not follow facility's policies and procedure for missed medication. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 6/13/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses: encephalopathy (a disturbance of brain function that causes confusion, memory loss and coma in severe cases ), DM2, other liver cirrhosis, chronic gout, anxiety disorder (differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety), and recurrent Major Depressive Disorder. During a review of Resident 1's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 5/22/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 14 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had no cognitive impairment. During a concurrent interview and record review on 6/12/25 at 4:57 p.m. with the Director of Staff Development (DSD) in the DSD's office, Resident 1's MAR and Progress Notes dated 5/23/25 were reviewed. The MAR, dated 5/23/25 at 9 a.m. indicated Resident 1 did not receive Allopurinol for gout, Duloxetine for depression, Empagliflozin for Diabetes Mellitus Type 2 Mellitus, Linagliptin for DM2, and Rifaximin for cirrhosis due to code 11 which indicated the medication was not available. The PN dated 5/23/25 indicated the LN did not document the provider was notified of Resident 1's missed medication dose. The DSD stated the LN should have notified the physician of the missed dose and documented the communication with the physician but did not. The DSD stated when a medication dose was missed and the provider was not informed, Resident 1 might not maintain the correct therapeutic drug level (the specific amount or concentration of a drug or medicine that needs to be present in a person's bloodstream to produce the desired positive effect). The DSD stated this could lead for Resident 1's chronic health condition becoming worse. The DSD stated the LN did not follow the facility's policies and procedure for missed medication dose. During a review of the facility's policy and procedure titled, Administering Medications, revised 12/2012, the policy indicated 3. Medications must be administered in accordance with the orders, including any required time frame. 4. Medications must be administered within one (1) hour of their prescribed time . During a review of the facility's P&P titled, IF11: Unavailable Medications not dated, the P&P indicated B. Nursing staff shall: 1) Notify the attending physician of the situation and explain the circumstances, expected availability and optional therapy(ies) that are available. a. If the facility nurse is unable to obtain a response from the attending physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. 2) Obtain a new order and cancel/discontinue the order for the non-available medication. 3) Notify the pharmacy of the replacement order. During a review of the National Library of Medicine Professional Referenced titled, Nursing Rights of Medication Administration, published 4/4/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK560654/) the reference indicated, .Right time-administering medications at a time that was intended by the prescriber .A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability of other chemical mechanisms .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen according to facility policy and procedures and the FDA (Food and Drug Administration-is a government agency responsible for protecting the public health) Food Code when: 1. There was brown, grey, and black debris observed in several areas in the kitchen, including one ventilator fan in the milk refrigerator, two vents above the dishwasher area, one vent in front of the milk refrigerator and one vent in front of the food warming table. 2. There was black and brown debris found on the cabinet shelves next to the stored clean bowls. 3. There was brown debris on every shelf inside of one food cart. 4. There was brown debris on top of the toaster and brown particles found inside the toaster. 5. There was a beef roast inside a plastic bag covered in ice stored in the meat freezer. These failures had potential for cross contamination (when harmful bacteria accidentally moves from one food item to another) and exposure of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) of residents' food resulting in food-borne illness (stomach illness acquired from ingesting contaminated food) to a population of 53 of 54 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 12/3/24 at 7:40 a.m., with the Dietary Manager (DM), in the kitchen, the ventilator fan in the milk refrigerator had black debris. The milk and juice ready for resident consumption were stored directly underneath the fan. The DM stated the black debris in the ventilator fan should have been cleaned. The DM stated the drinks stored underneath the ventilator fan were ready to go [ready for residents' consumption] to residents. During a concurrent observation and interview on 12/3/24 at 8:13 a.m., with the DM, in the kitchen, two vents on the ceiling above the dishwasher, one above the food warmer and one in front of the milk refrigerator had brown, grey and black debris. The DM stated the two vents were dirty and needed to be cleaned. During an interview on 12/5/24 at 2:37 p.m., with the Infection Preventionist (IP), the IP stated the vents and fan in the milk refrigerator were dirty and needed to be cleaned. The IP stated the black stuff, I don't know what that is. The IP stated cross contamination (when harmful bacteria accidentally move from one food item to another) could have occurred. The IP stated potential outcomes for residents would be gastrointestinal (the organs and systems that process food and liquids in the body) infections with hospitalization s up to death. During an interview on 12/5/24 at 3:45 p.m., with the DM, the DM stated the expectation would be for the vents and fans to be clean with no debris. The DM stated there was potential for cross contamination to have occurred to residents. The DM stated residents could get sick. The DM stated the facilities Sanitation policy was not followed. During an interview on 12/5/24 at 4:35 p.m., with the Maintenance Director (MD) the MD stated he was responsible for cleaning the vents and the vents should have been clean and spotless and were not. The MD stated residents could have been affected by airborne pathogens (bacteria floating in the air which attach to surfaces of products or fall down to the ground) and dust from the debris on the vents. The MD stated the Sanitation policy and procedure was not followed. During an interview on 12/10/24 at 9:20 a.m., with the Director of Staff Development (DSD)/IP, the DSD stated the expectation was for the vents and fan to be cleaned and replaced if needed. The DSD stated residents could get sick from cross contamination. The DSD stated the policy and procedure Sanitation was not followed by kitchen and maintenance staff. During an interview on 12/10/24 at 10:17 a.m., with the Registered Dietician (RD), the RD stated the expectation was for the vents and fan to be cleaned every month and as needed, but they didn't appear to be. The RD stated cross contamination could have occurred to residents. The RD stated dust or particles could have fell in food and caused a food-borne illness. The RD stated food-borne illness could cause sickness, weight loss and death. The RD stated staff did not follow the facility kitchen Sanitation policy and procedure. During a review of FDA (Food and Drug Administration) Food Code 2022, 4-602.13 Nonfood-Contact Surfaces, the FDA Food Code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. During a review of FDA (Food and Drug Administration) Food Code 2022, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-27B Contact Surfaces, and Utensils, the FDA Food Code indicated, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, POLICY: The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. PROCEDURE: . 11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams cracks and chipped areas . 16. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents . which will be cleaned by maintenance staff . 2. During a concurrent observation and interview on 12/3/24 at 8:10 a.m., with the DM, in the kitchen, two cabinet shelves had black and brown debris. and next to the shelves were stored clean bowls. The DM stated, the cabinet shelves should be cleaned to prevent cross contamination. During an interview on 12/5/24 at 2:37 p.m., with the IP, the IP stated the black and brown debris on the shelves next to the stored clean bowls looked like rust. The IP stated the shelves with black and brown debris should have been replaced. The IP stated cross contamination could have occurred. The IP stated potential outcomes for residents would be gastrointestinal infections with hospitalization s up to death. During an interview on 12/10/24 at 9:20 a.m., with the DSD/IP, the DSD stated the shelving and cabinet with black and brown debris should have been cleaned and/or replaced. The DSD stated residents could get sick from cross contamination. The DSD stated the Sanitation policy and procedure was not followed by kitchen staff. During an interview on 12/10/24 at 10:17 a.m., with the RD, the RD stated the black and brown debris on the shelves looked like corrosion and was not in good repair. The RD stated cross contamination could have occurred to residents. The RD stated particles could fall from the shelves and get into the food which could cause food-borne illness. The RD stated food-borne illness could result in resident sickness, weight loss and death. The RD stated staff did not follow the facility kitchen Sanitation policy and procedure. During a review of FDA (Food and Drug Administration) Food Code 2022, 4-602.13 Nonfood-Contact Surfaces, the FDA Food Code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. During a review of FDA (Food and Drug Administration) Food Code 2022, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-27B Contact Surfaces, and Utensils, the FDA Food Code indicated, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, POLICY: The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. PROCEDURE: . 11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams cracks and chipped areas . 16. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents . which will be cleaned by maintenance staff . 3. During a concurrent observation and interview on 12/3/24 at 8:15 a.m., with the DM, in the kitchen, the food cart shelves had brown debris. The DM stated the tray cart should have been cleaned and was not. The DM stated, I don't know what that is [brown debris in the food cart shelves]. The DM stated prepared resident food trays were stored inside the cart and cross contamination could have occurred. During an interview on 12/5/24 at 2:37 p.m., with the IP, the IP stated prepared resident food were stored inside food carts and cross contamination could have occurred. The IP stated the food cart needed to be replaced. The IP stated potential outcomes for residents would be gastrointestinal infections with hospitalization s up to death. The IP stated kitchen Sanitation policy and procedure was not followed. During an interview on 12/10/24 at 9:20 a.m., with the DSD/IP, the DSD stated the food cart needed to be cleaned and replaced. The DSD stated residents could get sick from cross contamination. The DSD stated the Sanitation policy and procedure was not followed by kitchen staff. During an interview on 12/10/24 at 10:17 a.m., with the RD, the RD stated the expectation was for the food cart to be clean and was not. The RD stated residents could have gotten food-borne illness from cross contamination which could result in resident sickness, weight loss and death. The RD stated staff did not follow the facility kitchen Sanitation policy and procedure. During a review of FDA (Food and Drug Administration) Food Code 2022, 4-602.13 Nonfood-Contact Surfaces, the FDA Food Code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. During a review of FDA (Food and Drug Administration) Food Code 2022, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-27B Contact Surfaces, and Utensils, the FDA Food Code indicated, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, POLICY: The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. PROCEDURE: . 11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams cracks and chipped areas . 16. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents . which will be cleaned by maintenance staff . 4. During a concurrent observation and interview on 12/3/24 at 7:56 a.m., with the DM, in the kitchen, brown debris was found on top of the toaster and brown particles were found inside the toaster. The DM stated the expectation for the toaster was to be clean and not have crumbs (small fragments of bread or crackers). During an interview on 12/5/24 at 2:37 p.m., with the IP, the IP stated the toaster should have been clean. The IP stated cross contamination could have occurred. The IP stated potential outcomes for residents would be gastrointestinal infections with hospitalization s up to death. The IP stated kitchen Sanitation policy and procedure was not followed. During an interview on 12/5/24 at 3:45 p.m., with the DM, the DM stated staff did not follow the kitchen policy and procedures. During an interview on 12/10/24 at 9:20 a.m., with the DSD/IP, the DSD stated it looked like grease on top of toaster. The DSD stated the toaster needed to be cleaned and/or replaced. The DSD stated residents could get sick from cross contamination. The DSD stated the policy and procedure Sanitation and Electrical Food Machines were not followed by kitchen staff. During an interview on 12/10/24 at 10:17 a.m., with the RD, the RD stated the expectation for the toaster was to be clean and was not. The RD stated there was corrosion (the gradual breakdown of material) on top of the toaster. The RD stated residents could have gotten a food-borne illness from cross contamination. The RD stated food-borne illness could cause resident sickness, weight loss and death. The RD stated staff did not follow the facility kitchen Sanitation and Electrical Food Machines policy and procedures. During a review of the facility's policy and procedure (P&P) titled, Electrical Food Machines, dated 2023, the P&P indicated, .Keep and maintain all food machines in good operating, sanitary condition. This includes . toasters . TOASTERS: 1. Clean daily. 2. Remove crumbs from the crumb tray daily and wipe the toaster case with a soft, damp cloth. If the case is greasy, use a non-abrasive cleaning compound to clean it . During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the P&P indicated, POLICY: The Food & Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. PROCEDURE: . 11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams cracks and chipped areas . 16. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents . which will be cleaned by maintenance staff . During a review of FDA (Food and Drug Administration) Food Code 2022, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-27B Contact Surfaces, and Utensils, the FDA Food Code indicated, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. 5. During a concurrent observation and interview on 12/3/24 at 8:03 a.m., with the DM, in the kitchen, a beef roast inside a plastic bag covered in ice, was stored inside the meat freezer. The DM stated, it [roast beef] is not supposed to look like that. During an interview on 12/5/24 at 3:45 p.m., with the DM, the DM stated the expectation for the roast was not have any ice buildup. The DM stated bacteria could have grown on the roast and residents could get sick. During an interview on 12/10/24 at 9:20 a.m., with the DSD/IP, the DSD stated the roast had freezer burnt and the roast quality was not good and should be thrown away. The DSD stated residents could get food-borne illness from eating the roast. During an interview on 12/10/24 at 10:17 a.m., with the RD, the RD stated the roast was not sealed properly and had freezer burn (when the meat becomes dry and tough due to moisture loss from being exposed to cold air in the freezer). The RD stated the roast should have been discarded (thrown in the trash). The RD stated the freezer burn would affect the quality of the meat and texture. The RD stated staff did not follow the facility kitchen Freezer Storage policy and procedure. During a review of the facility's policy and procedure (P&P) titled, Freezer Storage, dated 2023, the P&P indicated, .PROCEDURE: . 5. Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn .

Based on observation, interview and record review, the facility failed to maintain an effective infection prevention and control program for 54 of 54 sampled residents when: 1. The facility's Water Management Program (WMP) was not implemented since 4/8/22 to reduce the risk of Legionella (waterborne bacteria which can cause life threatening pneumonia - a lung infection) and other waterborne pathogens (germs that cause disease) in accordance with the facility's WMP. This failure placed the residents at risk for cross contamination (when harmful bacteria accidentally move from one food item to another), infection and had the potential for not identifying the risk of waterborne illnesses such as Legionella. 2. Resident 13 and Resident 30's oxygen nasal cannula (a small thin flexible tube with two prongs that fit into the nostrils and connects to an oxygen source) was on the floor. These failures placed Resident 13 and Resident 30 at risk for cross contamination which could result in infections and illness. 3. Licensed Vocational Nurse (LVN) 2 did not wipe or sanitize Resident 14's two inhaler's mouthpiece after use and prior to puting the inhalers in the box. This failure had the potential for Resident 14 to develop infection which could lead to serious health condition. Findings: 1. During a concurrent interview and record review on 12/6/24 at 2:39 p.m. with the Maintenance Director (MD), the facility policy and procedure titled WMP, dated 4/2022 was reviewed. The WMP indicated, . [Facility Name] promotes proactive steps to establish healthy, infection-free environments for their residents, staff and visitors. When residents contact Legionnaires' disease, it is often the result of exposure to inadequately managed building water systems, which can be prevented. Date of Plan Review: 4/8/22 .Water Management Team . Maintenance Director . Administrator . Director of Staff Development . Director of Nursing . Infection Prevention . The MD stated the last facility annual review of the WMP was in April 2022. The MD stated he was responsible for Legionella oversight in the facility. The MD stated he has been in his position since April 2024 and had never been part of an annual review or committee for Legionella. The MD stated a yearly review of the WMP was important to identify areas in the facility where legionella could grow, implement interventions to reduce the risk of legionnaires disease and ensure early detection. The MD stated due to a lack of WMP annual review, legionella could have been in building undetected. During an interview on 12/6/24 at 3:20 p.m., with the Infection Preventionist (IP), the IP stated she had not been part of an annual review or committee for legionella. The IP stated Legionella was a reportable communicable disease. The IP stated due to the lack of an annual review, the facility could have missed legionella in the water system. The IP stated the facility did not follow the WMP policy and procedure for Legionella. During an interview on 12/10/24 at 3:05 p.m. with the Administrator (ADM), the ADM stated the facility had not conducted an annual review of the WMP for Legionella since 4/2022 and he had not been part of an annual review for Legionella. The ADM stated the WMP policy and procedure for Legionella was not followed. During a review of the facility's policy and procedure (P&P) titled, Legionella Water Management Program, dated July 2017, the P&P indicated, Policy Statement: our facility is committed to the prevention, detection and control of waterborne contaminants, including Legionella . Policy Interpretation and Implementation: 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team will consist of at least the following personnel: A. The infection preventionist. B. the administrator. C. The medical director. D. The director of Maintenance and E. The director of environmental services . 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of legionnaires disease. 4. The water management program used by our facility is based on the Centers for Disease Control and Prevention . recommendations for developing a Legionella water management system. 5. The water management program includes the following elements: . 6. The Water Management Program will be reviewed at least once a year, or sooner if any of the following occur: A. the control limits are consistently not met; B. There is a major maintenance or water service change; C. There are any disease cases associated with the water system; or D. There are changes in laws, regulations, standards, or guidelines . 2. During an observation on 12/3/24 at 8:38 a.m., in Resident 13's room, Resident 13 oxygen nasal cannula was on the floor while her oxygen concentrator (a medical device that gives patient supplemental oxygen) continued to deliver oxygen. During an observation on 12/3/24 at 3:45 p.m., in Resident 30's room, Resident 30's oxygen nasal cannula was on the floor while her oxygen concentrator continued to deliver oxygen. During a concurrent observation and interview on 12/3/24 at 4 p.m., with Licensed Vocational Nurse (LVN) 2, in Resident 30's room, Resident 30's nasal cannula was on the floor while her oxygen concentrator continued to deliver oxygen therapy. LVN 2 stated the nasal cannula should not be on the floor and was an infection control issue. LVN 2 stated cross contamination (when harmful bacteria accidentally move from one food item to another) could have occurred. During a concurrent observation and interview on 12/3/24 at 4:05 p.m., with LVN 2, in Resident 13's room, Resident 13's oxygen nasal cannula was on the floor while her oxygen concentrator continued to deliver oxygen therapy. LVN 2 stated the oxygen nasal cannula should not be on the floor. LVN 2 stated the nasal cannula should be replaced. During a review of Resident 13's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated, Resident 13 was admitted to the facility on [DATE] with a diagnosis which included Chronic Obstructive Pulmonary Disease (COPD- a common lung disease that makes it difficult to breathe) and acute respiratory failure with hypoxia (lungs are suddenly not able to get enough oxygen into their blood, causing a lack of oxygen throughout their body). During a review of Resident 13's Order Listing Report (OLR), dated 12/10/24, the OLR indicated, . [Resident 13] . Order Summary: Oxygen therapy- Apply Oxygen at 4 liters (unit of measurement) per/minute as needed for COPD . Order status: Active . Created Date/By: 11/3/24 . During a review of Resident 30's Face Sheet, the face sheet indicated, Resident 30 was admitted to the facility on [DATE] with a diagnosis which included acute respiratory failure with hypoxia, asthma (a chronic lung disease that makes it difficult to breathe) and Morbid Obesity (a person's weight that exceeds an individual's desirable weight by more than 100 pounds). During a review of Resident 30's Order Listing Report (OLR), dated 12/10/24, the OLR indicated, . [Resident 30] . Order Summary: Oxygen therapy- Apply Oxygen at 4 liters (unit of measurement) per/minute as needed for acute respiratory failure . Order status: Active . Created Date/By: 11/11/24 . During an interview on 12/5/24 at 2:37 p.m., with the Infection Preventionist (IP), the IP stated the oxygen nasal cannula on the floor was unacceptable. The IP stated the potential outcome for a resident could be an infection, rehospitalization and even death. The IP stated cross contamination for Resident 13 and Resident 30 could have occurred. The IP stated staff did not follow the facility policy and procedure for Oxygen Administration. During an interview on 12/10/24 at 9:20 a.m., with the Director of Staff Development (DSD)/IP, the DSD stated the oxygen nasal cannula on the floor would have been considered infectious and needed to be thrown away and replaced. The DSD stated Resident 13 and Resident 30 had the potential for an infection and could get really sick. During an interview on 12/10/24 at 2:34 p.m. with the Director of Nursing (DON), the DON stated the expectation was for the oxygen nasal cannula to be on Resident 13 and Resident 30's nose and not on the floor. The DON stated Resident 13 and Resident 30 could have acquire bacteria and germs from cross contamination. The DON stated the facility's policy and procedure for Oxygen Administration was not followed by staff. During a review of a professional reference from https://www.homecaremag.com/february-2020/dont-let-oxygen-concentrator-lead-infection titled Don't Let an Oxygen Concentrator Lead to Infection, Dated 1/2020, the professional reference indicated, .2 In Use Nasal Cannula . For patients switching to portable oxygen or pro re nata home oxygen administration, nasal cannula storage can be problematic. The nasal cannula prongs often become contaminated when patients don't properly protect the cannula between uses (i.e., leaving the nasal cannula on the floor, furniture, bed linens, etc.). Then the patient puts the contaminated nasal cannula back in their nostrils and directly transfers potentially pathogenic organisms from these surfaces onto the mucous membranes inside their nasal passages, putting them at risk of developing a respiratory infection. Educate the patient on how to store the nasal cannula between uses in a manner that does not allow it to have direct contact with potentially contaminated surfaces. Either keep the in-use nasal cannula somewhere that does not allow contact with a surface or place it on a cleaned surface, inside an open clean container, or in an open plastic bag . 40641 3. During a review of Resident 14's Admission Record, dated 12/6/24, the AR indicated Resident 14 was admitted to the facility on [DATE], with diagnoses which included congestive obstructive pulmonary disease [COPD- a chronic lung disease causing difficulty breathing]) and asthma [a chronic lung disease that causes inflammation and tightening of the muscles around the airways, making breathing difficult]). During concurrent observation and interview on 12/6/24 at 10:45 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 prepared Resident 14's medications including two inhalers. Resident 14 administered her inhalers and gave inhalers back to LVN 2 and LVN 2 placed the inhalers back in the box without cleaning or sanitizing the mouth piece. LVN 2 stated he should have wiped the inhaler's mouthpiece before putting it back in the box because Resident 14 put the inhaler in her mouth and mouth have bacteria. LVN 2 stated, Moisture is a breeding ground for bacteria, and mouth is moist all the time. LVN 2 stated not sanitizing or wiping the mouth piece of the inhaler could result in respiratory infection. During an interview on 12/10/24 at 1:46 p.m. with Infection Preventionist (IP), the IP stated the practice was to clean or rinse the mouthpiece of inhalers after each use use to prevent infection. The IP stated bacteria could grow around the mouthpiece when not cleaned and transferred in the oral cavity and when inhaled goes straight in the lungs and cause infection. During an interview on 12/10/24 at 5:30 p.m. with the Director of Nursing (DON), the DON stated her expectation was to wipe the inhaler's mouthpiece after each use. The DON stated mouth have bacteria and when the inhaler's mouthpiece was placed in the mouth and not cleaned after use, bacteria could multiply and transfer to the mouth, causing infection which could lead to serious health condition. During a review of facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, . Staff follows established facility infection control procedures ([ . handwashing, antiseptic technique, gloves .]) for the administration of medications, as applicable .

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for nine of 13 sampled residents (Residents' 2, 4, 6, 9, 14, 21, 26, 29, 31, 34, and 106) when: 1. Licensed Vocational Nurse (LVN) 1 checked Resident 106's blood sugar level (BS-amount of sugar in the blood) without closing the privacy curtain or the door. 2. LVN 3 checked Resident 34's blood pressure (B/P-measures the pressure of circulating blood against the walls of blood vessels [channels that carry throughout the body]) and did not provide privacy. 3. LVN 3 administered medications to Residents' 2, 4, 6, 9, 21, 26, 29, 31, and 34 without closing the privacy curtain. These failures resulted in Resident 2, 4, 6, 9, 21, 26, 29, 31, 34, and 106 not provided respect and dignity during care which could potentially impact residents' well-being leading to vulnerability, decreased dignity, anxiety, stress and depression. Findings: 1. During a concurrent observation and interview on 12/5/24 at 4:35 p.m. in the East Wing cart with LVN 1, LVN 1 entered Resident 106's room. Resident 106 was lying in bed and inside the room with Resident 106 was another resident, facility staff, and a visitor. LVN 1 approached Resident 106 bedside and checked his blood sugar without closing the privacy curtain or the door, while the other resident, staff and the visitor watched LVN 1 performed the BS checked to Resident 106. LVN 1 stated he did not close the privacy curtain or the door when he checked Resident 106's blood sugar and should have. During a review of Resident 106's clinical record titled, Admission Record (AR-a medical document which contains resident's medical history, current health status, diagnosis, medications, and legal documents), dated 12/6/24, the AR indicated Resident 106 was admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar level in the blood) and respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood). During a review of Resident 106's Minimum Data Set (MDS- a standardized tool that collects clinical and demographic information about residents in a nursing home), assessment dated [DATE], the MDS indicated Resident 106's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 106 had no cognitive deficit. During an interview on 12/10/24 at 1:55 p.m. with Infection Preventionist (IP), the IP stated the facility practice was to provide privacy and to maintain residents' dignity during care. The IP stated LVN 1 should have closed the privacy curtain or closed the door to ensure staff and visitors walking in the hallway would not see LVN 1 checked Resident 106's blood sugar. 2. During a concurrent observation and interview on 12/5/24 at 5:39 p.m. in the west wing inside Resident 34's room, Resident 34 was sitting in her wheelchair at bedside. LVN 3 approached Resident 34 and checked Resident 34's blood pressure without closing the privacy curtain or the door, while staff and other residents was outside the room walking by the hallway. LVN 3 stated she did not provide privacy to Resident 34 when she checked the blood pressure and should have closed the privacy curtain. During a review of Resident 34's clinical record titled, AR, dated 12/6/24, the AR indicated Resident 34 was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure) and pain. During a review of Resident 34's MDS, assessment dated [DATE], indicated Resident 34's BIMS assessment score was 13 out of 15 indicating Resident 34 had no cognitive deficit. 3. During an observation on 12/5/24 at 5:05 p.m. in the west wing hallway, LVN 3 prepared Resident 31's medications. LVN 3 walked inside Resident 31's room and Resident 31 was sitting on her wheelchair. LVN 3 proceeded to administer Resident 31's medication without closing the privacy curtain. During a review of Resident 31's clinical record titled, AR, dated 12/6/24, indicated Resident 31 was admitted to the facility on [DATE] with diagnoses which included diabetes and back pain. During a review of Resident 31's MDS, assessment dated [DATE], indicated Resident 31's BIMS assessment score was 15 out of 15 indicating Resident 34 had no cognitive deficit. During an observation on 12/5/24 at 5:15 p.m. in the west wing hallway, LVN 3 prepared Resident 21's medications. LVN 3 walked inside, and Resident 21 was lying in bed watching TV. LVN 3 proceeded to administer Resident 21's medications without closing the privacy curtain. During a review of Resident 21's clinical record titled, AR, dated 12/6/24, indicating Resident 21 was admitted to the facility on [DATE] with diagnoses which included hypertension and diabetes. During a review of Resident 21's MDS, assessment dated [DATE], indicated Resident 21's BIMS assessment score was 9 out of 15 indicating Resident 21 had moderate cognitive deficit. During an observation on 12/5/24 at 5:22 p.m. in the west wing hallway, LVN 3 prepared Resident 26's medications. LVN 3 walked inside Resident 26's room and Resident 26 was lying in bed watching TV. LVN 3 proceeded to administer Resident 26's medications without closing the privacy curtain. During a review of Resident 26's clinical record titled, AR, dated 12/6/24, indicated Resident 26 was admitted to the facility on [DATE] with diagnoses which included morbid obesity (more than 80 to 100 pounds above ideal body weight) and pain. During a review of Resident 26's MDS, assessment dated [DATE], indicated Resident 26's BIMS assessment score was 15 out of 15 indicating Resident 26 had no cognitive deficit. During an observation on 12/5/24 at 5:25 p.m. in the west wing hallway, LVN 3 prepared Resident 29's medication. LVN 3 walked inside Resident 29's room and administered Resident 29's medication without closing the privacy curtain. During a review of Resident 29's clinical record titled, AR, dated 12/6/24, indicated Resident 29 was admitted to the facility on [DATE] with diagnoses which included muscle weakness and Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements). During a review of Resident 29's MDS, assessment dated [DATE], indicated Resident 29's BIMS assessment score was 14 out of 15 indicating Resident 29 had no cognitive deficit. During an observation on 12/5/24 at 5:35 p.m. in the west wing hallway, LVN 3 prepared Resident 2's medications. LVN 3 walked inside Resident 2's room and Resident 2 was sitting up in her wheelchair at bedside eating dinner. LVN 3 proceeded to administer Resident 2's medications without closing the privacy curtain. During a review of Resident 2's clinical record titled, AR, dated 12/6/24, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses which included history of falling and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's MDS, assessment dated [DATE], indicated Resident 2's BIMS assessment score was 6 out of 15 indicating Resident 2 had severe cognitive deficit. During an observation on 12/5/24 at 5:39 p.m. in the west wing hallway, LVN 3 prepared Resident 34's medication. LVN 3 walked inside Resident 34's room and Resident 34 was sitting up in her wheelchair at bedside. LVN 3 administered Resident 34's medication without closing the privacy curtain. During a review of Resident 34's clinical record titled, AR, dated 12/6/24, indicated Resident 34 was admitted to the facility on [DATE] with diagnoses which included fracture (break in bone) and history of falls. During a review of Resident 34's MDS, assessment dated [DATE], indicated Resident 34's BIMS assessment score was 13 out of 15 indicating Resident 34 had no cognitive deficit. During an observation on 12/5/24 at 6:08 p.m. in the west wing hallway, LVN 3 prepared Resident 6's medication. LVN 3 walked inside Resident 6's room and Resident 6 was lying in bed watching TV. LVN 3 proceeded to administer Resident 6's medication without closing the privacy curtain. During a review of Resident 6's clinical record titled, AR, dated 12/6/24, indicated Resident 6 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (one-sided muscle weakness) and hemiparesis (partial weakness on one side of the body), and muscle weakness. During a review of Resident 6's MDS, assessment dated [DATE], indicated Resident 6's BIMS assessment score was 9 out of 15 indicating Resident 6 had moderate cognitive deficit. During an observation on 12/5/24 at 6:12 p.m. in the west wing hallway, LVN 3 prepared Resident 9's medications. LVN 3 walked inside Resident 9's room and Resident 9 was lying in bed watching TV. LVN 3 proceeded to administer Resident 9's medications without closing the privacy curtain. During a review of Resident 9's clinical record titled, AR, dated 12/6/24, indicated Resident 9 was admitted to the facility on [DATE] with diagnoses which included osteoporosis (condition in which bones become weak and brittle) and back pain. During a review of Resident 9's MDS, assessment dated [DATE], indicated Resident 9's BIMS assessment score was 14 out of 15 indicating Resident 9 had no cognitive deficit. During an interview on 12/10/24 at 2:44 p.m. with LVN 2, LVN 2 stated it was important to make sure privacy was provided to residents during medication administration. LVN 2 stated it was a dignity issue and residents rights to their privacy. LVN 2 stated, We need to provide as much privacy as we can to our residents, there are residents, staff and visitors walking by. During an interview on 12/10/24 at 3:38 p.m. with LVN 3, LVN 3 stated it was the facility practice to provide privacy when administering medications to residents. LVN 3 stated she did not close the privacy curtain and doors when she administered medications to multiple residents. LVN 3 stated she violated resident's rights to their privacy when she did not close the privacy curtain or closed the door. LVN 3 stated there are residents, staff and visitors walking by and did not need to see what was going on inside resident's room. During an interview on 12/10/24 at 5:21 p.m. with the Director of Nursing (DON), the DON stated her expectation was for licensed nurses to provide privacy during medication administration. DON stated it was a dignity issue and violation of resident rights for not closing privacy curtains and doors. The DON stated there are other resident in the rooms and family members visiting in the room and did not need to know what is going on. During a review of facility's policy and procedure (P&P) titled, Dignity, dated 2/2021, the P&P indicated, . Residents are treated with dignity and respect at all times . Residents' private space and property are respected at all times . Staff promote, maintain and protect resident privacy, including bodily privacy during assistance . During a review of facility's policy and procedure (P&P) titled Promoting/Maintaining Resident Dignity, dated 9/2/22, the P&P indicated, . All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . Maintain resident privacy .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services on acquiring, receiving, dispensing, and administering of all drugs to meet the needs of 54 residents residing in the facility when the contracted pharmacist did not check the expiration date of the lorazepam (medication used to treat anxiety and seizure- [a burst of uncontrolled electrical activity in the brain]) medication stored in the emergency kit (E-kit-contains medications provided to residents during emergency situations). This failure placed residents at potential risk for taking expired medications which could lead to serious consequences including reduced effectiveness in treating resident's condition in an event of an emergency and potential adverse reaction. Findings: During a concurrent observation, interview and record review on 12/6/24 at 12:25 p.m. with the Director of Nursing (DON) in the medication room, the refrigerator e-Kit which contained two vials of lorazepam 2MG/ML (milligram-unit of measurement/milliliter-unit of measurement), with an expiration date of 11/30/24. The DON stated The E-kit should have been replaced before or on the date the medication [lorazepam] expired. The DON stated a resident could have needed the medication after it expired and there was no medication available to administer. The DON stated the pharmacist was in the facility in November 2024 and did not order a new E-kit for replacement if she noticed the lorazepam was near expiration. During an interview on 12/10/24 at 2:55 p.m. with Licensed Vocational Nurse (LVN) 2. LVN 2 stated he checked the temperature of the medication room including the refrigerator and he did not remember checking the refrigerator E-kit for the expiration dates of the medications. LVN 2 stated the pharmacist comes in the facility every month and inspects medications and expiration dates stored in the E-kit. The LVN 2 stated the pharmacist should have noticed the lorazepam was expired and should have ordered a new E-kit. During an interview on 12/10/24 at 4:50 p.m. with the DON, the DON stated the refrigerator E-kit was last opened on 10/17/24 when a resident needed a lorazepam injection. The DON stated it was the responsibility of the pharmacist to check the expiration dates of medications in the E-kit. The DON stated it was also the responsibility of the licensed nurses to check the expiration date of medications in the E-kit when checking the temperature of the refrigerator every shift and to notify the pharmacy if the E-kit needed to be replaced. During a phone interview on 12/10/24 at 5:46 p.m. with the pharmacist (PHARM), the PHARM stated, I was in the facility last month, I did a quick glance of the E-kit and checked if it was opened, and it was not, and I did not see any expired medications. The PHARM stated she would have recommended to have the E-kit replaced if there was medication nearing its expiration date. The PHARM stated there was only one vial of lorazepam in the E-kit to use during an emergency and was expired which could result in neglecting residents needs during an emergency. During a review of facility's policy and procedure (P&P) titled, Automated Dispensing Machine for First Dose and Emergency Medications, dated 1/22, the P&P indicated, . The pharmacy will provide (e.g., weekly, semi-annual, monthly) inspection to evaluate . Condition and expiration dates of medications stored in the dispensing machine .

Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled in accordance with the facility's Administering Medications, Discontinued Medications, and Storage of Medications policy and procedure when: 1. Treatment cart was left unlocked and unsupervised in front of the nursing station. This failure had the potential for residents and staff to access medicated ointments inside the cart and used which could lead to serious health condition. 2. Resident 14's two inhalers (a device used to give medications in the form of a spray that is breathed in through the mouth) did not have an open date or expiration date on the medication. 3. Resident 14's nasal spray (a devised used to give medications in the form of spray through the nose) did not have an on date or expiration date on the medication. 4. Resident 18's inhaler did not have an open date or expiration date on the medication. These failures had the potential for the medications to be given to Residents' 14 and 18 which could cause adverse reactions (harmful, unintended result caused by a medication) and decreased medication potency and could compromise therapeutic effectiveness of Resident 14 and Resident 18's inhaler and nasal spray. 5. Discontinued inhalation and anticoagulant injection medications with no label and resident name was kept in a clear plastic container placed in the corner of medication room. This failure had the potential for the medications to be administered to residents which could cause adverse reactions. Findings: 1. During initial tour on 12/3/24 at 7:34 a.m. in front of the nursing station, the treatment cart was unlocked and unsupervised. During a concurrent observation and interview on 12/3/24 at 7:42 a.m. with Licensed Vocational Nurse (LVN) 1 in front of the nursing station, LVN 1 verified treatment cart parked near the nursing station was unlocked. LVN 1 stated there are medicated ointments, and other medications inside the treatment cart. LVN 1 stated the treatment cart should have been locked to prevent residents and unauthorized staff access the medications inside the treatment cart which could result in serious health condition. During an interview on 12/10/24 at 5:30 p.m. with the Director of Nursing (DON) the DON stated her expectation was for licensed nurses to ensure the treatment cart was locked when not supervised. The DON stated residents with dementia could access cart, and ingest the medications, which could lead to adverse side effects of medications or more serious health issues. 2. During a review of Resident 14's Admission Record, (document containing resident personal information) dated 12/6/24, the AR indicated Resident 14 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD-chronic lung disease causing difficulty breathing) and asthma (a chronic lung disease that causes inflammation[swelling] and tightening of the muscles around the airways making breathing difficult). During a review of Resident 14's Minimum Data Set (MDS- a functional and cognitive abilities assessment) assessment, dated 11/1324, indicated the Brief Interview for Mental Status (BIMS) score was 14 out of 15 (a BIMS score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe impairment), which indicated Resident 14 had no cognitive impairment. During a concurrent observation and interview on 12/06/24 at 10:40 a.m. in east wing hallway, Licensed Vocational Nurse (LVN) 2 prepared Resident 14's medications including Budesonide-Formoterol Fumarate inhaler (a prescription medication used to treat COPD) which did not have open date or expiration date. LVN 2 prepared Tiotropium Bromide Monohydrate Inhaler (prescription medication used to treat asthma) with no open date or expiration date. LVN 2 stated there should have been an open dates and expiration dates for both inhalers to know when medications would expire. LVN 2 stated he did not know when medications were opened. LVN 2 stated it was important to know the date medication was opened to ensure medication was not administered past the expiration date. LVN 2 stated expired medications could be less effective and would not benefit Resident 14 who has COPD and asthma. LVN 2 stated licensed nurses are responsible in making sure to write on the box the date medications were opened. 3. During a concurrent observation and interview on 12/6/24 at 2:41 p.m. with LVN 4 in east wing cart, LVN 4 opened the medication cart and inside one of the drawers was Resident 14's Ipratropium nasal spray (prescription medication used to treat asthma) which did not have open date and expiration date. LVN 4 stated there should have been an open date and expiration date to ensure medication was not administered to Resident 14 past its expiration date. During an interview on 12/10/24 at 1:52 p.m. with Infection Preventionist (IP), the IP stated it was the responsibility of the licensed nurse opening the medication box for the first time to write down the date it was opened and the expiration date to prevent administration of expired medications to residents. The IP stated expired medication may be less effective or sometimes could be stronger which could cause serious health issues. During an interview on 12/10/24 at 3:40 p.m. with LVN 3, LVN 3 stated it was the responsibility of the licensed nurse opening the box of medication to write the date medication it was opened and the expiration date. LVN 3 stated it was important to label medication with open date and expiration date to ensure expired medications are not administered to residents. LVN 3 stated medications past its expiration dates are less effective and would not benefit residents receiving the medication. 4. During a review of Resident 18's Admission Record, dated 12/10/24, the AR indicated Resident 18 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities) and wheezing (a high-pitched sound made when breathing is restricted/obstructed in the lungs). During a review of Resident 18's MDS assessment dated [DATE] indicated Resident 18's BIMS was seven of 15 which indicated Resident 18 had severe impairment in daily decision making. During a concurrent observation and interview on 12/6/24 at 3:06 p.m. with LVN 4 in the hallway next to the nursing station, LVN 4 opened east wing medication cart and inside one of the drawers was one albuterol sulfate inhaler (prescription medication used to treat asthma) which did not have an open date or expiration date. LVN 4 stated there should have been an open date and expiration date written on the packaging to ensure effectiveness of medication. LVN 4 stated the medication was only good for 30 days from the time it was opened. LVN 4 stated albuterol sulfate inhaler would not be effective after 30 days of being opened and it would not benefit Resident 18 who has asthma. 5. During a concurrent observation and interview on 12/6/24 at 12:25 p.m. with the Director of Nursing (DON) in the medication room, placed in the corner was a clear plastic bag which stored a box of enoxaparin (prescription medication used to prevent deep vein thrombosis [blood clots]) with no label and patient identifier, two unopened foil pack of ipratropium inhalation solution and one unopened foil pack of albuterol inhalation solution which did not have label and patient identifier. The DON stated the medication labels should not have been removed and medications placed in the clear plastic container for destruction. The DON stated the medications are not facility supplies and should have been labeled specific to residents. The DON stated it was not acceptable because there was a potential to be administered to other residents. The DON stated she was responsible in destroying non-narcotic medications at least once a week with another licensed nurse. During an interview on 12/10/24 at 1:46 p.m. with the IP, the IP stated expired and discontinued medications should be pulled out from the medication cart and placed in the clear plastic container in the medication room for destruction. The IP stated medication label with patient information should not be removed from the box of the medication to prevent administration of medication to other residents. During an interview on 12/10/24 at 4:46 p.m. with the DON, the DON stated her expectation was for licensed nurses to write the date medication was opened and the expiration date to ensure expired medications are not administered to residents. The DON stated expired or discontinued medication should be pulled out from the medication cart right away and placed in the plastic container in the medication room for destruction and labels should not be removed. The DON stated there was a potential risk for expired or discontinued medications could be administered to residents when not removed from the medication cart which could lead to adverse reaction. During a review of facility's policy and procedure (P&P) titled, Administering Medications, dated 4/19, the P&P indicated, . The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container . During administration of medications, the medication cart is kept closed and locked when out of sight . the cart must be clearly visible . During a review of facility's P&P titled, Discontinued Medications, dated 4/07, the P&P indicated, . Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies . During a review of facilities P&P titled, Storage of Medications, dated 11/2020, the P&P indicated, . Drugs and biologicals used in the facility are stored in locked compartments . Drug containers that have missing, incomplete, or incorrect labels are returned to the pharmacy for proper labeling . Compartments . containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended .

Based on observation and staff interview during the survey period from 12/3/24 through 12/10/24, the facility failed to ensure each bedroom accommodated no more than four residents in (room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]). Findings: Throughout the survey period from 12/3/24 through 12/10/24 three resident bedrooms had more than four residents in each bedroom. rooms [ROOM NUMBER] had eight residents per room. Although the bedrooms accommodated more than four residents, each room met the required needs of the residents, as well as the required square footage. The residents had a reasonable amount of privacy, and closet and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for the mobility of the residents. Wheelchairs, devices, and toilet facilities were accessible. The health and safety of the residents will not be adversely affected by the continuance of this waiver. Room Number: Number of Beds: 11 8 12 8 14 8 Recommend waiver continue in effect Don [NAME], HFES Health Facilities Evaluator Supervisor Date Request waiver continue in effect. ____________________________________ Administrator Date

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for one of three sampled residents, Resident 1, when licensed nurses did not develop and implement effective interventions to prevent falls. Licensed nurses and certified nursing assistants (CNAs) were aware of Resident 1 ' s low cognitive status, confusion, low safety awareness and inability to follow instructions for using the call-light. These failures resulted in Resident 1 getting up from bed unassisted and unsupervised on 6/21/22, experienced an avoidable fall with injuries. Following the fall Resident 1 was sent to the Emergency Department (ED) of the local hospital where a pelvic fracture was diagnosed . Resident 1 suffered decreased mobility following the fall and suffered pain to the left wrist and on 6/24/22 was diagnosed with left wrist fracture (break in the bone) as a direct result of the fall. Findings: During a review of Resident 1's clinical record titled, Admission Record (document containing resident personal information), undated, the Admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included: .arthropathy (disease of the joints) . repeated falls . cognitive communication deficit (impairment in the process of acquiring knowledge and understanding through thought, experience, and the senses) . difficulty in walking . dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) . During a review of the Resident 1 ' s Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 6/13/22, the MDS indicated Resident 1 ' s Brief Interview for Mental Status (BIMS- screening tool used in nursing home to assess cognition) assessment score was 3 (three) out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 1 had a severe cognitive deficit. During a concurrent observation and interview on 6/30/22, at 12:13 p.m., with Resident 1, Resident 1 sat in her wheelchair at bedside and ate lunch. Resident 1 was alert but confused. Resident 1 had a large bruise to the left side of her forehead and stated she did not know where it came from. During a review of Resident 1 ' s progress note titled General Note, dated 6/21/22, at 3:45 p.m., written by Licensed Vocation Nurse (LVN) 1, the General Note indicated, .Staff alerted to fall by crashing sound and call for help. Resident last seen in bed by CNA [Certified Nursing Assistant] during vitals 5 (five) mins [minutes] before fall. Resident found sitting upright on floor near C-bed [her roommates bed across the room] . hematoma (solid swelling of clotted blood within the tissues) to left forehead . No immediate skin issues or injuries noted . Resident unsteady . MD (medical doctor) and family notified, obtained order for transfer to [name of general acute care hospital (GACH)] for treatment and evaluation . During a review of Resident 1 ' s Occupational Therapy Treatment Encounter Note(s), dated 6/22/22, the Occupation Therapy Treatment Encounter note indicated, .Precautions: fall risk . Pt [patient] c/o [complained of] pain in L [left] hand/wrist area, grimaced [ugly, twisted expression on a person's face, typically expressing disgust, pain] and screeched when therapist took pt ' s (patient ' s) hand to initiate sitting balance, AM [morning] shift nurse was notified and to follow up . Pt (patient) demonstrated bed mobility with Max A [maximum assistance-therapist performs 75% of the work] . however observation of resistiveness . Response to Tx [treatment] . Response to Session Interventions: Pt appeared more confused and c/o pain in L wrist/hand area, nursing staff notified and to follow up . During an interview on 6/30/22, at 12:49 p.m., with CNA 2, CNA 2 stated she was assigned to Resident 1. CNA 2 stated staff were aware Resident 1 was unsteady on her feet, frequently reached for items out of reach and got out of bed or her chair unassisted without supervision. CNA 2 stated Resident 1 was confused and reminding her to use the call light was not effective because Resident 1 would not remember to use it. CNA 2 stated Resident 1 ' s roommate would call for help when she witnessed Resident 1 get up unsupervised. CNA 2 stated Resident 1 required two-person physical assistance to change her position in bed and transfer from the bed to the wheelchair. CNA 2 stated after Resident 1 ' s fall on 6/21/22, Resident 1 frequently complained of pain to her left wrist. CNA 2 stated since the fall on 6/21/22, Resident 1 was unable to move her wrist in certain positions during activities of daily living (ADLs- fundamental skills required to independently care for oneself). During an interview on 6/30/22, at 12:55 p.m., with Resident 2, Resident 2 stated she was Resident 1 ' s roommate and witnessed Resident 1 ' s fall (on 6/21/22). Resident 2 stated Resident 1 had gotten out of bed and walked to Resident 2 ' s beside. Resident 2 stated no staff there was nearby, so she used her call light to call for help. During a concurrent interview and record review on 6/30/22, at 1:06 p.m., with LVN 1, Resident 1 ' s Assessment Outcomes, dated 3/7/22 was reviewed. The Assessment Outcomes indicated, .Fall Risk Score . 7.0 . LVN 1 stated Resident 1 ' s fall risk score on admission was seven, which meant Resident 1 was at a lower risk for falls. LVN 1 stated Resident 1 was confused, wheelchair bound (confined to a wheelchair) and required extensive assistance of two people for bed mobility and to transfer, which increased her fall risk. LVN 1 stated he was the nurse on duty when Resident 1 fell on [DATE]. LVN 1 stated he was outside of Resident 1 ' s room when a CNA told him Resident 1 had fallen inside her room. LVN 1 stated he walked into Resident 1 ' s room and found her sitting on the floor next to the bed across the room. LVN 1 stated Resident 1 had a large hematoma (solid swelling of clotted blood within the tissues) on the left side of her forehead, and he sent Resident 1 to the Emergency Department (ED) for evaluation. LVN 1 stated, The hospital documents showed a right hip fracture and they returned her [Resident 1]. LVN 1 stated Resident 1 ' s fall was avoidable. LVN 1 stated Resident 1 required more supervision than provided for her. LVN 1 stated Resident 1 would get up unsupervised when in bed and the best way to prevent falls would be getting her out of bed and into her wheelchair more frequently and provide her with more activities. LVN 1 stated a day or two after the fall Resident 1 started to guard her left wrist and an X-ray (creates pictures of the inside of your body) was done which indicated a left wrist fracture. During a concurrent interview and record review on 6/30/22, at 2:50 p.m., with the Minimum Data Set Coordinator (MDSC), Resident 1 ' s MDS Assessment Section G dated 6/13/22, was reviewed. The MDSC stated the MDS Section G was used to assess how much assistance Resident 1 needed with activities of daily living and mobility (ability to move or be moved freely and easily). The MDSC stated Resident 1 ' s MDS Section G indicated, Resident 1 required extensive assistance from two people to transfer between surfaces such as bed to wheelchair and wheelchair to toilet. The MDSC stated Resident 1 was unable to steady herself without assistance and could not safely ambulate alone. The MDSC stated Resident 1 ambulated with therapy staff only. The MDSC stated Resident 1 did not have enough supervision to prevent falls. The MDSC stated Resident 1 would benefit from one-on-one supervision but it was not realistic in the facility due to staffing. The MDSC stated Resident 1 had complained of left wrist pain a couple of days after the fall and an x-ray was taken, which indicated a fracture to her left wrist. During a telephone interview on 7/5/22, at 11:37 a.m., with the Certified Occupational Therapy Assistant (COTA), the COTA stated she worked with Resident 1 the day after she fell (6/21/22). The COTA stated, When we tried to get her up, she had a fear of falling and sitting edge of bed the day after the fall. The COTA stated Resident 1 ' s fear of falling affected her participation in therapy. The COTA stated Resident 1 was impulsive and there were times she would walk in to perform therapy and she would find Resident 1 standing up at bedside alone. The COTA stated Resident 1 ' s mental status (stated of mind) was not consistent to use a call light effectively. The COTA stated Resident 1 was unable to safely transfer or ambulate by herself. The COTA stated when she worked with Resident 1, Resident 1 would say Ow when she moved her left wrist. The COTA stated she usually would grab Resident 1 ' s hand to work with her but the resident kept pulling her left hand away and she notified the nurse. During a review of Resident 1 ' s Emergency Department document titled Encounter Report, dated 6/21/22, the report indicated, . admitted : 6/21/22 . discharge date : 6/22/22 . History . Fall . BIBA (brought in by ambulance) from [facility name] for fall from wheelchair, hematoma to left side of head . reports left head pain . Patient presents to ED for evaluation after fall. She stays at (SNF- skilled nursing facility) nursing home and reportedly fell out of her wheelchair . Her fall was apparently not witness [sic] . Discussion . Patient presents to ED for evaluation after fall. She suffered head injury and scalp contusions (bruises) . Patient noted to have right pubic ramus fracture . Clinical Impression . 1. Fall, initial encounter . 2. Injury of head . 3. Closed fracture of ramus of right pubis . Imaging Results . XR [x-ray] Pelvis Complete . 6/21/22 . Reason for exam: Pain status post fall . Impression: 1. Nondisplaced fracture (broken bones not out of alignment) of the right inferior pelvic ramus (lower margin of the pelvis) . During a review of Resident 1 ' s progress note titled General Note, dated 6/23/22 at 4 p.m., the note indicated, .Resident c/o [complained of] pain to left wrist and left side of body . therapy notified this writer MD [physician] notified via phone received order for x ray . and another order for left wrist . During a review of Resident 1 ' s x-ray results titled, Patient Report, dated 6/24/22, the x-ray results indicated, .Procedure . Left Wrist . Findings . Bones/Joints: Distal dorsal radial cortical fracture [when the one of the two bones in the forearm breaks near the wrist] irregularity noted, likely acute (sudden) [traumatic injury that causes a clean and immediate break in the bone] . During a review of the facility ' s policy and procedure (P&P) titled, Fall Prevention and Fall Related Injury Management, dated 4/11/17, the P&P indicated, .Policy: It is the policy of this care center that all residents will be evaluated for fall risk in order to plan and develop interventions to reduce the risk for falls and injuries. The care center will evaluate, treat, investigate, and document fall incident investigation findings . Procedure: 1. Upon admission to the care center, the licensed nurse will evaluate the patient/resident ' s fall risk . 2. The licensed nurse and/or Interdisciplinary Team (IDT) will develop an initial fall/injury prevention care plan based on the patient/resident specific risk factors that will be communicated to the staff . Care and Documentation . 1. When a patient/resident fall occurs, the employee making the discover immediately notifies the licensed nurse to conduct an appropriate evaluation, provide interventions and/or emergency care as needed . During a professional reference review retrieved from https://nursinghomehelp.org/wp-content/uploads/2019/03/F689-falls-regs-and-careplanning.pdf titled Falls: the Regs and Care Planning, dated 3/19/19, the reference indicated, .Avoidable accident . means that an accident occurred because the facility failed to . Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision . Implement interventions, including adequate supervision and assistive devices, consistent with a resident ' s needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident . Supervision/adequate supervision . refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed . This determination is based on the individual resident ' s assessed needs and identified hazards in the resident environment. RISKS . Resident Vulnerability . Functional status . Medical condition . Cognitive abilities . Adequacy of supervision is defined by type and frequency, based on the individual resident ' s assessed needs . Adequate supervision to prevent accidents is enhanced when the facility . Accurately assesses a resident . to determine whether supervision to avoid an accident is necessary . WHY DO THEY FALL? . Lower extremity weakness . Balance disorders . Functional impairments (difficulty rising from a chair, getting on or off toilet, etc.) . Gait disorders . Cognitive impairment . Incontinence . During a professional reference review retrieved from https://nursinghomehelp.org/wp-content/uploads/2017/11/AHRQ_RAND_Module3.pdf titled Improving Safety in Long-Term Care Facilities, dated June 2012, the reference indicated, .Safety means avoiding, preventing, and lessening the effects of harm and injury while residents are in a health care setting . Within nursing centers, one of the biggest safety challenges is preventing falls . To prevent injury from falls, all nursing staff need knowledge and skills . Being aware means that we are alert to the needs of our residents. We are tuned in and tend to their needs. To do this, we need to learn to watch residents, noticing and thinking clearly about what is going on with them . When we notice something that might affect a resident ' s safety, it is our job to respond and do what is needed to protect the resident . A risk factor for falling is one that, in clinical studies, has been found to present frequently in people who fall. Research shows that there are several key risk factors for falls among nursing center residents. Many residents have more than one risk factor. The more risk factors a person has, the more likely he or she is to fall . Risk Factors Related to the Resident . If residents have fallen in the past, or if they have a pattern of falling, they are much more likely to fall in the future . gait and balance problems are always suspect in a resident who falls and are an important risk factor for falling . Many nursing center residents suffer from Alzheimer ' s disease or dementia, which may put them at additional risk. In general, people who have dementia are more likely to fall than people who don ' t, and they are more likely to be injured in a fall. When people with dementia move about when they are not being watched and do not have help, they are at greater risk for falling. Staffing and organization of care . Inadequate staffing may leave residents who are likely to fall without proper supervision . There are many interventions that can be tried to limit the risk of future falls . Keep frequently needed items (glasses, water, blankets, call lights, telephone) close to a resident where they can be reached safely Take the resident to the bathroom often . More frequent toileting . Falls surveillance . Changing staffing schedules to provide increased monitoring .